Causes and Treatment of Diarrhea in Hospice

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Definition

An abnormal looseness of the stools (increased liquidity or decreased consistency). A standard medical definition is the passage of more than 3 unformed stools in 24 hours. Uncontrolled diarrhea can cause dehydration, electrolyte imbalance, skin breakdown, and fatigue. Understanding its causes, prevention, and treatment will help most people find relief.

Causes

  • laxative use
  • inflammation of the mucosa from chemotherapy
  • inflammation of the mucosa from radiation therapy
  • inflammation of the mucosa from infection (including c-Diff)
  • carcinoid Syndrome
  • some types of cancer: colon, pancreatic, biliary, lymphoma
  • short bowel syndrome
  • post surgical: colon resection, cholecystectomy
  • inflammatory bowel disease
  • virus
  • fecal impaction
  • food intolerance
  • medication side effects
  • psychological

Assessment

History

  • onset, acute or chronic diarrhea
  • precipitating/relieving factors
  • timing
  • what diseases/illness does this person have that may cause the diarrhea
  • medications (esp. antibiotics, chemotherapy), radiation therapy in past year
  • review of diet
  • food intolerance
  • previous bowel movements (how often, routine toileting), Last Bowel movement (LBM)
  • frequency and volume of stools
  • associated symptoms (nausea, cramping, fever, gas),
  • anxiety
  • social/spiritual concerns
  • medical equipment that may be helpful (BSC, bedpan, etc)
  • impact on functionality
  • quality of life

Physical Exam

  • appearance of patient
  • auscultation of bowel sounds
  • palpate abdomen for tenderness
  • digital rectal exam
  • signs of dehydration, infection
  • appearance of stool: liquid, color, presence of blood or mucus
  • perianal skin integrity/irritation

Non Pharmacological Interventions

  • Stop offending agent (if known & possible)
  • Clear liquid or BRAT (Bananas, Rice, Apples, Tea, Toast) diet
  • Avoid stimulating agents: caffeine, lactose products, spicy food, high fiber or high fat foods.
  • Avoid large meals: eating small frequent snack size portions
  • Avoid fresh fruits and vegatables
  • Maintain hydration and electrolyte replacement (Gator-Ade®Pedialyte®, broth, caffeine free soft drinks)
  • Advance diet slowly as diarrhea subsides
  • Perianal skin care

Pharmacological Interventions

Pharmacological treatment should be based on relieving cause of diarrhea whenever possible. Resolution of underlying factor(s) should be primary goal whenever possible. If no signs/symptoms of an infection are present:

  • Lomotil (Diphenoxylate/Atropine) 2.5 mg tablet: 2 tablets x 1 dose, then 1 tablet after each loose stool. Not to exceed 8 doses in 24h.
  • Imodium (Loperamide) 2 mg tablets: 2 tablets x 1 dose, then 1 tablet after each stool. Not to exceed 8 doses in 24h.

If C-Diff is the cause:

  • Flagyl (Metronidazole) 250 mg or 500 mg tablets: 1 tablet TID/QID for up to 14 days
  • Vancomycin 125 mg tablets: 1 tablet QID for up to 10 days

For cramping symptoms related to diarrhea:

  • Levsin (Hyoscyamne) 0.125- 0.25 mg every 6h PRN

Other:

  • Cholestyramine can reduce the diarrhea in radiation-induced enteritis, as can addition of a stool bulking agent such as psyllium (Metamucil)
  • Mesalamine is good at treating flares of ulcerative colitis.
  • Pancrelipase May be used for pancreatic insufficiency induced diarrhea

Utilize team collaboration in assessment, intervention and education with the patient and family.

 

Evaluate and Document symptom at each visit until resolved. Evaluate discontinuing medications as symptoms resolve.

References

Clinical Practice Guidelines: The Hospice of the Florida Suncoast (2008).

 

Economou DC. Bowel management: constipation, diarrhea, obstruction and ascites.

In: Ferrell B & Coyle N, eds Textbook of Palliative Nursing 2nd ed, pp 219- 238. Oxford University Press, 2006.

 

Grauer P, Shuster J & McCrate-Protus B. (2008). Palliative Care Consultant: A reference guide for palliative care 3RD ed.

Kendall/Hunt publishing, 2007.

 

Kuebler KK, Davis MP & Moore CD. (2005). Palliative Practices: An Interdisciplinary Approach. Elsevier/Mosby: Missouri.

 

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

 

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

 

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

 

Sykes, N, Diarrhoea. In: Doyle D, Hanks G, Cherny N, Calman K eds Oxford 

Textbook Palliative Medicine. 3rd ed. pp. 490 -496, Oxford University, 2005.

 

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