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Fast Fact and Concept #96: Diarrhea in Palliative Care

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Title: Fast Fact and Concept #96: Diarrhea in Palliative Care

Author(s): Jeffrey Alderman, MD

Diarrhea is a debilitating and embarrassing problem, defined as an abnormal looseness of the stools (increased liquidity or decreased consistency). Patients with uncontrolled diarrhea are at increased risk for dehydration, electrolyte imbalance, skin breakdown, and fatigue.

Common Causes Diarrhea can usually be divided into different types and treatment will vary depending on cause: Secretory, Osmotic, Mechanical or Motility disorder. In palliative care, the overuse of laxatives, typically seen when the management of constipation is suddenly ?stepped up? is a common cause. Other causes include partial intestinal obstruction, fecal impaction, pancreatic insufficiency, Clostridium difficile infection, chemotherapeutics, and radiation enteritis. Infectious diarrhea is especially common in HIV infection (Cryptosporidia, Giardia lambila, E. histolytica, and Cytomegalovirus.)

Evaluation: review diet, medications, laxatives, procedures, timing of movements in relation to ingestion of food or liquids, and a description and quantity and quality of stool. When performing a physical exam, make sure to palpate the abdomen and do a rectal exam. Radiographs are often not necessary, but may help clarify a partial bowel obstruction. Keep in mind that patients at the end-of-life are also at risk for developing the same diarrheal illnesses that occur everyday in the general population (viral/bacterial gastroenteritis, adverse effects of medications).

Treatment -- General: Ensure adequate hydration; encourage sips of clear liquids; IV hydration should be considered for severe dehydration. Simple carbohydrates, toast or crackers, will add back small amounts of electrolytes and glucose; milk and other lactose-containing products should be avoided.

Medications include bulk forming agents, antimicrobials, absorbents, and narcotics: Kaolin and Pectin (Kaopectate®) is a suspension of adsorbent and bulk-forming agents, which can provide modest relief from diarrhea. However, Kaolin-Pectin may take up to 48 hours to produce an effect and can interfere with the absorption of certain medications. Antibiotics Infectious diarrhea should be identified and treated with appropriate antibiotics. Bismuth has an additional antimicrobial effect, and can be added for increased symptomatic control against organisms such as enterotoxigenic E. Coli. Loperamide (Imodium®) reduces peristalsis in the gut, increases water reabsorption, and promotes fecal continence, making it a potent anti-diarrheal agent. Because it only weakly crosses the blood-brain barrier, loperamide?s side effect profile is more favorable than other opioids (e.g. codeine or diphenoxylate (Lomotil®)). The initial dose of Loperamide is 4 mg, with titration to 2 mg after each loose stool, with the typical dose being 4 ? 8 mg per day. Although the package insert recommends a maximum of 16 mg in a 24-hour period, up to 54 mg per day of loperamide has been used in palliative care settings with few adverse effects (see Oxford Textbook). Note: loperamide should be used with caution if an infectious diarrhea is suspected. Aspirin and Cholestyramine can reduce the diarrhea in radiation-induced enteritis, as can addition of a stool bulking agent such as psyllium (Metamucil, others), while Mesalamine is good at treating flares of ulcerative colitis. Pancrelipase. Is used for pancreatic insufficiency. Although costly, Octreotide is effective with profuse secretory diarrhea seen in HIV disease, and those with high effluent volume from a stoma. It may be given via continuous subcutaneous infusion at a rate of 10 ? 80 ?g every hour until symptoms improve.

References:

Oxford Textbook Palliative Medicine. 2nd ed. 1998. Oxford. U. Press, NY, pp. 521-525. Fallon M. O'Neill B. ABC of palliative care. Constipation and diarrhoea BMJ. 1997; 315:1293-6.

Saunders DC. Principles of symptom control in terminal care. Med Clin North Amer 66): 1175, 1982.

Mercadante, S in Principles and Practice of Palliative Care and Supportive Oncology. 2nd Edition, Lippincott, pp 233-237

McEvoy, GK, Editor, AHFS Drug Information-2003. American Society of Health-System Pharmacists, Bethesda, MD, pp.2740-41

Ruppin H. Review: loperamide--a potent antidiarrhoeal drug with actions along the alimentary tract. Alimentary Pharmacology & Therapeutics. 1(3):179-90, 1987 Jun.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Alderman J. Fast Facts and Concepts #96 Diarrhea in palliative care. August 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 8/2003

Format: Handouts

Purpose: Instructional Aid

Audience(s)
Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Cardio-pulminary, Constitutional, Gastrointestinal, Metabolic, Musculoskeletal, Neurologic, Non-pain symptoms/disorders/syndromes, Oral/communication, Psychiatric, Sexuality and reproduction, Skin/lymphatic, Kaopectate, Imodium, Lomotil


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