- Diet: Suggest bananas, rice, noodles, white bread, skinned chicken, white fish.
- Fluid: Ensure adequate hydration and K, Mg replacement. Ensure at least 2-3 L per day (more depending on diarrhoea output).
- Drugs: Stop laxatives/other drugs that may be contributing e.g. metoclopramide.
- General care: Remember patients are at risk of low albumin, neutropenia, sepsis, ileus, pseudo-obstruction, prolonged illness or even death so careful, daily review essential
Chemotherapy induced diarrhoea
Check SACT regimen and date last given. Patients on SACT are at risk of neutropenic sepsis - check temperature.
There is specific advice for diarrhoea induced by the following SACT: capecitabine, irinotecan, EGFRi TKIs, immunotherapy.
- History to include other SACT toxicities (risk of damage to rest of GI tract and skin – manage nausea/ mucositis /sepsis/hand-foot syndrome according to local guidelines)
- Assessment of fluid balance status (BP, pulse etc) and signs of systemic infection.
- Establish IV access and check bloods – renal function, FBC, CRP, magnesium, albumin, blood cultures if signs of systemic sepsis.
- Stool sample (send for urgent culture, C diff toxin and viral screen - discuss with microbiology)
- Abdominal XR to exclude ileus/ obstruction/ perforation /megacolon (when clinically stable)
- Careful examination of mucous membranes.
- Clinical observations (NEWS, daily weights, cumulative fluid balance chart)
- Send stool urgently. Inform microbiology personally and discuss management with microbiologist. If haematology patient or strong suspicion of infective diarrhoea, withhold anti-diarrhoeal medication until stool result available.
- Do not withhold antidiarrhoeals for more than 12-24 hours without thorough senior medical review. In oncology, give antidiarrhoeals before stool result back.
- Give antibiotics according to local policy (eg for C diff or neutropenic sepsis).
- Isolate until infection excluded.
- Immediate IV fluid resuscitation. Replace fluid and electrolyte losses. Adjust ongoing fluids according to fluid balance status and renal function.
- Stop ACE-inhibitors/ diuretics/ NSAIDs.
- Stop 5-FU/ capecitabine chemotherapy.
- Nil by mouth if vomiting, abdominal distension, abdominal tenderness or obstruction on AXR.
- Antidiarrhoeals (exclude infection by stool sample first if haematology patient)
- Loperamide (give 4mg on admission then prescribe 2mg every 4 hours)
- Codeine phosphate 30-60mg q 4 hours if loperamide ineffective or prn in addition to loperamide depending on diarrhoea / hydration.
- Hyoscine butylbromide (buscopan) 20mg sc prn for abdominal spasms.
- Octreotide
- Grade 4 diarrhoea: 500mcg sc on admission, then octreotide 300mcg tid.
- Grade 3 diarrhoea: 150mcg sc then 150mcg sc tid or 500mcg/24 hours by subcutaneous infusion (withhold if not on maximal anti-diarrhoeals prior to admission but review every 24 hours).
- Nil by mouth (except sips) if abdominal pain or distension or abnormal AXR.
- Antibiotics (other than for infective diarrhoea)
- Pyrexia (temp > 38⁰C) - start neutropenic sepsis antibiotic policy immediately – do not wait for FBC.
- On irinotecan – give ciprofloxacin or broad spectrum antibiotics.
- Grade 4 diarrhoea – give broad spectrum antibiotics.
- Close monitoring of clinical observations (NEWS, daily weights, cumulative fluid balance chart) with prompt action if deterioration.
- At least daily medical review - assess and treat other chemotherapy-related toxicities according to specific guidelines and watch for developing sepsis.
- Daily FBC, U+E, albumin as high risk of neutropenia/sepsis.
- Analgesia and antiemetics for pain and nausea (follow local guidelines but caution with antipyretics as may mask developing fever)
- If pyrexial but not neutropenic, culture and give antibiotics according to patient’s condition and local guidelines.
- Consider dietician involvement and nutritional support e.g. total parenteral nutrition (TPN).
- Ensure admission is reported to oncology team and annotated in chemocare so that next SACT dose can be delayed/ altered as appropriate.
- Reduce then stop octreotide.
- Reduce frequency of loperamide and codeine then give on an as required basis rather than regularly (avoid constipation).
- Start oral fluids then light diet as long as tolerated.
- Discharge when symptoms settled and tolerating diet.
- Ensure prescribed regular loperamide and codeine phosphate as above.
- Give regular hyoscine butylbromide as above.
- Increase octreotide dose incrementally (depending on response) every 12-24 hrs to max 1500mcg/24hours (best given by 24 hour sc pump) until diarrhoea slows.
- Careful review of fluid balance/weights/electrolytes/nutrition.
- Repeat abdominal X-ray if abdominal distention/pain.
- Surgical review if very dilated bowel loops on X-ray, as indicated.
- Discuss with seniors/HDU if concerns.
- Repeat AXR and consider CT CAP.
- If abdominal distension /pain.
- consider stopping loperamide in case it has induced ileus.
- consider surgical review if CT abnormal.
Patients can deteriorate quickly but should fully recover. Discuss with consultant and HDU/ ITU if concerns.
- Contact specialist team supervising cancer treatment.
- Contact the on call oncology registrar via the Western General Hospital switchboard on 0131 537 1000. Annotate on chemocare and let SACT scheduler know.