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

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

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

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

5. Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

6. Pathophysiology l 7 to 9 liters of fluid reach the large intestine daily l Loose stools occur if even less than100 ml not absorbed l Chemotherapy: damaged intestinal mucosa and increased fluid overwhelm large bowel capacity  Irinotecan has cholinergic effect l 7 to 9 liters of fluid reach the large intestine daily l Loose stools occur if even less than100 ml not absorbed l Chemotherapy: damaged intestinal mucosa and increased fluid overwhelm large bowel capacity  Irinotecan has cholinergic effect

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

8. Assessment l History o What is “normal” for the patient? o Description of stool (consistency, frequency, volume, blood, etc.) o Onset and duration of diarrhea o Presence of weight loss o Systemic symptoms o Medications can be causative (including chemotherapy) l Physical o Examine for signs of dehydration, fever l History o What is “normal” for the patient? o Description of stool (consistency, frequency, volume, blood, etc.) o Onset and duration of diarrhea o Presence of weight loss o Systemic symptoms o Medications can be causative (including chemotherapy) l Physical o Examine for signs of dehydration, fever

9. Management l Establish normal bowel pattern l Avoid gas-forming foods  e.g., milk (lactose) l Increase bulk l Transient, mild diarrhea  Attapulgite  Bismuth salts l Establish normal bowel pattern l Avoid gas-forming foods  e.g., 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 o Loperamide 4 mg then 2 mg q 2 h until diarrhea-free for 12 hours o 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 o Loperamide 4 mg then 2 mg q 2 h until diarrhea-free for 12 hours o 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. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.