Management of Diarrhea in Palliative Care

Assessment and Causes

The National Comprehensive Cancer Network recommends screening for severity of diarrhea using grading systems to determine appropriate intervention level 2
Potential causes of diarrhea in palliative care patients include medications, local factors, late effects of radiation therapy, malabsorption, and fecal impaction, according to the American Society of Clinical Oncology 1, 3
The European Society for Medical Oncology notes that late effects of radiation therapy can contribute to diarrhea in palliative care patients 1, 3
Malabsorption from tumor effects or previous surgery can also cause diarrhea in palliative care patients, as stated by the National Comprehensive Cancer Network 3
Fecal impaction can present paradoxically as diarrhea, as reported by the American College of Gastroenterology 4

For patients with years to months of life expectancy, the National Comprehensive Cancer Network recommends providing oral hydration and electrolyte replacement, as well as implementing dietary modifications such as a bland/BRAT diet and reducing fatty food intake 2, 1
Loperamide can be started at 4 mg initially, then 2 mg after each loose stool, with a maximum dose of 16 mg/day, according to the European Society for Medical Oncology 2
For patients not already on opioids, diphenoxylate/atropine can be considered at a dose of 1-2 tablets every 6 hours as needed, with a maximum of 8 tablets/day, as recommended by the American Society of Clinical Oncology 2
For infection-induced diarrhea, the National Comprehensive Cancer Network recommends treating with appropriate antibiotics, such as metronidazole or vancomycin for C. difficile 2

Skin care is crucial for patients with diarrhea, especially those who are incontinent, and skin barriers can be used to prevent irritation from fecal material, as stated by the American Academy of Hospice and Palliative Medicine 1, 5
For elderly patients, diarrhea can more rapidly lead to dehydration, electrolyte imbalance, and renal function decline, according to the American Geriatrics Society 4
For radiation-induced diarrhea, referral to an expert dietician and highly caloric nutritional supplements may be beneficial, as recommended by the European Society for Medical Oncology 3
Colesevelam is better tolerated than cholestyramine for bile salt malabsorption, according to the American Gastroenterological Association 3

Overflow diarrhea should not be mistaken for true diarrhea, and fecal impaction should always be ruled out, as stated by the American College of Gastroenterology 3, 4
The prevalence of diarrhea in palliative care is around 20%, which is less common than constipation, according to the National Comprehensive Cancer Network 4
Metoclopramide should not be used in patients with complete bowel obstruction, as it may worsen symptoms, as recommended by the American Society of Clinical Oncology 6