1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3i Symptoms – Diarrhea Module 3i Symptoms – Diarrhea EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Diarrhea... l Definition: stool that is looser than ‘normal’ and / or increased in frequency

4. ... Diarrhea Epidemiology l Impact: At best, annoying At worst, life-threatening l Prevalence: 30 – 90 % of patients on some anti- neoplastic agents Epidemiology l Impact: At best, annoying At worst, life-threatening l Prevalence: 30 – 90 % of patients on some anti- neoplastic agents

5. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

6. Pathophysiology l 7 – 9 liters of fluid reaches the large intestine daily l Loose stools with < 100 ml not absorbed l Chemotherapy: damaged intestinal mucosa and increased fluid overwhelms large bowel capacity Irinotecan has cholinergic effect l 7 – 9 liters of fluid reaches the large intestine daily l Loose stools with < 100 ml not absorbed l Chemotherapy: damaged intestinal mucosa and increased fluid overwhelms large bowel capacity Irinotecan has cholinergic effect

7. Causes of diarrhea l Infections l GI bleeding l Malabsorption l Medications l Obstruction l Overflow incontinence l Stress l Infections l GI bleeding l Malabsorption l Medications l Obstruction l Overflow incontinence l Stress

8. Assessment l History What is ‘normal’ Description (consistency, frequency, volume, blood, etc) Onset and duration Weight loss Systemic symptoms Medications (including chemotherapy) l Physical Dehydration, fever l History What is ‘normal’ Description (consistency, frequency, volume, blood, etc) Onset and duration Weight loss Systemic symptoms Medications (including chemotherapy) l Physical Dehydration, fever

9. Management l Establish normal bowel pattern l Avoid gas-forming foods Eg, milk (lactose) l Increase bulk l Transient, mild diarrhea Attapulgite Bismuth salts l Establish normal bowel pattern l Avoid gas-forming foods Eg, milk (lactose) l Increase bulk l Transient, mild diarrhea Attapulgite Bismuth salts

10. Management of persistent diarrhea l Loperamide l Diphenoxylate / atropine l Paregoric l Tincture of opium l Octreotide l Loperamide l Diphenoxylate / atropine l Paregoric l Tincture of opium l Octreotide

11. Chemotherapy- associated diarrhea l May be life-threatening l Aggressive oral hydration l Expectant management Loperamide 4 mg then 2 mg q 2 h until diarrhea-free for 12 hours Octreotide for refractory diarrhea l Admit for severe diarrhea, nausea, vomiting, fever, sepsis or bleeding l May be life-threatening l Aggressive oral hydration l Expectant management Loperamide 4 mg then 2 mg q 2 h until diarrhea-free for 12 hours Octreotide for refractory diarrhea l Admit for severe diarrhea, nausea, vomiting, fever, sepsis or bleeding

12. Carcinoid-associated diarrhea l Opioid for mild case l Cholestyramine l Octreotide l Opioid for mild case l Cholestyramine l Octreotide

13. Pancreatic insufficiency- associated diarrhea l Low fat diet l Exogenous pancreatic lipase l Low fat diet l Exogenous pancreatic lipase

14. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience