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Diarrhea and its Multiple Causes
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Professional Oncology Education
Diarrhea and its Multiple Causes
Time: 15:54
Annette Bisanz, MPH, RN
Advanced Practice Nurse
Nursing Administration
The University of Texas MD Anderson Cancer Center
Hello. My name is Annette Bisanz. And today we’re going to
discuss diarrhea and its multiple causes.
Spanish Translation
La diarrea y sus múltiples causas
Transcripción del video
Educación Oncológica Profesional
La diarrea y sus múltiples causas
Duración: 15:54
Annette Bisanz, MPH, RN
Enfermera de Práctica Avanzada
Administración de enfermería
MD Anderson Cancer Center de la Universidad de Texas
Hola, mi nombre es Annette Bisanz y hoy hablaremos de la
diarrea y sus múltiples causas.
The objectives for this partic --- this session is that all participants
will be able to: assess for multiple causes of diarrhea; include all
causative factors in the patient's treatment plan; and discuss the
use of the Diarrhea Assessment and Treatment Tool, named the
DATT.
El objetivo de esta sesión es que todos los participantes
sean capaces de: evaluar las múltiples causas de la diarrea;
incluir todos los factores causales en el plan de tratamiento
del paciente; y conocer el uso de la Herramienta de
evaluación y tratamiento de la diarrea, llamada DATT.
Diarrhea and its
Multiple Causes
Annette Bisanz, MPH, RN
Advanced Practice Nurse
Nursing Administration
Diarrhea and its Multiple Causes
Objectives
All participants will be able to
• Assess for multiple causes of diarrhea
• Include all causative factors in the treatment plan
• Discuss use of the Diarrhea Assessment and
Treatment Tool (DATT)
1
Diarrhea and its Multiple Causes
NCI Definitions for Diarrhea with Grade
• Mild: 2-3 stools above normal per day (Grade 1)
• Mild-Moderate: 4-6 stools above normal per day
(Grade 2)
• Moderate-severe: 7-9 stools above normal with
possible severe cramps or incontinence (Grade 3)
• Severe: 10 or more stools above normal and may
have bloody diarrhea (Grade 4)
Diarrhea and its Multiple Causes
Clinical Definition of Diarrhea
• Above three loose stools per day
• Need volume
Diarrhea and its Multiple Causes
Classifications of Diarrhea
•
•
•
•
•
Secretory
Osmotic
Exudative
Malabsorptive
Dysmotility
The NCI definitions for diarrhea are, using a grading system: Mild
diarrhea, Grade 1: 2-3 stools above normal per day; Mild to
Moderate: 4 to 6 stools above normal per day, or Grade 2;
Moderate Sev --- to Severe: 7 to 9 stools above normal, with
possibly severe cramps and in --- incontinence; and Grade 4 is
Severe: 10 or more stools above normal, and the patient may
have bloody diarrhea.
El NCI define la diarrea mediante un sistema de
clasificación. Diarrea leve, grado 1: de 2 a 3 evacuaciones
por día más de lo normal; leve a moderada: de 4 a 6
evacuaciones más de lo normal, o grado 2; moderada a
grave: 7 a 9 evacuaciones más de lo normal, posiblemente
con calambres graves e incontinencia; y grave o grado 4: 10
o más evacuaciones más de lo normal, posiblemente con
sangre.
The clinical definition of diarrhea that I think is important is if the
patient has more than 3 loose stools per day. It’s very important in
treating diarrhea that we understand the volume or the amount of
liquid that the patient is excreting in the stool. And --- and that’s --that’s one of the things that sometimes we lack in our clinical
practice. And so I challenge people to look at the volume, not so
much as the number of times, because each stool, one could be
25 cc., one could be 100 cc., one could be 1000 cc., so we need to
really focus more in our clinical practice on the volume of the
amount of diarrhea that the patient is having.
There are different classifications of diarrhea. There’s secretory
diarrhea, osmotic diarrhea, exudative, malabsorptive, and
dysmotility.
