Page 35 Complete Your CE Test Online - Click Here and liver are commonly affected. Acute GVHD usually manifests within 100 days after transplant, although it can occur as early as 7 to 10 days after transplant. Symptoms of gastrointestinal GVHD include nausea and vomiting, severe abdominal pain and cramping, and watery diarrhea. The volume of accompanying GVHD-associated diarrhea may reach up to 10 liters per day and indicates the degree and extent of mucosal damage. It may resolve or develop into a chronic form requiring long-term treatment and dietary management. Diarrhea with pain and fever may mean neutropenic enterocolitis. Some of the more severe cases of diarrhea may be caused by neutropenic enterocolitis (also known as necrotizing enterocolitis or typhlitis). Symptoms typically start 10 to 14 days after starting cytotoxic chemotherapy, especially cytosine arabinoside, vinca alkaloids, and doxorubicin. There have been reports linking it to alemtuzumab, pegylated interferon, anthracyclines, and a number of other chemotherapy drugs as well. Neutropenic enterocolitis is often a missed diagnosis because it may present like appendicitis at first, and there is no official case definition. Symptoms include right lower quadrant pain, fever, watery or bloody diarrhea (in about a quarter to a half of patients), nausea, vomiting, and bloating. Inflammation of the bowel wall can lead to perforation and peritonitis; bacteremia is fairly common, and fungemia can also occur. This condition typically involves the cecum, and when it is distended, the blood supply can be compromised and lead to further damage. The incidence rate in adults on cytotoxic chemo (e.g., for leukemias) is roughly 4% to 6%, although a report of 12% incidence was reported in patients with hematopoietic stem cell transplant. Complications can include bowel obstruction, perforation, abscesses, GI bleeding, sepsis, and death. The mortality rates are widely variable, and average about 40% to 50%. Treatment, to date, ranges from aggressive supportive care with antibiotics and antifungals to surgical management. Further chemotherapy must be withheld until complete recovery and possibly with primary prophylaxis. Patients who recover and need more chemotherapy may benefit from a right hemicolectomy before proceeding. Nursing consideration: Early recognition and treatment of neutropenic enterocolitis, which often mimics appendicitis in neutropenic patients, can improve outcome. Management of chemo-related diarrhea Early assessment and aggressive interventions are essential in diarrhea. In uncomplicated diarrhea, treatment is often empiric and nonspecific. Whenever possible, underlying causes, such as fecal impaction, should be treated. Medications, such as bulk laxatives and promotility agents (e.g., metoclopramide) are discontinued if being used for opioid management. Dietary changes are commonly used to help stop or lessen the severity of diarrhea. Some recommend that patients eat foods that build stool consistency, are low in fiber, and do not stimulate or irritate the gastrointestinal tract. In some cases, dietary modification for diarrhea management includes advising patients to eat small, frequent meals and avoid lactose-containing food (e.g., milk and dairy products), spicy foods, alcohol, caffeine-containing foods and beverages, certain fruit juices, gas-forming foods and beverages, high-fiber foods, and high- fat foods. For mild diarrhea, the BRAT (bananas, rice, apples, toast) diet may reduce the frequency of stools. Patients with diarrhea are encouraged to increase clear liquid intake to at least 3 liters per day (e.g., water, sports drinks, broth, weak decaffeinated teas, caffeine-free soft drinks, clear juices, and gelatin). Pharmacologic treatment is commonly used for diarrhea. Its goals include inhibition of intestinal motility, reduction in gut secretions, and promotion of absorption. Absorbents include agents that form a gelatinous mass that makes fecal material denser. Methylcellulose and pectin are most commonly used, but there is little data to support their efficacy. These bulk-forming agents may not be tolerated in some patients because of the large volume required for therapeutic effect and the associated abdominal discomfort and bloating. Adsorbents – such as kaolin, clays, and activated charcoals – have been used extensively, but no data support their use. Furthermore, they may inhibit absorption of other oral antidiarrheals that may be administered. Opioids bind to receptors in the gut and reduce diarrhea by reducing transit time. Loperamide is the most common opioid used because of its availability and reduced effect on cognition, although codeine and other opioids can also be effective. Common loperamide doses begin with 4mg, followed by 2mg after each unformed stool with a maximum of about 12mg/day. Regardless of dose, loperamide may be less effective in patients with Grade 3 or Grade 4 diarrhea. Mucosal prostaglandin inhibitors, also referred to as antisecretory agents, include aspirin, bismuth subsalicylate, corticosteroids, and octreotide may help. Aspirin may be useful for radiation-induced diarrhea. Bismuth subsalicylate is believed to have direct antimicrobial effects on the bacterium Escherichia coli. This agent is contraindicated in patients who should not be taking aspirin, and large doses can produce toxic salicylate levels. Corticosteroids reduce edema associated with obstruction and radiation colitis and can reduce hormonal influences of some endocrine tumors. Other pharmacologic therapies for the relief of diarrhea may be specific to the underlying cause. Delayed diarrhea (>24 hours) occurs with irinotecan and can be severe. In a small study of seven patients, six patients obtained relief with oral neomycin, 1,000mg, three times daily. This relief occurred without reduction in the active metabolite of irinotecan, SN-38; thus the poorly metabolized antibiotic did not alter efficacy of the chemotherapeutic agent. In another small study of 37 patients with non-small cell lung cancer receiving irinotecan, investigators alkalized the feces through oral administration of sodium bicarbonate, water, and ursodeoxycholic acid while speeding transit time of the drug metabolites (thought to reduce damage to the intestinal lumen by reducing stasis of the drug) through the use of magnesium oxide. The incidence of delayed diarrhea was significantly reduced in this group when compared with 32 patients receiving the same chemotherapeutic regimen without oral alkalization and controlled defecation. GVHD diarrhea In addition to antidiarrheal agents and immunosuppressive medications, a specialized five-phase dietary regimen may be instituted to effectively manage the diarrhea associated with GVHD. Phase 1 consists of total bowel rest until the diarrhea is reduced (NPO). Phase 2 reintroduces oral feedings consisting of beverages that are isotonic, low residue, and lactose free. If these beverages are well tolerated, Phase 3 may reintroduce solids containing minimal lactose, low fiber, low fat, low total acidity, and no gastric irritants. In Phase 4, dietary restrictions are progressively reduced as foods are gradually reintroduced and tolerance is established. Phase 5 includes the resumption of the patient’s regular diet, but most patients usually remain lactose intolerant. Mild cognitive impairment Cognitive changes with a cancer diagnosis are very common, with patients complaining of short-term memory loss, mental fogginess, difficulty concentrating, and loss of ability to multitask or perform mathematical calculations. These cognitive changes can start during or after cancer treatment, and some have even been observed as occurring before treatment began. Although it is often called chemo brain, the full etiology of this problem is unclear. Studies that look at people after cancer treatment cannot account for other effects of diagnosis, treatment, or baseline differences. A multifactorial problem Researchers are also looking at other factors that affect cognitive function. For example, surgery and anesthesia have at least a short term effect on cognition, especially in older patients, which typically resolves over a period of days to months. The stress of diagnosis and treatment, endocrine changes, nausea medications, low blood counts, depression, hormone changes, fatigue, anxiety, normal aging, and cardiovascular disease can all affect cognitive function, and some of these factors may play a role in cognitive changes before, during, and after cancer treatment. Subjective complaints versus objective measures Subjective observations of cognitive decline do not always match objective cognitive testing. Some studies have observed that patient