How I manage patients with complex GI problems. Mark Williams ST5 Haematology Manchester Royal Infirmary

Transcription

1 How I manage patients with complex GI problems Mark Williams ST5 Haematology Manchester Royal Infirmary

2 Contents Causes of transplant (+chemotherapy) associated diarrhoea Conditioning & drug related Graft versus host disease (GvHD) GI Infections Diagnostic approach Common management challenges Fluid replacement Electrolyte replacement Providing symptomatic relief Specific therapies

3 Transplant associated diarrhoea The burden of disease The majority (50-91%) of patients will be affected by diarrhoea at some point during their transplant (as will many chemotherapy patients) Ranging from mild to debilitating Often distressing Some cases are inevitable (eg. Melphalan ASCT) Some represent potentially life threatening complications that require early diagnosis and aggressive management

4 Transplant associated diarrhoea The burden of disease Psychological aspects of severe diarrhoea Opening bowels every hour Exhausting Disrupts sleep and visiting Patients can become socially isolated Suffering incontinence Affects privacy and dignity Effect on body image Effect on mood and motivation

5 Transplant associated diarrhoea Common causes Chemotherapy-related diarrhoea Gut mucosa contains rapidly dividing cells Chemotherapy prevents renewal of gut lining Diarrhoea often secretory Particularly problematic with alkylating agents Melphalan, Busulfan TBI Radiation enteritis Drug related Antibiotics/PPI/MMF/Metoclopramide/Oral magnesium

6 Transplant associated diarrhoea Common causes Graft versus host disease Following allogeneic transplant the donor cells recognize the recipient cells as foreign. The gut is a common site of immune assault. Acute GvHD Defined as occurring in the first hundred days post HSCT Better thought of as part of a clinical syndrome gut/liver/skin (late onset agvhd) Skin most commonly affected, rarely gut alone Profuse diarrhoea, nausea & vomiting, severe abdo pain & cramps In severe cases GI bleeding and paralytic ileus

7 Transplant associated diarrhoea Common causes

8 Transplant associated diarrhoea Common causes Chronic GvHD Occurs after 100 days No typical features that are diagnostic of chronic GI GvHD Multiple potential symptoms Upper GI Nausea, vomiting, dysphagia, anorexia Lower GI Diarrheoa, steatorrhoea Multiple potential alternative differential diagnoses Confirmation of diagnosis often requires biopsy and exclusion of other conditions

9 Transplant associated diarrhoea Common causes Infections Viruses CMV EBV, HSV, Adeno Enteroviruses: rotavirus, norovirus, echovirus, astrovirus Bacteria C.Diff?low incidence (4-13%)?Bradyrhizobium enterica cord colitis syndrome Fungi Parasites cryptosporidium, microsporidia, giardia (rare)

10 Diagnostic Approach History volume/frequency/colour/odour/pain/n&v/fever Timing First two weeks likely conditioning related Around engraftment GvHD the most common cause Infections can occur at anytime GI Imaging (AXR +/- CT) especially if abdominal pain or peritonitis Stool culture: Bacteria (C.Diff), Viruses (Entero), Parasites CMV PCR GI Biopsy often needed to confirm GvHD and exclude CMV colitis Remember the possibility of dual pathology (eg. GvHD + Infection)

11 General management principles Gut rest Low residue diet resumption of normal diet Provide nutrition TPN Stop exacerbating medications Give medications IV if non-absorption likely Fluid/Electrolyte replacement (see below) Exclude C.Diff before starting anti-motility agents Treat underlying cause where possible

12 Common management challenges Fluid The problem: Patients may be losing 2-10L/day from the GI tract Most are too unwell to manage oral replacement alone Most are hypoalbuminaemic leading to peripheral oedema this makes clinical assessment of fluid status challenging Faecal incontinence is common when diarrhoea is severe Making losses difficult to quantify Line space can be limited (especially when all medications are IV a common situation with severe GI pathology)

13 Common management challenges Fluid Some suggestions: Accurate measurement of stool output is vital to track response (or non-response) to treatment and also to guide replacement Weighing bed sheets/pads etc. Faecal collection systems IV fluid +/- human albumin solution (HAS) Line space if there is not enough space to give everything prescribed then this needs to be discussed with the medical team May need additional access (peripheral cannulas) Combined infusions (eg. TPN with volume/electolyte content) Rationalise medications (are medications always more important than fluid?!)

14 Common management challenges Electrolytes The problem: Damage to the GI mucosa causes loss of serum into the lumen leading to depletion of electolytes and proteins Potassium, Magnesium, Phosphate Depletion exacerbated by: Poor intake Diuretic use (hypoalbuminaemic oedema) Medications: Ciclosporin (Mg), Foscarnet (K, Mg, PO) TBI Line space issues (as above)

15 Common management challenges Electrolytes Some suggestions: Aggressive replacement of electrolytes not done well! May need twice daily blood sampling If unable to keep up with everything then discuss with the medical team: Which IV/medication should take priority? Can some medications be given via NGT/SC or stopped? Can the electrolyte content of the TPN be increased? Are we going to manage on the ward or should we involved ITU?

16 Common management challenges Symptomatic relief The problem Pain/Cramps Diarrhoea Incontinence Distressing Risk of incontinence-associated dermatitis Patients may be opening their bowel five times an hour Physical and chemical (increased ph) damage to the skin Constant cleaning exacerbates contact dermatitis Impaired wound healing - chemotherapy or TBI Increased risk of infection - immunocompromised

17 Common management challenges Symptomatic relief Therapies Analgesia (opiates useful as also constipating) syringe drivers Anti-spasmodics Buscopan Constipating agents EXCLUDE C.DIFF FIRST Loperamide opioid: reduces GI motility, limited absorption Octreotide Somatostatin analogue Reduces gut motility and output Remember to stop once diarrhoea settles Ondansetron

18 Common management challenges Symptomatic relief Managing incontinence Siderooms with toilets Commode near to bed Sanitary pads Often overwhelmed Needs regular changing Skin care Gentle cleansing as soon as possible, avoid soap & water Moisturization Protective barrier

19 Common management challenges Symptomatic relief Faecal collection systems (Flexi-Seal, ActiFlo, Dignicare) Soft silicone tube with low pressure rectal balloon Generally comfortable and well tolerated Indicated when patients have little or no bowel control and liquid or semi-liquid stool Advantages: Contain and divert stool Protect wounds from contamination Allow accurate measurement of GI output Reduced spread of infection

20 Common management challenges Symptomatic relief Faecal collection systems cont Must have rectal examination before insertion Contraindicated if rectal mucosal damage/ulceration May be a problem with GvHD Can cause severe rectal bleeding Not suitable for mobile patients

21 Specific therapies Acute GvHD Steroids 1 st line (BIOPSY SHOULD NOT DELAY TREATMENT) Grade II GVHD: 1mg/kg Methylpred Grade III-IV GVHD: 2mg/kg Methylpred 80% mortality if refractory Oral budesonide non-absorbable steroid 2 nd Line: ECP, IL2-R Ab, Anti-TNF (etanercept), MTOR inhibitors, MMF 3 rd Line: Mesenchymal stem cells, Pentostatin, Campath CMV Colitis Ganciclovir, Foscarnet

22 So how best to manage these patients?! Intensive supportive care: Accurate fluid balance Guides adequate fluid replacement Allows assessment of treatment response Aggressive correction of electrolytes Additional access if needed Early symptomatic intervention Consider using faecal collection systems This all requires good communication between medical and nursing teams to allow clinical prioritization of therapy

23 Thanks for listening Any questions?