La definición clínica de diarrea, que considero importante,
es más de 3 evacuaciones blandas por día. Al tratar la
diarrea, es esencial conocer el volumen o la cantidad de
líquido que el paciente excreta en las evacuaciones. Y eso
es algo que a veces nos falta en nuestra práctica clínica,
por lo que recomiendo observar el volumen y no tanto la
cantidad de evacuaciones, porque una podría ser de 25 cc,
otra de 100 cc y otra de 1000 cc. Debemos centrar nuestra
práctica clínica en la cantidad de diarrea que el paciente
presenta.
Existen diferentes clasificaciones de la diarrea: diarrea
secretora, osmótica, exudativa, malabsortiva y por
dismotilidad.
2
Diarrhea and its Multiple Causes
Mechanisms of Diarrhea
• Decreased absorption of fluid and electrolytes
• Increased secretion of fluid and electrolytes
Diarrhea and its Multiple Causes
Mechanisms of Diarrhea
•
•
•
•
Decreased absorption of fluid and electrolytes
Defective absorption
Osmotically active agents in lumen
Increased intestinal motility
Diarrhea
•
•
•
•
Increased secretion of fluid
and electrolytes
Endogenous secretagogues
Exogenous toxins
Diarrhea and its Multiple Causes
Secretory Diarrhea
Characterized by:
Associated with:
• Increased secretion of
fluids and electrolytes
• Interferes with
digestive enzymes
• Damage of
intestinal mucosa
• Increased intestinal
motility
•
•
•
•
•
•
Neuroendocrine tumors
VIPoma
Gastrinoma
Carcinoid Syndrome
Secretory adenoma
Intestinal inflammation
The mechanisms of diarrhea are: a decreased absorption of fluid
and electrolytes, which normally are reabsorbed back into the
system through the --- the wall of the intestine; and the other is
increased secretion of fluid and electrolytes into the col --- into the
GI tract.
Los mecanismos de la diarrea son: una menor absorción de
líquidos y electrolitos, que normalmente se reabsorben en el
sistema a través de la pared intestinal; y una mayor
secreción de líquidos y electrolitos hacia el tracto
gastrointestinal.
So if you look at this diagram, you’ll see the left-hand arrow there,
that things are just kind of moving through the GI tract, maybe very
fast. There’s not the absorption that normally should be taking
place back into the system taking place. There’s a defective
absorption then, and osmotically active agents in the lumen can
definitely increase the GI motility. If you look at the arrow on the
right, there’s increased secretion from the wall of the intestine, and
there’s fluid and electrolytes pouring into the GI tract faster than
the GI tract can handle it. And this can be caused from
endogenous secretagogues or exogenous toxins. And so it’s
important to realize that the patient could have one or both of these
mechanisms going on at the same time, depending on the kind of
diarrhea, or the multiple types of diarrhea that the patient is having.
En este diagrama, las flechas de la izquierda indican el
desplazamiento a través del tracto gastrointestinal, tal vez
con demasiada rapidez. No se produce la absorción que
normalmente debería ocurrir en el sistema. Como la
absorción es defectuosa, los agentes osmóticamente
activos del lumen suelen aumentar la motilidad
gastrointestinal. La flecha a la derecha indica que hay
mayor secreción de la pared intestinal, y los líquidos y
electrolitos que llegan al tracto gastrointestinal con más
rapidez que la que este puede manejar. Esto puede ser
causado por secretagogos endógenos o por toxinas
exógenas. Es importante advertir que el paciente podría
tener uno de estos mecanismos o ambos activos al mismo
tiempo, según el tipo de diarrea o los múltiples tipos de
diarrea que esté teniendo.
Hablemos primero de la diarrea secretora. La diarrea
secretora se caracteriza por una mayor secreción de
líquidos y electrolitos. Interfiere con las enzimas digestivas,
por lo cual la comida no se metaboliza correctamente, se
daña la mucosa intestinal y aumenta la motilidad
gastrointestinal. Se asocia con tumores neuroendocrinos,
VIPomas, gastrinomas, síndrome carcinoide, adenomas
secretores e inflamación intestinal, como Clostridium
Difficile.
Let’s first talk about secretory diarrhea. Secretory diarrhea is
characterized by an increased secretion of fluids and electrolytes.
It interferes with the digestive enzymes, so the food isn’t
metabolized appropriately, and there’s damage of the intestinal
mucosa and increased GI motility.
