II. Causes: Chemotherapy-Induced Diarrhea
- Fluoropyrimidines (e.g. 5-FU)
- Irinotecan
- Immunotherapy
- Other agents
III. Evaluation
- Identify a cause!
- Clostridium difficile
- Cytomegalovirus Infection
- Reactivation of latent Viral Hepatitis
- See Chemotherapy causes above
- Often associated with Radiotherapy near bowel (Abdomen, Pelvis, Rectum)
- See Radiation Colitis
- Consider bowel ischemia or perforation (esp. if bleeding)
- Other common complications of Chemotherapy
IV. Labs
- Complete Blood Count with differential
- Comprehensive metabolic panel
- C-Reactive Protein
- Blood Cultures (indicated if fever present)
- Enteric Bacteria PCR (consider)
-
Clostridioides difficile testing indications
- Prolonged hospitalization
- Advanced age
- Recent Antibiotic use
- Feeding Tubes
- Proton Pump Inhibitors
V. Imaging
- Consider CT Abdomen if associated with Abdominal Pain
VI. Management
- Discuss with patient's oncologist
- Fluid Resuscitation and Electrolyte replacement
- Antiemetics (e.g. Ondansetron)
- Antidiarrheals (e.g. Loperamide) AFTER infectious cause excluded
- Loperamide 4 mg, then 2 mg for every loose stool (max 16 mg/day)
- Octreotide 100-150 mcg SQ three times daily (or start 25-50 mcg IV three times daily up to 500 mcg tid)
- Indicated in Loperamide resistant Diarrhea, to reduce colon secretions
- Antispasmodics for abdominal cramping
- Other agents (if infection excluded)
- Corticosteroids (e.g. Rectal Budesonide)
VII. Prevention
- Lactobacillus with Radiation Therapy or Chemotherapy
VIII. Course
- Anticipate Radiotherapy related Diarrhea for 1-2 weeks