Diarrhoea

Diarrhoea is defined as the passage of more than 3 episodes of unformed stools in a day.

Problems that can result from diarrhoea

• Distress
• Dehydration
• Electrolyte imbalance
• Malnutrition and pressure ulcers

• Gastroenteritis
  • Viruses
  • Common bacteria (e.g. E. coli, Campylobacter, Salmonella)
• Clostridium difficile
  • Cancer patients are prone to this as they are immune-compromised and often receive multiple broad spectrum antibiotics
  • Treat with oral Metronidazole 400mg t.d.s.
• Enteral feeding
  • Can cause diarrhoea in 10-60% of patients due to high osmotic content, rapid or high volume feeding and hypoalbuminaemia
  • Switching to high fibre feeds like Jevity may help
• Tumour-related causes
  • Rectal cancers commonly secrete mucus that may present as diarrhoea
  • Pancreatic cancer causing pancreatic or biliary obstruction can cause diarrhoea
  • Rare causes include VIPomas (vasoactive intestinal peptide) and gastrinomas
• Treatment-related causes
  • Chemotherapy-related – Drugs or neutropenic enterocolitis
  • Radiotherapy-related – Acute radiation enterocolitis occurs within the first six weeks of radiotherapy. Chronic radiation enterocolitis occurs months to years after radiotherapy.
• Post-surgical
  • Extensive bowel resection causes reduced water absorption band diarrhoea
• Post-procedural
  • Coeliac plexus block can lead to loss of sympathetic tone and acute diarrhoea

Non-pharmacological measures

• Avoid dairy products
• Use oral rehydration salts or isotonic drinks
• Replace electrolyte and fluid losses
• Prevent pressure ulcers with barrier creams, pressure-relieving mattresses and regular turning

Pharmacological measures

• Loperamide 2-4mg t.d.s. (up to max. 16mg/day)
• Hyoscine butylbromide (Buscopan) 20mg b.d.–q.d.s.
• Codeine 30-60mg t.d.s.–q.d.s.
• AVOID Lomotil (Diphenoxylate/Atropine) in the elderly as Atropine may cause delirium
• Subcutaneous Octreotide infusion 300-800mcg/24h for diarrhoea uncontrolled by the above agents eg short gut syndrome.

Note : Do not use anti motility agents in infectious diarrhoea
If symptoms are not controlled with measures outlined here, please consult your local palliative care service.

• Andreyev J, Ross P, Donnellan C, Lennan E, Leonard P, Waters C, et al. Guidance on the management of diarrhoea during cancer chemotherapy. Lancet Oncol. 2014 Sep;15(10):e447-e460.
• Hum A, Koh M. The Bedside Palliative Medicine Handbook. Singapore: Armour Publishing; 2013.