Diarrhoea
Questions
- What chemotherapy is the patient on and when was the last treatment/tablet?
- Is the patient on any of the following: Atezolizumab, Ipilimumab, Nivolumab, Pembrolizumab, Tremelimumab, Capecitabine, Erlotinib, Irinotecan, Pemetrexed?
- Is the patient receiving radiotherapy? On what part of their body? When was the last treatment?
- What is normal bowel habit?
- How many stools a day is the patient passing or how much stoma output is there above normal amount?
- Are stools/stoma output formed, loose or watery? Any faecal incontinence/urgency? Nocturnal movements?
- Is there any abdominal pain?
- For how many days has the patient had diarrhoea? Is it interfering with activities of daily living?
- Is the patient able to eat and drink normally? Is the patient passing clear urine?
- Does the patient have any other chemotherapy toxicities , e.g. mouth ulcers, N/V, PPE, stomatitis, mucositis?
- Any recent antibiotic treatment or hospital admissions?
- Have they taken any laxatives or anti-sickness medication or anti-diarrhoeal medication within the last 24 hours?
Grade 1 (Green)
Increase of 2-3 stools/day over pre-treatment baseline.
Or mild increase in stoma output
Advice
Stop oral anticancer treatment until AOS review
Dietary modification:
- avoid lactose containing products, spices, high fibre foods, high-fat foods, caffeine, alcohol, fruit juices
- encourage fluid intake (8-10 glasses of clear water)
- small frequent meals (banana, toast, rice, pasta)
Keep anal area clean and intact
Consider Loperamide 4 mg followed by 2 mg every 2 hours, up to 16 mg in 24 hours or codeine phosphate if ineffective
Phone daily until patient improves.
Patient MUST phone if diarrhoea worsening
Grade 2 for > 24 hours despite max anti-diarrhoeal or if other symptoms
Take immediate action as for grade 3/4
Grade 2 (Amber)
Increase of 4-6 stools/day over pre-treatment baseline.
Or moderate increase in stoma output.
Moderate cramping or nocturnal stool
Advice
Stop oral anticancer treatment until AOS review
Dietary modification:
- avoid lactose containing products, spices, high fibre foods, high-fat foods, caffeine, alcohol, fruit juices
- encourage fluid intake (8-10 glasses of clear water)
- small frequent meals (banana, toast, rice, pasta)
Keep anal area clean and intact
Consider Loperamide 4 mg followed by 2 mg every 2 hours, up to 16 mg in 24 hours or codeine phosphate if ineffective
Phone daily until patient improves.
Patient MUST phone if diarrhoea worsening
Grade 2 for > 24 hours despite max anti-diarrhoeal or if other symptoms
Take immediate action as for grade 3/4
Grade 3 (Red)
Increase of 7-9 stools/day over baseline or incontinence.
Or severe increase in stoma output.
Severe cramping, nocturnal stool interfering with ADL
Advice
Review all medications and STOP DRUGS that may be contributing to diarrhoea, including anti cancer treatment
Admit patient
Take stool sample
FBC, U&E
Grade 4 (Red)
Increase of >10 stools/day over baseline and/or grossly bloody diarrhoea and/or need for parenteral support
Advice
Review all medications and STOP DRUGS that may be contributing to diarrhoea, including anti cancer treatment
Admit patient
Take stool sample
FBC, U&E
Handover management with patient’s team, discuss all interruptions of treatment with team +/- AOS prior to proceeding. Arrange follow up review as necessary
Initial assessment – patient seen in AOCU
- Read specific drug information sheet in addition to general diarrhoea guidance
- Interrupt SACT/chemotherapy including oral chemotherapy drugs, if applicable, ensure discussed with the Acute Oncology Service Team and/or treating team.
- Initial assessment
- Observation: temperature, Pulse, Saturation of Oxygen, respiration rate. Early Warning Score (NEWS)
- Investigations: FBC, U&E, CRP, abdominal X-Ray, Stool sample for C&S
Treatments
Initial Management
- Consider infective diarrhoea – isolate until infection ruled out
- Pyrexia (T> 38°C) – initiate neutropenic sepsis protocol – do not wait for FBC
- If on immunotherapy discuss with gastroenterology team for management of colitis
- Send stool sample and inform microbiology and discuss management with microbiologist
- Withhold anti-diarrhoeal treatment if haematology patient or strong suspicion for infective diarrhoea
- Replace fluids and electrolyte loss
- Adjust on-going fluids according to fluid balance status and renal function
- Stop ACE-inhibitors, diuretics, NSAIDs
Anti-diarrhoeal
- Haematology – discuss with haematology team on call before starting anti-diarrhoeal
- Oncology – Consider Loperamide 4 mg after the 1st loose movement and 2 mg following each loose stool (max 16 mg per 24 hours)
- If Loperamide ineffective, consider codeine phosphate 30-60 mg every 4 hours (max 240 mg per 24 hours) instead or in addition
- Reduce/stop anti-diarrhoeal after 12 hours free of diarrhoea
- If grade 4 – Octreotide 500 mcg by sc injection on admission, then 300 mcg TDS and immediate IV broad spectrum antibiotics . Withhold if not on maximum anti-diarrhoeal treatment at admission but review every 24 hours
- Consider buscopan if abdominal cramps
- Nil by mouth if abdominal distension or abnormal AXR
- Do not withhold anti-diarrhoeal for more than 12-24 hours without thorough senior medical review
- Antibiotics as per local policy
