• 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 

• 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.