It’s associated with
neuroendocrine tumors, VIPomas, gastrinomas, carcinoid
syndrome, secretory adenomas, and interstitial --- and intestinal
inflammation as in C. difficile.
3
Diarrhea and its Multiple Causes
Secretory Diarrhea
• Persists even when fasting
• Produces large volumes of stool (more than 1
liter/day)
• Produces negative pathology reports
• Occurs in patients with a carcinoid tumor with
symptoms of flushing, hypotension, vasodilation
and bronchoconstriction
Diarrhea and its Multiple Causes
Chemotherapy InducedInduced-Diarrhea (Secretory
(Secretory)
Secretory)
Characterized by:
• Imbalance between
absorption and
secretion in the
small bowel
• Damage to
intestinal mucosa
• Bacterial overgrowth
and opportunistic
infection
Associated with:
• Antimetabolites
• Combination of
chemotherapeutic
agents and biologic
response modifiers
• Dosing schedules
• Cytoprotectants (Mesna)
Diarrhea and its Multiple Causes
Common Anticancer Agents Associated with Diarrhea
• Irinotecan
• 5 FU/Leucovorin
• Hi dose cisplatin,
oxaliplatin,
paclitaxel and
cyclophosphamide
• Topotecan
• Methotrexate
• Nitrosureas
•
•
•
•
•
•
•
Cytosine arabinoside
Doxorubicin
Daunorubicin
Hydroxyurea
Thioguanine
5-azacitidine
Biotherapy:
– Interleukin-2
– Interferon
Secretory diarrhea persists even when the patient is fasting. It
produces large volumes of stool, usually more than 1 liter per day.
It produces negative pathology reports. You won't find that there’s
other organisms in the stool. And it occurs in patients with a
carcinoid tumor along with symptoms of flushing, hypotension,
vasodilation, and bronchoconstriction.
La diarrea secretora persiste incluso cuando el paciente
está ayunando. Produce grandes volúmenes de
evacuaciones, generalmente más de 1 litro por día, pero los
informes patológicos son negativos. No se encuentra ningún
organismo en las evacuaciones, y ocurre en pacientes con
tumor carcinoide, junto con síntomas de rubor, hipotensión,
vasodilatación y broncoconstricción.
Chemotherapy induced diarrhea is also considered a secretory
type of diarrhea because it --- it secretes a lot of fluid into the
intestine and it’s characterized by an imbalance between the
absorption and the secretion in the small bowel. And there’s
damage to the intestinal mucosa, and there can be a bacterial
overgrowth and opportunistic infections occurring due to the
myelosuppression of the patient.
It’s associated with
antimetabolite
chemotherapies,
a
combination
of
chemotherapeutic agents and biologic response modifiers. Dosing
schedules can make a difference in the amount of diarrhea the
patient has. And cytoprotectants like Mesna can cause diarrhea.
La diarrea inducida por la quimioterapia también se
considera un tipo de diarrea secretora, dado que segrega
mucho líquido en el intestino y se caracteriza por un
desequilibrio entre la absorción y la secreción en el intestino
delgado. Se daña la mucosa intestinal, y puede haber un
desarrollo bacteriano excesivo, así como infecciones
oportunistas, que ocurren debido a la mielosupresión del
paciente. Se asocia con las quimioterapias antimetabólicas,
una combinación de agentes quimioterapéuticos y
modificadores de la respuesta biológica. Las dosificaciones
pueden marcar una diferencia en la cantidad de diarrea del
paciente y los citoprotectores como Mesna pueden causar
diarrea.
Los anticancerígenos comúnmente asociados con la diarrea
son el irinotecán, 5-FU/leucovorina, cisplatino en altas
dosis, oxaliplatino, paclitaxel, ciclofosfamida, topotecán,
metotrexato, las nitrosureas, citosina arabinósido,
doxorrubicina, daunorrubicina, hidroxiurea, tioguanina, 5azacitidina y la bioterapia, lo cual incluye interleucinas e
interferones.
