Annette Bisanz, MPH, RN
Advanced Practice Nurse
The University of Texas, MD Anderson Cancer Center
Hello. My name is Annette Bisanz and today we are going to discuss the treatment of diarrhea.
The objectives of this session will be that: all participants will be able to state the treatment for diarrhea caused by chemotherapy and radiation treatment; to discuss the drugs available for the treatment of diarrhea; and to determine when to use ActiFlo bowel management system.
Remember, in treating diarrhea, the primary principle is to treat the cause, not the symptom. If we treat just the symptom and don't hit all of the causes of diarrhea, we will still have diarrhea.
The problem with diarrhea management is that it is often undertreated. Often times, the patient can have multiple diarrhea stools per day and they may be taking two Imodium® per day or two Lomotil® per day, and that is not maximum therapy. So, that's why we want to cover this very thoroughly, so people get optimum treatment for their diarrhea. We also collect stool or count number of stools without assessing the actual volume of the output of stool. When PRN anti-diarrhea medicines are ordered, we don't give enough to have a positive outcome. And we don't treat all the causes of diarrhea.
This slide shows the classification of anti-diarrheal agents, and there are four classifications. There's intestinal transit inhibitors: and you see the medications under that group are like your Imodium®, your Lomotil®, opium, or any kind of opiate, and enkephalin analogues. Then there is -- there are your anti-secretory agents: octreotide acetate, berberine, chloride channel blockers, aspirin, nicotinic acid, calmodulin inhibitors. And under pro-absorptive agents there is glucose, amino acids, oral rehydration solutions, and clonidine. And under your intraluminal agents are clays, activated charcoal, cholestyramine, and psyllium and bismuth. When you look at that list, I think we all have to admit that many of those drugs are not used very much in the treatment of diarrhea, and so I think it's important that we understand the purpose of the different drugs and begin to try to develop newer --- new ways to treat diarrhea in cancer patients. When you go to the literature, there's very little research done in the area of diarrhea management. But these are your classifications.
And let's first talk about treatment of secretory or exudative diarrhea --- or secretory and exudative diarrhea, because physiologically pretty much the same thing is happening within the GI tract. And this is post-chemotherapy and abdominal radiation. Step 1: The patient can take up to 8 Imodium® per day. This is 2 mg. tablets. If that doesn't work, then go to Step 2. In Step 2, the patient can alternate 1 Lomotil® with 2 Imodium®, and those are 2 mg. Imodium, every 3 hours around the clock. However, to prevent the patient from flipping into constipation, withhold the next dose if there is no stooling since the prior dose. Step 3: Alternate 2 Lomotil® with 2 Imodium® every 3 hours around the clock. Again, withhold the next dose if there is no stooling since the prior dose. After doing that for a couple of days, you can kind of understand how much anti-diarrhea medication the patient needs. And then, instead of going around the clock, we need to allow our patients to sleep a little bit. We can then try to give the optimum dose the patient needs to control their diarrhea and allow them to sleep through the night. If the above two steps -don't work, step 3 -- if the above three steps don't work, add opiates as needed. We know the side effect of opioids is constipation, and so they have been found to be very helpful in people that don't respond totally to anti-diarrhea medicines. If patients on chemotherapy are refractory to the above treatments, oftentimes they will respond to oc --- octreotide acetate.
Dietary and medication restrictions for chemotherapy and radiation-induced diarrhea are as follows: have the patient eat a low-residue diet and no medicinal fiber; avoid milk and dairy products; avoid spicy and fried foods; avoid alcohol and caffeine; and avoid prune and orange juice because these act as laxatives; and avoid prokinetic drugs like metoclopramide or ethyro --- erythromycin.
The patients need to be involved in helping us to know what the state of their diarrhea is when they go home. And the symptoms that we need to teach them to report to us are excessive thirst, fever, dizziness, light-headedness, palpitations, rectal spasms, and this is --- another name for this is tenesmus, and what the patients will describe...they feel like they have an urge to have a bowel movement, but when they go and sit on the commode, they can't go. And so, this is a spasm and the medication that's frequently used for that is something like an antispasmodic like Bentyl, 10 mg., given 30 minutes before each meal and at bedtime. The patient may also --- we also want them to --- to tell us if they're having excessive cramping, if they have watery or bloody stools, or continued diarrhea in spite of the anti-diarrheal treatment that we've prescribed for them.
