Symptom Specific Services

Diarrhea
• Will I experience diarrhea during cancer treatment?
• How can radiation cause diarrhea?
• When does chemotherapy cause diarrhea?
• How will my doctor determine the severity of my diarrhea?
• What foods should I avoid if I have diarrhea?
• What foods are preferred during radiation or if I have diarrhea?
• What can be done to minimize the risk of diarrhea caused by radiation?
• How can diarrhea caused by chemotherapy be effectively treated?

Will I experience diarrhea during cancer treatment?
Diarrhea may be associated with cancer treatments. For most patients the main cause of diarrhea is radiation, although certain types of chemotherapy can also cause diarrhea. Diet can also contribute to diarrhea, due to the use of milk products or soy-based food supplements commonly recommended. Examples of these food supplements are Ensure Plus or Jevity Plus, Ultracal or Boost Plus, Fibersource, or Comply. These products are given either by mouth or through a nasogastric tube to supplement patients who are protein/calorie-depleted.

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How can radiation cause diarrhea?
The large and small bowels are very sensitive to radiation. The amount of damage to normal tissues increases as the radiation dose increases. Since larger doses are needed for most tumors in the abdomen and pelvis, bowel inflammation is likely to occur when treating tumors in this region.

Almost all patients undergoing radiation to the abdomen, pelvis, or rectum will show signs of inflammation of the intestinal tract, which can cause diarrhea. Chronic radiation inflammation may appear months to years after finishing radiation oncology.

Several factors determine the occurrence of diarrhea during radiation oncology. These factors include the dose of radiation, tumor size and spread, amount of normal bowel treated, concurrent chemotherapy, use of radiation implants, and individual patient factors (such as previous surgery to the abdomen or pelvis, high blood pressure, diabetes, pelvic inflammatory disease, or poor nutrition).

The risk of having diarrhea usually increases as the dose of radiation and the area of normal bowel treated increases. The patient factors listed above can also decrease blood flow to the bowel wall. This can affect bowel movement and increase the chance of radiation injuries.

Patients with bowel inflammation may experience nausea, vomiting, abdominal cramping, frequent urge to have a bowel movement, and watery diarrhea. Symptoms of an inflamed rectum include a mucus-like discharge, rectal pain, and rectal bleeding, which may be a result from radiation damage to the anus or rectum. These symptoms usually get better two to three weeks after treatment ends.

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When does chemotherapy cause diarrhea?
When chemotherapy affects the cells lining the intestine, it can cause diarrhea (watery or loose stools). Diarrhea can be associated with the following chemotherapy treatments, either alone or in combinations:

• Fluorouracil (5-FU)

• Capecitabine (Xeloda, Roche)

• Irinotecan (CPT-11; Camptosar, Pharmacia & Upjohn)

• Topotecan (Hycamtin, SmithKline Beecham)

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How will my doctor determine the severity of my diarrhea?
As part of your examination, your physician will ask you questions about the following:

• Your usual pattern of bowel movements

• Your pattern of diarrhea, including:
when it started
how long it has lasted
frequency, amount, and type of stools
other symptoms (such as gas, cramping, bloating, urgency, bleeding, and rectal soreness)

• Your nutrition, including:
height and weight
usual eating habits
any change in eating habits
amount of fiber in the diet
signs of dehydration (such as poor skin tone, increased weakness, or fatigue)

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What foods should I avoid if I have diarrhea?
• Milk and milk products

• Whole-bran bread and cereal

• Nuts, seeds, and coconut

• Fried, greasy, or fatty foods

• Fresh and dried fruit and fruit juices, such as prune juice

• Raw vegetables

• Rich pastries

• Alcohol and tobacco

• Chocolate, coffee, tea and soft drinks with caffeine

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What foods are preferred during radiation or if I have diarrhea?
• Fish, poultry, and meat that is cooked, broiled, or roasted

• Bananas, applesauce peeled apples, and apple and grape juices

• White bread and toast

• Macaroni and noodles

• Baked, boiled or mashed potatoes

• Cooked vegetables that are mild, such as asparagus tips, green and waxed beans, carrots, spinach, and squash

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What can be done to minimize the risk of diarrhea caused by radiation?
To minimize the risk of chronic radiation bowel inflammation, health professionals use different methods to try and reduce the area that is exposed to radiation. Patients may be positioned to protect as much of the small bowel as possible from the radiation treatment, or they may be asked to have a full bladder during treatment to help push the small bowel out of the way. The amount of radiation may be adjusted to deliver lower amounts more evenly or higher amounts to specific areas. If a patient has surgery, clips may be placed at the tumor site to help designate the area to be irradiated.

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How can diarrhea caused by chemotherapy be effectively treated?
Diarrhea caused by chemotherapy can be treated with antidiarrheal agents. The most effective medications are synthetic opioids, such as loperamide (Imodium, Janssen). These are the most commonly used antidiarrheal agents because they slow the muscle action of the intestines, they have few side effects, and the cost is low. While useful in the treatment of mild diarrhea, it is relatively ineffective for diarrhea caused by chemotherapy when it is used at the manufacturer's recommend dose.

A flow chart for managing chemotherapy related diarrhea is available at http://www.mcmahonmed.com/wworks/CHARTS/cid/text/figure.html

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