The common anti-cancer agents associated with diarrhea are:
irinotecan, 5-FU/Leucovorin, high-dose cisplatin, oxaliplatin,
paclitaxel,
cyclophosphamide,
topotecan,
methotrexate,
nitrosureas, cytosine arabinoside, doxorubicin, daunorubicin,
hydroxyurea, thioguanine, 5-azacitidine, and biotherapy, including
interleukins and interferons.
4
Diarrhea and its Multiple Causes
Osmotic Diarrhea
Characterized by:
Associated with:
• Ingestion of an
oral solute not
fully absorbed
• Ingestion of
nonabsorbable or
hyperosmolar substances
• Rapid transit and
decreased exposure
of luminal contents
to the intestinal wall
• Possibly an enteral
feeding
Diarrhea and its Multiple Causes
In Osmotic Diarrhea
• Stool volumes are less than 1 liter per day
• Stools decrease if patient is fasting
• Sodium and postassium in stool is not altered
Diarrhea and its Multiple Causes
Exudative Diarrhea
Characterized by:
• Intestinal damage
• Inflammation
• Release of
prostaglandin
Associated with:
• Radiation colitis
• Infections
Let’s now go to osmotic type of diarrhea. Osmotic type of diarrhea
is characterized by ingestion of an oral solute that’s not fully
absorbed. There’s a rapid transit and a decreased exposure of --of the luminal contents to the intestinal wall so that ab --reabsorption is not taking place. This is associated with ingestion
of nonabsorbable or hyperosmolar substances. It could possibly
be an enteral feeding that is too hyperosmolar and the GI tract just
cannot tolerate it. It also could be sorbitol-based liquid medication,
and a lot of people are not aware of that. If they’re taking strictly
liquid medication, it may be sorbitol- based, and that’s sugar, and
they are having problems with that, or sugar-free products can also
cause an osmotic type of diarrhea.
In osmotic diarrhea, the stool volumes are less than 1 liter per day
and the stools decrease if the patient is fasting. Sodium and
potassium in the stool is not altered like it is with the secretory
diarrhea.
Now let’s go to exudative diarrhea. Exudative diarrhea is
characterized by intestinal damage, inflammation, and a re --release of prostaglandin. It’s associated with radiation colitis and
infections.
Pasemos ahora a la diarrea de tipo osmótico. El tipo de
diarrea osmótico se caracteriza por la ingestión de un soluto
oral que no es totalmente absorbido. Hay un tránsito rápido
y una menor exposición del contenido luminal a la pared
intestinal, por lo cual la reabsorción no se lleva a cabo. Esto
está asociado con la ingestión de sustancias no absorbibles
o hiperosmolares. Podría deberse a una alimentación
enteral demasiado hiperosmolar, no tolerada por el tracto
gastrointestinal. También podría deberse a medicamentos
líquidos a base de sorbitol, cuyos efectos muchas personas
desconocen. Si el paciente toma medicamentos
estrictamente líquidos, es posible que estén basados en
sorbitol, lo cual es azúcar, y eso genera problemas; los
productos sin azúcar también pueden causar diarrea de tipo
osmótico.
En la diarrea osmótica, los volúmenes de evacuación son
de menos de 1 litro por día y las evacuaciones disminuyen
si el paciente ayuna. A diferencia de la diarrea secretora, no
se alteran los niveles de sodio y potasio en las
evacuaciones.
Pasemos a la diarrea exudativa. Se caracteriza por daño e
inflamación intestinal y la liberación de prostaglandina. Se la
asocia con infecciones y cólicos provocados por la
radiación.
