1. Diarrhoea A thrilling topic for a Wednesday morning! Emma Lowe

2. Overview Assessment Causes Management – Non-specific – Specific

3. Question A 52 year old man presents with a 6 month history of epigastric pain and diarrhoea. Passes up to 5 watery stools per day which are sometimes difficult to flush and foul smelling. He can recall one episode of black stool in the past month. Which would be the best investigation to aid diagnosis? A – CCK test B – Parathyroid Sestamibi Scan C – Secretin stimulation test D – Fasting VIP plasma level E – OGD

4. Types of diarrhoea Increase in frequency and fluidity of bowel action Osmotic – Increased amounts of water are drawn into the bowel Secretory – Enhanced formation of gastrointestinal secretions Often multi-factorial

5. Assessment History – Steatorrhoea – Blood/mucus – Recent constipation – Profuse watery diarrhoea not relieved by fasting (hormonal) Review medication and diet Look for signs of dehydration Stool sample

6. Causes TOP THREE (in cancer patients) – Laxative overuse – Overflow diarrhoea – Partial bowel obstruction Drugs Treatment associated Tumour related Malabsorption syndromes Gastroenteritis Hormone related Pseudomembranous colitis

7. Foods Raw fruit (fresh and dried) Nuts Greens Beans Lentils Onion Coleslaw Sauerkraut Spicy foods Wholegrain Wholemeal

8. Management Consideration of the underlying cause Specific vs non-specific antidiarrheal agents Increase fluid intake Treat the physiological effects Protect the perianal skin – Zinc cream

9. Loperamide Potent µ opioid receptor agonist Directly absorbed in the gut wall and increased GI transit time by decreasing propulsion and non- propulsive activity Increases anal sphincter tone and can improve night- time continence Doesn’t cross blood brain barrier so no central effect Maximum effect may take 16-24 hours and last 3 days 4mg PO STAT, 2mg post BO (max 16mg/24hrs) Can increase up to 24mg/24hrs in treatment related Chronic diarrhoea aim for 2mg BD

10. Other non-specific drugs Aim to use a single drug Codeine/Morphine – Associated with central effects Diphenoxylate (with atropine = Lomotil) – 2.5mg QDS (equivalent to Loperamide 2mg BD) – Opioid agonist, similar to loperamide – Does cross the blood brain barrier so can have central effects

11. Common causes Laxative induced diarrhoea – Should resolve within 24 hours of laxatives being stopped. – May need to introduce at a lower dose. Overflow diarrhoea – Rectal measures and laxatives Bowel obstruction – Surgery – Symptomatic management (Octreotide, steroids, buscopan)

12. Drugs Laxatives Antacids Magnesium salts SSRIs Antibiotics Iron Mefanamic acid NSAIDs Stop drug +/- switch to an alternative Oestrogens Theophyllin Anticholinergics Sulphonylureas Caffeine Chemotherapy – 5-FU, Mitomycin, Methotrexate, Doxorubicin, Etoposide

13. Radiation induced diarrhoea Common in 2 nd -3 rd week of radiotherapy to pelvis/abdomen Risk factors: high dose and length of treatment, volume of normal bowel treated, tumour size, concomitant chemotherapy, NCI grading -0: None -1: Increase of <4 stools over pre-treatment -2: Increase of 4-6 stools or nocturnal stools -3: Increase of 7+ stools or incontinence or need for parenteral hydration -4: Physiological consequences requiring intensive care or haemodynamic collapse 5-15% will go on to develop chronic diarrhoea Mild to moderate (1-2) – Loperamide (up to 24mg/24hrs then switch to Octreotide) Severe (3-4) – Octreotide via CSCi Aspirin/NSAIDs inhibit prostaglandins which reduce gastric secretions (RCTs show mixed results) Various other possibilities including steroids, formalin, oestrogen/progesterone, cholestyramine Cochrane review protocol has been set but not done

14. Malabsorption Carcinoma of head of pancreas causing pancreatic insufficiency (steatorrhoea) Gastrectomy: poor mixing of fluid with pancreatic secretions (steatorrhoea) Vagotomy: Increased water secretion into the colon Ileal resection: less able to absorb bile acids. Fluid in bowel increased. Colectomy: Water-absorbing properties are lost. May need extra fluid and salt. Fistula: Any or all of these problems

15. Malabsorption Fat Malabsorption – Steatorrhoea – Pancreatic insufficiency, biliary obstruction, bacterial overgrowth – Pancreatic enzymes, H2 receptor antagonists/PPI (to prevent breakdown of pancreatic enzymes), dietary advice Bile salt malabsorption – Ileal resection, bacterial overgrowth – Cholestyramine: bile salt chelator

16. Pseudomembranous colitis Acute, exudative colitis usually caused by C.Diff. Copious diarrhoea with mucus and blood, abdominal cramps, fever. Any antibiotics, most typically Ciprofloxacin and Cephalosporins. PPIs increase the risk, as does immunocompromise Stool for C.Diff toxin Sigmoidoscopy Avoid antidiarrheals Metronidazole 400mg TDS for 14 days Vancomycin 125mg QDS for 14 days

17. Hormonal Carcinoid – Diarrhoea in 75% – 5HT3 antagonists can reduce the diarrhoea – Octreotide Zollinger-Ellison syndrome – Gastrin secreting tumour, causes increased gastric acid production. – Main symptoms related to acid production – Fasting Gastrin (>1000) +/- secretin stimulation test – PPI, H2 Antagonist for symptoms, definitive surgery – Octreotide Others – Medullary carcinoma of the thyroid – VIPoma

18. Others Local tumours – Surgery, chemotherapy, radiotherapy (palliative for symptomatic benefit) Bacterial overgrowth – Broad spectrum antibiotics

19. Question A 52 year old man presents with a 6 month history of epigastric pain and diarrhoea. Passes up to 5 watery stools per day which are sometimes difficult to flush and foul smelling. He can recall one episode of black stool in the past month. Which would be the best investigation to aid diagnosis? A – Short Synacthen test B – Parathyroid Sestamibi Scan C – Secretin stimulation test D – Fasting VIP plasma level E – OGD

20. Question - Answer A 52 year old man presents with a 6 month history of epigastric pain and diarrhoea. Passes up to 5 watery stools per day which are sometimes difficult to flush and foul smelling. He can recall one episode of black stool in the past month. Which would be the best investigation to aid diagnosis? A – Short Synacthen test B – Parathyroid Sestamibi Scan C – Secretin stimulation test D – Fasting VIP plasma level E – OGD Zollinger Ellison Syndrome

21. References Fallon, M. O’Neill, B. ABC of palliative care: Constipation and diarrhoea. BMJ, 1997;315:1293 PCF4 Watson et al (Eds). Oxford Handbook of Palliative Care. 2009, 2 nd Edition, Oxford University Press Woodruff, R (Ed). Palliative Medicine. 2004, 4 th Edition, Oxford University Press