Diarrhoea
Diarrhoea
Appropriate assessment to identify cause and severity of symptoms
Explanation to patient and family at all stages
Consider disease-specific palliative therapy
Institute non-pharmacological interventions
Prescribe appropriate first-line treatment
Diarrhoea is an increase in the frequency of defaecation and/or fluidity of the faeces. If severe, it may manifest as faecal incontinence. In palliative care diarrhoea can be acute (less than 14 days) or chronic (lasting more than 2 weeks). In HIV diarrhoea may be due to the HIV infection itself and a causative organism of infective diarrhoea may not be evident.
Appropriate assessment to identify cause and severity of symptoms
The presence of fever or blood in the stools are indications for microscopy to identify an infective cause of diarrhoea. Depending on the duration and severity of the diarrhoea, a limited non-invasive diagnostic workout is appropriate e.g. stools for culture and sensitivity, acid-fast bacilli, ova, parasites, clostridium difficile toxin. CMV should be considered in patients with CD4 count less than 50.
It is important to assess for signs of dehydration.
Causes
| Laxative overdose Faecal impaction with overflow Partial obstruction Radiation enteritis Steatorrhoea Drugs including some HAART drugs | Antibiotics Gastro-enteritis, mainly ciral Infections: salmonella, giardia, campylobacter, clostridiumdifficile, cytomegalovirus, cryptosporidium and microsporidium |
Explanation to patient and family at all stages
Explain the cause of the diarrhoea and the importance of maintain good hydration.
Correct reversible factors
Appropriate antibiotics for infective diarrhoea.
If inappropriate laxatives have been used adjust laxative treatment accordingly.
Consider disease-specific palliative therapy
HAART for patients who are HIV positive.
Institute non-pharmacological interventions
Review diet. Improve hydration for home-based care patients. Boil one litre of water, add 8 level teaspoons of sugar and half-teaspoon salt. Allow the mixture to cool and give a cup full of the mixture every time the patient has diarrhoea.
Patients who have undergone a colectomy continue to experience diarrhoea and will require an extra 1 litre of fluid daily, additional salt, vitamin and iron supplements.
Prescribe appropriate first-line treatment
Loperamide 4mg stat and 2mg after each loose stool (do not exceed 16 mg in 24 hours).
In severe chronic diarrhoea in seriously ill patients use codeine phos 60mg tds or morphine suspension 5-10mg 4 hourly.
Monitor the patients especially when fluid intake is inadequate.
Octreotide (sandostatin) is a synthetic somatostatin analogue that is approved for the treatment of profuse diarrhoea and is effective in treating diarrhoea in HIV patients. The disadvantage is the high cost and it has to be administered subcutaneously.
For pancreatic deficiency, pancreatin may help; preparation of choice is creon.
Drugs for treating diarrhoea
| DISEASE | TREATMENT |
| Acute radiation enteritis | NSAID Octreotide |
| Steatorrhoea | Pancreatin supplements |
| Cholegenic diarrhoea | Colestryramine (an anion exchange resin) |
| Pseudo-membranous colitis | Metronidazole Vancomycin |
| Ulcerative colitis | Sulfasalazine Corticosteroids |
| Infection | Appropriate antibiotic |
| CMV (Cytomegalovirus) | Ganciclovir/cytovene Foscarnet/foscavir Cidofovir/visitide Valganciclovir/valcyte |
| NON-SPECIFIC TREATMENT | |
| Absorbents | Hydrophilic bulking agents Pectin |
| Adsorbents | Kaolin Chalk Activated charcoal |
| Mucosal PG inhibitors | Aspirin Bismuth subsalicylate |
| Opioids | Codeine Morphine Diphenoxylate Loperamide |
| Somatostatin analogues | Octreotide |
Review assessment and management regularly.
At all stages of management consider
Involvement of interdisciplinary team including dietician.
Referral to appropriate service/more experienced clinician.