5
Diarrhea and its Multiple Causes
Exudative Diarrhea
• Results from mucosal damage and causes
decreased amount of functional mucosa
• Releases prostaglandin as a result of intestinal
damage and inflammation
• Common treatment is a prostaglandin inhibitor
(ASA, ibuprofen)
Diarrhea and its Multiple Causes
Radiation InducedInduced-Diarrhea (Exudative
(Exudative)
Exudative)
is Secondary to:
• Acute enteritis and colitis
• Partial villi atrophy and fibrosis making the
lining slick
• Impairment of bile acid absorption if ileum
is involved
• Bacterial overgrowth
• Chronic inflammation (nuclear atypia, epithelial
flattening and cell degradation)
Diarrhea and its Multiple Causes
Malabsorptive Diarrhea
Characterized by:
• A disease resulting
in malabsorption
of solutes
• Lack of pancreatic
enzymes
• Intolerance of gluten
Associated with:
• Lactose intolerance
• GI resection
• Celiac Sprue
Exudative diarrhea results from mucosal damage and causes
decreased amount of functional mucosa. And if you think of a
person after radiation, the GI tract can be almost raw, and so
anything that is raw will weep. And so that gives you an idea of
how exudative diarrhea is affecting the GI tract. And there is
usually a release of prostaglandin as a result of the intestinal
damage and inflammation. Common treatment is a prostaglandin
inhibitor. And interestingly enough, a prostaglandin inhibitor is
aspirin and ibuprofen. In clinical practice, this is seldom used in
oncology because we say, “While our patients are
myelosuppressed, we don’t want to give them aspirin. You know
their platelets may be down” or “maybe they’re on anticoagulant
medications.” But we meed --- we need to be innovative, and if we
understand the causative factor of the diarrhea, if they --- they
need an antiprostaglandin, why not use aspirin and ibuprofen? All
patients are not myelosuppressed and on anticoagulants.
Radiation induced diarrhea is ex --- an exudative type of diarrhea
and it’s secondary to acute enteritis and colitis. There is a partial
villi atrophy and fibrosis making the lining in the --- the GI tract
slick. There is impairment of bile acid absorption if the ileum is
involved, and there is --- there can be bacterial overgrowth and
chronic inflammation, nuclear atypia, epithelial flattening, and cell
degradation when the patient has this type of diarrhea.
Then there’s malabsorptive diarrhea. This is characterized by a
disease resulting in malabsorption of solutes. There’s --- there
may be a lack of pancreatic enzymes, for example, in patients who
have had a pancreatectomy. And the patient may be having an
intolerance to gluten. This is associated with lactose intolerance,
for example.
And many of our patients develop lactose
intolerance after many years being able to tolerate milk and milk
products. And so this needs to be addressed and assessed in
each of our patients. After a GI resection, the patient’s going to
have malabsorption because part of their GI tract may be missing,
and especially if the pancreas is missing, they miss the --- the
La diarrea exudativa deriva del daño en las mucosas y
reduce la cantidad de mucosa funcional. Después de la
radiación, el tracto gastrointestinal puede estar casi en
carne viva, por lo que exudará líquido. Esto da una idea de
cómo la diarrea exudativa afecta el tracto gastrointestinal.
Normalmente existe una liberación de prostaglandina
debido al daño y a la inflamación intestinal. El tratamiento
usual es un inhibidor de la prostaglandina y, curiosamente,
la aspirina y el ibuprofeno inhiben la prostaglandina. Esto se
utiliza raramente en la práctica clínica oncológica, porque
preferimos no administrar aspirina a los pacientes mientras
estén mielosuprimidos. Pueden tener un nivel bajo de
plaquetas, o estar recibiendo anticoagulantes. Pero
tenemos que ser innovadores, y si entendemos el factor
causante de la diarrea, si necesitan prostaglandina, ¿por
qué no usar aspirina e ibuprofeno? No todos los pacientes
están mielosuprimidos y recibiendo anticoagulantes.
La diarrea inducida por la radiación es de tipo exudativo,
secundario a la colitis y la enteritis agudas. La atrofia parcial
de vellosidades y la fibrosis reducen la resistencia del
revestimiento gastrointestinal. Si hay compromiso del íleon,
se deteriora la absorción de ácidos biliares, y con este tipo
de diarrea puede haber desarrollo bacteriano excesivo e
inflamación crónica, atipia nuclear, aplanamiento epitelial y
degradación celular.
Luego tenemos la diarrea malabsortiva. Se caracteriza por
una enfermedad que provoca malabsorción de solutos. Por
ejemplo, puede haber falta de enzimas pancreáticas en los
pacientes que han tenido una pancreatectomía. El paciente
puede tener intolerancia al gluten. Esto se asocia con la
intolerancia a la lactosa, por ejemplo. Muchos pacientes
desarrollan intolerancia a la lactosa después de años de
tolerar la leche y los productos lácteos. Esto debe evaluarse
en cada caso individual. Luego de una resección
gastrointestinal, el paciente tendrá malabsorción porque
parte del tracto puede faltar, y especialmente si hay
6
enzymes to digest fats. And then in celiac sprue, the patient
cannot metabolize gluten; and gluten is in wheat products, barley,
rye, and sometimes oats. And so this is a very important thing to
assess your patients for.
