Chemotherapy induced diarrhoea

• 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/pro-kinetics e.g. metoclopramide, domperidone
• General care: Remember patients are at risk of low albumin, neutropenia, sepsis, ileus, pseudo-obstruction, prolonged illness or even death so thorough daily reviews are essential 

• History of recent SACT agents including dates of administration, as well as full drug history.
• History of 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 stool frequency, timing (?nocturnal), volume, consistency and colour of stools, incl blood and mucous in stool. Ask about recent constipation, consider overflow diarrhoea - PR exam may be helpful.
• Assessment of fluid balance status (BP, pulse etc) and signs of systemic infection. 
• Clinical observations (NEWS, daily weights, cumulative fluid balance chart).
• 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). If significantly immunocompromised, send CMV PCR. 
• Abdominal XR to exclude ileus/obstruction/perforation/megacolon
• Careful examination of mucous membranes. 
• Establish Bristol Stool Chart monitoring (patient may be best placed to complete this).

• Send stool sample urgently. Inform microbiology and discuss management with microbiologist as appropriate. If significantly immunocompromised, send CMV PCR. 
• If haematology patient, withhold anti-diarrhoeal medication until stool result available. 
• If oncology patient, unless there is a strong suspicion of infective diarrhoea, give anti-diarrhoeals before stool result known.
• Do not withhold anti-diarrhoeals for more than 12-24 hours without thorough senior medical review.
• Give antibiotics according to local policy (e.g. 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. 
• Nil by mouth if vomiting, abdominal distension, abdominal tenderness or obstruction on AXR. 

• STOP laxatives and pro-kinetics e.g. metoclopramide
• STOP nephortoxics or fluid depleting drugs e.g. ACE-inhibitors/diuretics/NSAIDs.
• STOP 5-FU/capecitabine chemotherapy, TKIs and EGFRIs if grade ≥2 diarrhoea. 

• START anti-diarrhoeals (exclude infection by stool sample first if haematology patient/high suspicion of infection):  
  • Loperamide - give 4mg on admission then 2mg with every loose stool. If ≥7 stools/24hrs, give loperamide regularly 4mg QDS. If concerned about absorption, prescribe as loperamide oral melts
  • Add regular codeine 30-60mg QDS if loperamide ineffective, or PRN in addition to loperamide depending on diarrhoea/hydration. Caution in renal or hepatic impairment, or previous sensitivity to Codeine. May have limited value if already on significant doses of other opiates but to be considered on individual patient basis.
  • Octreotide
    • Grade 3 diarrhoea: 150mcg SC stat then 150mcg SC TDS or 500mcg/24 hours via subcutaneous infusion
    • Grade 4 diarrhoea: 500mcg SC stat, then octreotide 300mcg SC TDS.  
• START appropriate anti-emetics if nauseated – consider ondansetron/granisetron +/- cyclizine
• START hyoscine butylbromide (buscopan) 20mg orally or SC PRN vs bowel spasms/cramps if present.

• Indication for antibiotics: 
  • Pyrexia (temp > 38⁰C) - start neutropenic sepsis antibiotic policy immediately – do not wait for FBC. Low threshold to perform CT abdomen/pelvis if source unclear. 
  • If Grade 4 diarrhoea or on irinotecan – give broad spectrum antibiotics.
  • If proven infective diarrhoea on stool culture, treat appropriately

• If infective diarrhoea is confirmed on stool culture, discontinue anti-diarrhoeals and refer to specific infection guidance e.g. Clostridium difficile checklist
• Close monitoring of clinical observations (NEWS, daily weights, cumulative fluid balance chart) with prompt action if deterioration. 
• At least daily medical review
• Daily FBC, U+E, magnesium, albumin
• Titrate anti-diarrhoeals every 12-24hrs to effect
• If pyrexial but not neutropenic, culture and give antibiotics according to patient’s condition and local guidelines.
• Consider early dietician involvement and nutritional support e.g. total parenteral nutrition (TPN).
• Ensure admission is reported to oncology tumour group team and annotated in chemocare so that next SACT dose can be delayed/altered as appropriate.

• Ensure prescribed regular loperamide and codeine phosphate as above. 
• Give regular hyoscine butylbromide 20mg oral/SC QDS. 
• Increase octreotide dose incrementally (depending on response) every 12-24 hrs to max 1500mcg/24hours (best given via 24 hour SC pump) until diarrhoea slows.
• Careful review of fluid balance/daily weight/electrolytes/albumin/nutrition. Consider early involvement of dieticians for nutritional support e.g. TPN. 
• LOW threshold for repeat Abdominal X-ray +/- CT Abdomen/Pelvis in context of patient being systemically unwell, ongoing/worsening abdominal pain or tenderness on examination, distension, diarrhoea not settling, raised lactate.
• Refer to surgical team if peritonism, bowel loop dilatation or other concerns on imaging
• Discuss with seniors/HDU/ITU if concerns

Patients can deteriorate quickly with SACT-induced diarrhoea but should fully recover. It should be considered iatrogenic and potentially reversible. Early discussions with HDU/ITU teams are appropriate if patient is deteriorating.

• Octreotide: reduce then stop as soon as diarrhoea improving. Assess every 6-12hrs due to risk of ileus with prolonged use. 
• Reduce frequency/dose of loperamide and codeine, then give on a PRN basis rather than regularly to avoid constipation.  
• Start oral fluids then light diet as tolerated. See "General advice for patients with SACT-related diarrhoea" section above for dietary advice. 
• Discharge when symptoms settled and tolerating diet.

• Contact specialist oncology team supervising cancer treatment. 
• Contact the on call oncology registrar via the Western General Hospital switchboard on 0131 537 1000. On call registrar will annotate update on chemocare.