Diarrhea and constipation

Abstract

Diarrhoea and constipation are fairly frequent disorders in cancer patients. They may be symptomatic of a malignant disease or may develop as a sequel of specific cancer therapy, e.g. surgery, radiotherapy, or systemic treatment. Diarrhoea is frequent passing of increased amounts of loose or leaky stools. In systemic therapy, diarrhoea may be induced by certain cytostaics, target and hormonal drugs, and also some drugs applied as supportive therapy. These drugs cause diarrhoea establishing different mechanisms; the most frequent is the changed bacterial flora of the colon. The first step in the management of patients who suffer from cytostatic-induced diarrhoea is to assess the disease grade. The patients with mild or moderate disease should be referred to home care, advising them to follow appropriate dietetic regime and the therapy with a synthetic opioid without analgesic effect, e.g. loperamid. If the symptoms withdraw in 1-2 days, the therapy with loperamid should be discontinued 12 hours after the last loose stool. In case the symptoms persist, the dietetic regime and therapy with loperamid should be intensified and an antibiotic from chinolon group should be prescribed additionally. If the disease still persists, the therapy should be further intensified and additional laboratory and microbiology tests should be made. The patients with severe disease or moderate symptoms of diarrhoea accompanied by fever, abdominal pain and vomiting, and the patients with moderate diarrhoea in whom the symptoms get worse despite dietetic regime and loperamid, should be referred to parenteral treatment and intensive care in the hospital.
On the other hand, constipation, a condition of the digestive system in which patients experience hard feces that are difficult to expel, may also be directly or indirectly induced by malignant disease, or by specific cancer treatment, e.g. surgery, radiotherapy, or systemic treatment, and most frequently by supportive treatment with opioid analgesics. Constipation is induced by a combination of causes, therefore, its treatment requires a complex approach. Considering the specificity of each patient’s condition, the therapist should prescribe a combination therapy of non-pharmacological and, if needed, of pharmacological interventions that should be carried out regularly and consistently in order to assure to the patient the best quality of life and to alleviate the symptoms of constipation which cause general discomfort, abdominal pain, and low appetite.

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Povzetek

Driska (diareja) in zaprtje (obstipacija) sta relativno pogosta bolezenska znaka bolnikov z rakom. Pojavljata se kot znaka osnovne rakave bolezni ali kot posledici specifičnega onkološkega zdravljenja, to je operativnega zdravljenja, zdravljenja z obsevanjem ali pa sistemskega zdravljenja z zdravili. Driska pomeni bolezensko stanje, ko je iztrebljanj več in so obilnejša, blato pa mehko ali tekoče. Drisko v okviru sistemskega zdravljenja z zdravili povzročajo nekateri citostatiki, tarčna zdravila, hormonska zdravila in tudi nekatera zdravila, ki jih uporabljamo v podpornem zdravljenju. Ta zdravila povzročijo drisko na podlagi različnih mehanizmov, eden pomembnejših je sprememba črevesne flore. V obravnavi bolnika z drisko kot posledico zdravljenja s sistemskimi zdravili za zdravljenje raka, je potrebno najprej opredeliti stopnjo driske. V primeru blage do srednje hude driske je primerno zdravljenje na domu z ustreznim dietnim režimom in sintetičnim opioidom brez analgetičnega učinka loperamidom. Če se driska na ta način v 1 – 2 dneh umiri, 12 ur po zadnjem tekočem odvajanju zdravljenje zaključimo, oz. če driska ostaja nespremenjena zdravljenje z dieto in loperamidom intenziviramo, praviloma dodamo tudi antibiotik iz skupine kinolonov. V kolikor tudi to zdravljenje driske ne umiri, so potrebne dodatne laboratorijske in mikrobiološke preiskave, praviloma pa tudi intenzivnejše zdravljenje. Bolnik z izhodiščno hudo drisko, ali zmerno drisko z vročino, krčevitimi bolečinami v abdomnu in bruhanjem ter bolnik, ki se mu stanje sprva zmerne driske ob dietnem režimu in loperamidu poslabšuje, sodi v bolnišnico, kjer je potrebno parenteralno zdravljenje z intenzivnim nadzorom.
Tudi zaprtje, to je stanje, ko pri bolniku ugotovimo redko iztrebljanje majhnih količin trdega blata, ki ga spremlja mučno napenjanje, je lahko posledica neposrednega ali posrednega učinka osnovne rakave bolezni ali pa specifičnega onkološkega zdravljenja, to je operativnega zdravljenja, zdravljenja z obsevanjem ali sistemskega zdravljenja z zdravili, najpogosteje podpornega zdravljenja z opioidnimi analgetiki. Vzrok zaprtja je pogosto kombiniran, zato je tudi zdravljenje zaprtja kompleksno. Glede na bolnikovo specifično situacijo se odločimo za bolniku prilagojeno kombinacijo nefarmakoloških in po potrebi tudi farmakoloških ukrepov, ki jih je praviloma potrebno izvajati redno in dosledno, da bolniku zagotovimo čim boljšo kvaliteto življenja, ki mu jo sicer zaprtje s posledičnim splošnim neugodjem, bolečinami v abdomnu in oslabljenim apetitom pomembno okrni.