diarrheA

Description

Diarrhea is the abnormal increase of liquid in stool and increase in the frequency of passing stool (defecation). The person with diarrhea has watery or loose stool more than three times a day. Other symptoms include cramping, pain, feeling the urge to defecate, irritation of the skin around the anus (perianal), and inability to control defecation (fecal incontinence). Approximately 10% of the patients with advanced cancer suffer from diarrhea. Diarrhea lasting fewer than two weeks is called "acute diarrhea," and diarrhea lasting for longer than two months is called "chronic diarrhea."

Diarrhea is a debilitating condition that can significantly affect quality of life. Diarrhea can prevent patients from participating in social activities and going to work. Persons with diarrhea fear soiling their clothing or bed linens, a fear that prevents them from leaving home. Loss of sleep due to nighttime diarrhea can cause fatigue, which ultimately affects the patient's ability to function normally. Uncontrolled diarrhea can lead to chemical imbalances, loss of fluids (dehydration), and even death.

Causes

Although there are many causes of diarrhea, only those associated with cancer will be discussed. The most common cause of diarrhea in cancer patients is related to constipation or its treatment. Cancer patients may experience diarrhea as a result of their treatment, or it can be due to dietary changes, infections, hormone imbalances, digestion disorders, or inflammation. Treatment-related diarrhea can be caused by chemotherapy, hormone therapy, radiation therapy, biological response modifiers (drugs that improve the patient's immune system), or surgery. In addition, cancer patients may develop temporary lactose intolerance, which causes diarrhea.

Chemotherapy drugs kill the rapidly growing cancer cells. However, certain normal cells of the body are rapidly growing and they too are affected. Rapidly growing cells are found in the intestines, as well as other parts of the body. Diarrhea occurs as a result of injury to the cells of the intestine. These effects are temporary. Chemotherapy drugs, hormones, and biological response modifiers that frequently cause diarrhea include:

• Dactinomycin
• Daunorubicin
• Diethylstilbestrol diphosphate
• Doxorubicin
• Fluorouracil
• Flutamide
• Hydroxyurea
• Interferon
• Interleukin-2 (aldesleukin)
• Irinotecan
• Methotrexate
• Nitrosoureas
• Thioguanine

Radiation therapy can cause diarrhea if the intestines are in the treatment field. Diarrhea results from the injury and destruction of the cells lining the intestines, which leads to a decrease in the uptake (absorption) of fluids and an increase in the speed with which stool moves through the intestines. Radiation therapy can cause diarrhea, and other intestinal problems, many months or years after treatment has been completed.

Diarrhea usually develops within one week following pretreatment (chemotherapy and irradiation) for bone marrow transplantation. This diarrhea usually disappears within two weeks. Also, bone marrow transplant patients with graft-versus-host disease develop severe diarrhea.

Treatments

Prevention

There are some measures that can prevent diarrhea. Patients who are receiving abdominal radiation therapy can be put into certain positions to minimize exposure of healthy intestines to radiation. Diarrhea caused by chemotherapy cannot be prevented; however, the administration of atropine during treatment with irinotecan may prevent diarrhea. Patients should stop taking dietary supplements, as these can cause diarrhea.

There are many dietary changes that can be made to prevent or reduce diarrhea. Foods to avoid include:

• whole grain breads and cereals
• fresh or frozen fruits (except banana)
• dried fruits
• fruit juices with pulp and prune juice
• raw vegetables
• canned onions, corn, olives, pickles, and Brussels sprouts
• fatty foods
• dried beans
• rich desserts
• milk and milk products
• alcohol and caffeinated coffee and tea
• spicy foods
• fried foods

Management

Of the utmost importance in the treatment of diarrhea is the replacement of fluids lost by frequent, watery stools. The patient should drink six to eight glasses of fluid daily, including clear broth, ginger ale (without the fizz), water, weak tea, and commercial formulas that contain sugars and minerals (electrolytes). Patients with severe diarrhea may need intravenous fluid replacement either at home or in the hospital.

Diarrhea can cause the perianal skin to become irritated and painful; therefore, it needs to be cleaned thoroughly after each bout of diarrhea. Baby wipes or a mild soap with water can be used to clean the irritated skin. The area should be patted dry and occasionally exposed to air. Taking a sitz bath (sitting in a bathtub of shallow water) with lukewarm water may relieve the discomfort. Petroleum jelly or other type of barrier cream may be used.

The patient should eat small, frequent meals. Foods and drinks should be taken at room temperature. Foods that can help control diarrhea include:

• bananas
• applesauce
• boiled white rice
• tapioca
• white bread
• plain pasta
• creamed cereals
• eggs
• potatoes (without skin; mashed or baked)
• fish
• chicken or turkey (without skin)

There are some medications that can slow down the movement of stool through the intestines and increase intestinal water absorption. The patient may need a combination of drugs and/or dose adjustments to achieve relief. A physician should be consulted before any over-the-counter antidiarrheal medications are taken. Anti-diarrheal medications include:

• Atropine sulfate with diphenoxylate HCl (Lomotil)
• Codeine phosphate
• Loperimide HCl (Imodium-AD)
• Octreotide phosphate (Sandostatin)

These medications should not be used if infection as the cause of diarrhea has not been eliminated.

Patients who are experiencing diarrhea due to graft-versus-host disease will continue to take their immunosuppressant drugs. They may also be treated with corticosteroids and antidiarrheal medications.

Alternative and Complementary Therapies

Peppermint tea, chamomile tea, valerian capsules, or aloe vera juice may reduce cramping and intestinal spasms. An Ayurvedic physician may recommend taking equal parts of yogurt and water with fresh ginger, or a powder of beleric myrobalan fruit. Ginger capsules may relieve intestinal spasms and pain. Glutamine supplements may speed up the healing process and relieve irritated intestines.