# 096 diarrhea in palliativ.

# 096 Diarrhea in Palliative Care, 2nd ed http://www.mcw.edu/EPERC/FastFactsIndex/Documents/96DiarrheainPal.
FAST FACTS AND CONCEPTS #96
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 disordered motility. 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, pancreatic insufficiency, Clostridium difficile infection, chemotherapeutics,
and radiation enteritis. Infectious diarrhea is especially common in HIV infection (Cryptosporidia, Giardia lambila,
E. histolytica, and Cytomegalovirus). Severe constipation and fecal impaction can also cause diarrhea as
backed-up, liquefied stool may be all that the patient can pass (‘overflow diarrhea’).
Evaluation Review diet, medications, laxatives, procedures, timing of movements in relation to ingestion of food
or liquids, and a description of 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 or overflow diarrhea. 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
Treatment
General Ensure adequate hydration; encourage sips of clear liquids; parenteral hydration should beconsidered for severe dehydration. Simple carbohydrates, toast or crackers, will add back small amounts ofelectrolytes and glucose; milk and other lactose-containing products should be avoided.
Medications include bulk forming agents, antimicrobials, adsorbents, and opioids.
Kaolin and Pectin (Kaopectate®) is a suspension of adsorbent and bulk-forming agents, which canprovide modest relief from diarrhea. However, kaolin-pectin may take up to 48 hours to produce aneffect and can interfere with the absorption of certain medications.
Antibiotics: infectious diarrhea should be identified and treated with appropriate antibiotics, particularlyC. difficile enteritis.
Bismuth has an additional antimicrobial effect, and can be added for increased symptomatic controlagainst organisms such as enterotoxigenic E. Coli.
Loperamide (Imodium®), an opioid, reduces peristalsis in the gut, increases water reabsorption, andpromotes fecal continence, making it a potent anti-diarrheal agent. Because it only weakly crosses theblood-brain barrier, loperamide’s side effect profile is more favorable than other opioids (e.g. codeineor diphenoxylate [Lomotil®]). The initial dose of loperamide is 4 mg, with titration to 2 mg after eachloose stool, with the typical dose being 4 – 8 mg per day. Although the package insert recommends amaximum of 16 mg in a 24-hour period, up to 54 mg per day of loperamide has been used in palliativecare settings with few adverse effects. Note: loperamide should be used with caution if an infectiousdiarrhea is suspected.
# 096 Diarrhea in Palliative Care, 2nd ed http://www.mcw.edu/EPERC/FastFactsIndex/Documents/96DiarrheainPal.
Aspirin and Cholestyramine can reduce the diarrhea in radiation-induced enteritis, as can addition of astool bulking agent such as psyllium (Metamucil ).
Mesalamine and other antiinflammatories are used for inflammatory bowel disease.
Pancreatic Enzymes such as pancrelipase are used for pancreatic insufficiency.
Octreotide, although costly, is effective with profuse secretory diarrhea seen in HIV disease, and thosewith high effluent volume from a stoma. It may be given via continuous subcutaneous infusion at a rateof 10 – 80 mcg every hour until symptoms improve.
References
1. Doyle D, et al, eds. Oxford Textbook of Palliative Medicine. 3rd ed. New York, NY: Oxford University Press; 2. Fallon M, O'Neill B. ABC of palliative care. Constipation and diarrhoea. BMJ. 1997; 315:1293-6.
3. Saunders DC. Principles of symptom control in terminal care. Med Clin North Amer. 1982; 6: 1175.
4. Berger A, et al, eds. Principles and Practice of Palliative Care and Supportive Oncology. 3nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
5. McEvoy GK, ed. AHFS Drug Information 2003. Bethesda, MD: American Society of Health-System 6. Ruppin H. Review: loperamide--a potent antidiarrhoeal drug with actions along the alimentary tract.
Alimentary Pharmacology & Therapeutics. 1987; 1(3):179-90.
Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of
Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of
Fast Facts, are available at EPERC: www.eperc.mcw.edu.
Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition was edited by Drew A
Rosielle and published November 2007. Current version re-copy-edited April 2009.
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational
purposes only. Alderman J. Diarrhea in Palliative Care, 2nd Edition. Fast Facts and Concepts. October 2007; 96.
Available at: http://www.eperc.mcw.edu/fastfact/ff_096.htm.
Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice.
Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a
product in a 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.
ACGME Competencies: Medical Knowledge, Patient Care
Keyword(s): Non-Pain Symptoms and Syndromes
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