Let's talk about treatment of malabsorptive diarrhea. First of all, determine the cause and treat the cause, not the symptom. Okay so the cause of --- one cause of malabsorptive diarrhea is celiac sprue. So the treatment would be to withhold gluten, which is any wheat, barley, rye, and sometimes oats, from the diet, and that's usually the definitive treatment for celiac sprue. If the patient had a pancreatic resection, provide replacement enzymes. One of the things that the patients need to be taught, is they can assess if they --- they are getting enough enzymes by watching what happens to their stool when it falls in the toilet. If their stools float, they're not getting enough replacement of enzymes, and so they need to increase them. Many times the patients are told, "Well take 2 or 3 Creon®, for example, after each meal, and maybe 1 or 2 with a snack." But if their stools are floating, they're not taking enough. So they need to increase the --- the enzyme. You can't overdose on these enzymes, so it's very important to teach the patient so that they get adequate treatment for malabsorption of fats. The next thing is the lactose intolerance, and you can remove dairy from the diet, or you can have the patient get some Lactaid® milk. They can have milk but it is the Lactaid type that has the enzyme in it, so they can metabolize it, or they can get Lactaid® tablets and take that with any dairy product that they need help --- that they're lactose intolerant to. I might mention that lactose intolerance has different degrees. Some people just can't take milk, but they can eat cottage cheese, they can eat ice cream, yogurt, cheeses; that doesn't bother them. Others, they --- they can take milk but they can't eat hard cheese, maybe. They can't eat ice cream. So please be aware that there are different degrees of lactose intolerance, and that needs to be assessed so that they're doing the appropriate thing to get rid of the diarrhea associated with it.
The next is treating of dysmotility diarrhea following surgical intervention. It's important for the patients to understand the ana --- anatomical changes that take place after surgery. And if they're missing part of their GI tract, they need to realize what result that's going to have on their GI function. For example, if the patient's rectum is --- has been resected for rectal cancer, they no longer have the holding place for the stool, and so --- and they don't have an accommodation reflex when that stool comes down into the rectum to cease giving them the urge to have a bowel movement, because all of that is gone. And so --- we want the patients to be aware that if their rectum is gone, and they have no accommodation reflex or holding spot for the stool, that the stool will just come down and want to come straight out because there's no holding spot. And so we have to accommodate that --- for that in our treatments. So the first thing we do is give them fiber. We also provide fluid appropriately, food [and] medication. We also provide bowel training for these patients and we teach them about anal sphincter exercises. Anal sphincter exercises need to be understood appropriately on how to do these exercises. It is not a pumping motion: tighten, loosen, tighten, loosen. That is not appropriate. We tell patients it's like going to the gym. It's the sustained contraction and the sustained relaxation that strengthens the anal sphincter muscles so they are asked to tighten the muscle that they use to hold back a bowel movement and hold it to a count of one-one thousand, two-one thousand, three-one thousand, all the way up to ten-one thousand, and then they relax, and hold it again to the count of one-one thousand, two-one thousand, three-one thousand, up to ten-one thousand. When they're doing these exercises, they will do this four times a day, and each time they do it, do the exercise ten times. We also ask them to do it, not only sitting down (everybody can do it sitting down), but we ask them to practice it standing up and walking, because that's usually when they lose control, is when they can't get to the bathroom fast enough and combine the activities of holding the anal sphincter tight while they do get to the bathroom, so they need to practice that.
Okay, I just explained this, so this is a repeat of what we just talked about, and so they're going to repeat this exercise four times a day, sitting, standing, and walking eventually, okay.
Let's talk about the use of fiber, how they're going to use fiber to form the stool, and decrease the frequency. Remember, we have talked in the past about the fiber being used to either slow down the bowel or increase the GI motility. Here, we're going to slow down the bowel activity by giving them 3.4 grams of psyllium or 1 teaspoon of methylcellulose, which is Cit --- Citrucel®, in 2 ounces of water, after meals and at bedtime. And then they take no fluid for one hour afterwards. We do, though, gradually build up on this fiber, because since fiber can't be taken rapidly or it will cause the rebound effect of cramping, bloating, diarrhea, we need to introduce it gradually, especially on patients who are not used to taking a lot of fiber. And so we will start out with 3.4 grams of psyllium in 2 ounces of water after breakfast for five days. No fluid for one hour afterwards. After five days, day 6 through 10, we will add a dose to --- dinner --- after dinner, and day 11 through 15, add a dose to lunch, and day 16 through 20, add a dose to bedtime. By gradually increasing this, it will help in slowing down the stool because it has formed like a food bolus with the food that the patient just took in and slows everything down. It will not help the patient to take this fiber in between meals. Sometimes patients misunderstand and they eat their breakfast and they don't drink for an hour afterwards, and they're taking their fiber at 10:00 a.m. in the morning. That won't work. They have to take it immediately after so it forms that food bolus. Okay, the other thing that we encourage patients to do is limit their fluid at mealtime to 8 ounces. Because if they drink too much with their meals, it's going to give them the urge to have a bowel movement, and they'll have frequent stooling. And we ask them to drink in between meals. And then we ask them to eliminate hot liquids because hot liquids tend to increase GI motility and give you the urge to have a bowel movement. So we take away all hot liquids, and this includes coffee, tea, hot chocolate, even hot soup. Sometimes people don't relate hot soup to causing a problem, but it can. And then what we're going to do is start, after their stools slow down and form up, then we put them on a bowel training program at --- to slow down the frequency.