Diarrhea and its Multiple Causes
Dysmotillity AssociatedAssociated-Diarrhea
Characterized by:
• Dysfunctional
intestinal motility
Associated with:
• Colorectal resection
• Post gastrectomy
• Ileocecal valve resection
• Narcotic withdrawal
• Inflammatory conditions
(IBS)
• Drugs affecting peristalsis
Diarrhea and its Multiple Causes
• Assess current diarrhea treatment based on
causative factors
Okay, then you have your dysmotility associated diarrhea. This is
characterized by dysfunctional intestinal motility. It’s associated
with colorectal resection. Most of the people, after colorectal
resection, have not a diarrhea, but a frequent soft, formed stool in
very small amounts. This is not really a diarrhea, but the frequent
stooling is very disconcerting, and many of these people have to
stay near the bathroom. They’ll have 15 to 30 stools per day. We
do have treatment for that and we will discuss that. Post
gastrectomy, they --- they will have a dysmotility-associated
diarrhea. Also after an ileocecal valve resection, narcotic
withdrawal, inflammatory conditions like irritable bowel syndrome,
and drugs affecting peristalsis. And the one thing I think we don’t
think about is: the patient is nauseated and we are giving them
®
Reglan for nausea, metoclopramide. This will increase the GI
motility and it can also enhance diarrhea.
Diarrhea has many causes. And so what we need to do is assess
the current diarrhea treatment based on the causative factors for
our patients. And remember, if a patient has diarrhea, all causes
have to be treated for the diarrhea to go away.
ausencia de páncreas, carecerá de enzimas para digerir
grasas. En el caso de la enfermedad celíaca, el paciente no
puede metabolizar el gluten, que está presente en los
productos de trigo, cebada, centeno y, a veces, avena. Por
lo tanto, es muy importante evaluar a los pacientes en este
aspecto.
Luego está la diarrea asociada con la dismotilidad, que se
caracteriza por motilidad intestinal disfuncional y que está
asociada con la resección colorrectal. En la mayoría de los
casos, luego de una resección colorrectal no hay diarrea
sino evacuaciones blandas con forma, en cantidades muy
pequeñas. No es realmente diarrea, pero las deposiciones
frecuentes son desconcertantes y suele ser necesario estar
siempre cerca de un baño. Llegan a tener de 15 a 30
deposiciones por día. Para eso tenemos un tratamiento, que
luego explicaré. Tras una gastrectomía, los pacientes
tendrán diarrea asociada con dismotilidad. También la
tendrán si hay resección de la válvula ileocecal, interrupción
de estupefacientes, síndrome del intestino irritable y
administración de fármacos que afectan la peristalsis. A
veces no pensamos en las consecuencias: si un paciente
®
tiene náuseas, le damos Reglan , que es metoclopramida,
lo cual aumenta la motilidad gastrointestinal y agrava la
diarrea.
La diarrea tiene muchas causas. Es necesario evaluar el
actual tratamiento contra la diarrea para nuestros pacientes
en función de los factores causales. Recuerde que si un
paciente tiene diarrea, para resolverla es preciso tratar
todas las causas.
7
Diarrhea and its Multiple Causes
Diarrhea Assessment and Treatment Tool (DATT)
• A comprehensive approach to assessing diarrhea
• Organizes thought process
• Provides a guide for initial treatment
• Provides guidance in addressing all
causative factors
Diarrhea and its Multiple Causes
Diarrhea Assessment and Treatment Tool (DATT)
Continued
So we need a comprehensive approach to assessing diarrhea.
We need to have a way to organize our thought process so we
don't forget different types of diarrheas that could be existing in our
patients, and provide a guide for initial treatment. And so what we
did is develop a Diarrhea Assessment and Treatment Tool, called
the DATT, simply. And this provides guidance in addressing all
causative factors in diarrhea so that all of them can be addressed.