And the bowel training consists of this: once the stool is formed and frequency slows, then we ask them to eat a big breakfast, and then drink a hot liquid. So here's where we bring the hot liquid back. If that is not effective after three days, we always need to try something new with the bowels and let it kind of adjust for three days, and then if it's not effective, add 2 ounces of prune juice before breakfast, and then eat the big breakfast and drink the hot liquid. And it's like a gradual titration to --- to do what is needed to help the patient.
Now what I would like to discuss with you is fecal incontinence in the United States. And this occurs with diarrhea and, of course, constipation, but we do know that --- that fecal incontinence affects up to 5% of the general population. It affects 39% of nursing home residents. And it affects 33% of patients in acute care facilities. Fecal incontinence has been documented as one of the most common risk factors for pressure ulcer development. And so this is something we want to prevent in our patients.
If you want to collect the feces you --- and you want to consider a temporary fecal collection pouch, here are some ideas on the parameters to use: diarrhea has been undermanaged, and there is a potential to get it under control within a few days. You want to use something kind of temporary --- a temporary device --- if you have not adequately tried to control your diarrhea, and if there is a potential to get it under control. If the skin is in good condition, because the temporary fecal collection can have a --- a adaptive --- or an adhesive material that goes around the anus, and if the skin is in good condition, you can use a temporary fecal collection pouch. Okay, if the patient doesn't need medications administered through the rectum, this is a good fecal collection method for temporary use.
Okay, but, if you are considering long-term fecal collection for an incontinent diarrhea; the diarrhea is refractory to optimum treatment; the skin is compromised, the patient's diarrhea condition has a potential for existing indefinitely -- and this happens very frequently in our graft-versus-host disease population; the patient needs rectally administered medications; the patient is bedridden and sedated;...
...the patient has two to three at least liquid stools per day; the patient can't tolerate frequent repositioning (and this is common in our intensive care unit patients); patients with urinary catheter or other lines that are at risk for infection, or burns or donor sites or wounds likely to be contaminated by feces; if the patient has an infectious diarrhea like C. difficile; if formed stool needs to be liquefied and collected so that there's no contamination taking place; then the ---
then there is an ActiFlo bowel management system available. It is put out by Hollister, and this is just an example of what can be used to provide a protection for the patient under the former circumstances that I was describing to you. It's a very safe tube to put in. It's like a Foley catheter but it has been devised by a physician who has manufactured this to be able to not promote necrosis of the an --- anus and the rectal wall. And so, this is a very safe example of an indwelling device.
Contraindications to an ActiFlo bowel management system are: you wouldn't put anything like that where you would inflate a balloon if there is a mass in the rectum or surgical removal of the distal rectum (if it's not there), okay; if the patient has a radiation injury or proctitis or enteritis or scarring of distal rectum and anal canal; if the patient has a fecal impaction, you have to remove the fecal impaction first before you would put something like that in; and if the patient had recent rectal surgery (less than 2 months ago) then you would not want to use it; and lack of trying to see if the patient's diarrhea is refractory to treatment, because something like this can stay in for 29 days. If you only need it for two or three days, you want the temporary device. If the patient has weak sphincter function, even inflating a balloon in the rectum is not going to keep it in if the rec --- if the anal sphincter is very flaccid; and if the patient's platelets are below 50,000.
So in summary, you have learned about: fluid and dietary ideas to minimize stool frequency; you've learned about different drugs available for anti-diarrhea management; you've learned about the management of chemotherapy- and radiation therapy-induced diarrhea; how to preserve sph --- sphincter function through the anal sphincter exercises known as Kegel exercises; and the availability of stool collection or stool management device. I thank you for your attention.
Treating Diarrhea video
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