Para evaluarla, necesitamos abordarla integralmente.
Debemos organizar nuestro proceso analítico sin olvidar los
diferentes tipos de diarreas que podrían afectar a nuestros
pacientes, y ofrecer una guía para el tratamiento inicial.
Para ello, hemos desarrollado una herramienta de
evaluación y tratamiento de la diarrea llamada DATT que
ofrece una guía para abordar de manera integral todos los
factores causales de la diarrea.
And in this next slide there are two pages. And I -- I would just
like to discuss this with you and what this tool can do. This
diarrhea assessment and treatment tool begins by getting a history
of the patient's diarrhea and finding out exactly how long it has
existed; what kind of cancer treatments the patient is on; how does
the patient eat; does the patient aggravate his diarrhea by the
kinds of foods that he eats; and what’s the --- the patient's fluid
intake and output per day; and what are the types of stools that the
patient’s having; the laboratory results that have been already
addressed to see what the causative factors are of the diarrhea;
and the medications that have already been tried that have not
been successful. And then from there, after questioning the
patient on all the causative factors of the different types of
diarrhea, we begin to identify that the patient maybe has more than
one type of diarrhea, more than one causative factor causing
diarrhea. So once that’s identified, then we can begin to look at a
treatment program that addresses the entire spectrum of causative
factors of diarrhea. And so on the second page, we worked with
the Pharm.D.s here to help us in establishing an initial treatment
for the various causative types of diarrhea. And these are listed on
this sheet. What we have found is that it‘s very helpful in
organizing your thought processes, not forgetting anything that
could be causing the diarrhea, and if all of the types of diarrhea are
addressed, you have a much better chance of getting effective
treatment for your patient and the diarrhea will subside.
Esta diapositiva muestra dos páginas. Deseo analizar esto
con ustedes y describir la utilidad de esta herramienta. La
herramienta de evaluación y tratamiento de la diarrea
comienza por obtener una historia de la diarrea del paciente
y por averiguar exactamente cuánto tiempo ha existido; qué
tipo de tratamientos contra el cáncer está recibiendo el
paciente; cómo se alimenta el paciente; si los alimentos que
come agravan la diarrea del paciente; cómo es su ingesta
de líquidos y cuánto evacua por día; y qué tipos de
deposiciones tiene el paciente; qué resultados de
laboratorio ya se han abordado para ver cuáles son los
factores causales de la diarrea; y los medicamentos que ya
se han probado sin éxito. A partir de allí, luego de interrogar
al paciente sobre todos los factores causales de los
distintos tipos de diarrea, es posible identificar si el paciente
tiene más de un tipo de diarrea, más de un factor causal.
Una vez identificado esto, podemos empezar a evaluar un
programa de tratamiento que abarque todo el espectro de
factores causales de la diarrea. Para la segunda página,
trabajamos con nuestros doctores en farmacia para
establecer un tratamiento inicial para los distintos factores
causantes de la diarrea, los cuales se indican en esta hoja.
Comprobamos que es muy útil organizar el proceso
analítico, sin olvidar nada que pudiera causar la diarrea. Si
se abordan todos los tipos de diarrea, se tiene una mayor
probabilidad de lograr un tratamiento eficaz para resolver la
diarrea del paciente.
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Diarrhea and its Multiple Causes
Summary
You have learned:
• How to fully assess patients for all causative
factors of diarrhea
• The importance of treating all causes to eliminate
diarrhea symptoms
In summary, you have learned: how to fully assess patients for all
causative factors of diarrhea. You’ve learned the importance of
treating all causes to eliminate the diarrhea symptoms. And you’ve
learned how to use the Diarrhea Assessment and Treatment tool
to enhance your assessment of diarrhea. Thank you for your
attention.
En resumen, hemos aprendido: cómo evaluar por completo
todos los factores que causan diarrea; la importancia de
tratar todas las causas para eliminar los síntomas de
diarrea; y cómo utilizar la herramienta de evaluación y
tratamiento de la diarrea para mejorar la evaluación de la
situación. Gracias por su atención.
• How to use the DATT to enhance your
assessment of diarrhea
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