Guide to managing Gastrointestinal Pelvic Radiation Disease (PRD) using Algorithm V7 (January 2011)

Transcription

1 Guide to managing Gastrointestinal Pelvic Radiation Disease (PRD) using Algorithm V7 (January 2011) This algorithm is particularly designed to help clinical nurse specialists working in conjunction with a gastroenterologist to investigate and treat the GI symptoms of patients following pelvic radiotherapy. The basis for this guide is that: 1. Patients often have multiple symptoms 2. Many patients have more than one cause for their symptoms 3. Symptoms often have multiple causes 4. A systematic approach is needed to investigate symptoms otherwise causes are missed 5. After radiotherapy a slightly different approach may be needed to patients who have never had cancer. 6. The key to using the algorithm, is to identify patients symptoms accurately We have identified the following 23 symptoms as particularly relevant to this group of patients and present an algorithm of investigation and treatment for each one. Yes No Yes No Bleeding (rectal) Bloating Borborygmi Change in bowel habit (recent) Nausea Nocturnal need to defaecate Pain - abdomen Pain - back (new onset) Constipation Pain - perineal / anal / rectal Diarrhoea / loose stool Evacuation difficulty Faecal incontinence (soiling / leakage / pads) Flatulence (oral / rectal) Frequency of defaecation Loss of sensation of need to open bowel/ bladder Mucus Pruritus Steatorrhoea Tenesmus Urgency of defaecation Vomiting Weight loss

2 It is important that no practitioner should work with this guidance outside the scope of their competency and should ask advice about abnormal test results which they do not understand. We advise non-medically qualified personnel using this guidance to be sure from whom they can seek advice when they feel unable to deal with test findings especially those which need urgent discussions. Specific therapies are usually not listed by name but as class of potential drugs as different clinicians may have local constraints or preferences as to the medications available. Written information is often helpful to supplement the management of specific diagnoses. If local information sheets are not available, information sheets on the following disorders can be obtained from Dr. Andreyev s office at the Royal Marsden Hospital ( ). 1. Bile acid malabsorption, 2. Pancreatic insufficiency, 3. Small bowel bacterial overgrowth 4. Treatment of radiation-induced gastrointestinal bleeding 5. Toileting and pelvic floor & toileting exercises 6. Advice for those with constipation or who often need to strain Specific leaflets are also available on the following treatments. 1. Lactose free diet 2. Managing fibre in your diet 3. Taking antidiarrhoeals 4. Taking colesevelam 5. Taking normacol, 6. Using sucralfate enemas Version 7. January

3 Using the algorithm 1. identify the symptoms 2. use the algorithm to plan investigations 3. most patients have more than one symptom and so investigations need to be requested for each symptom 4. usually all investigations are ordered at the same time and the patient reviewed with all the results 5. when investigations should be ordered sequentially, the algorithm indicates this by stating 1st line, 2nd line etc 6. Treatment options are generally offered sequentially but clinical judgement should be used. Abbreviations used in the algorithm CMV CT FODMAPS HBO GI IBD MCT MRI OGD SeHCAT SIBO cytomegalovirus computer tomography fermentable oligo-, di- and mono-saccharides and polyols hyperbaric oxygen gastrointestinal inflammatory bowel disease medium chain triglycerides magnetic resonance imaging upper GI endoscopy 75 selenohomocholyltaurine small intestine bacterial overgrowth Version 7. January

4 Guideline for blood tests used within the Algorithm Routine blood screen includes: Full blood count, urea and electrolytes, glucose, calcium, liver function Additional blood screen includes: C reactive protein, coeliac serology, iron studies, red blood cell folate, thyroid function tests Action when blood tests return abnormal results Consider rechecking if clinical doubt, and seek advice for any abnormalities not considered below. Vitamin B12 deficiency 1. Recheck result once, if deficiency confirmed 2. Ask GP to start long-term intramuscular Vitamin B12 replacement after ensuring red blood folate levels are in the normal range Elevated ESR/CRP consider the following possibilities but also discuss: 1. Infection (including SIBO) 2. Inflammation (eg. IBD) 3. Recurrent malignancy 4. Non-GI cause RBC folate - deficiency Dietary advice/referral to dietician Iron studies If results suggest deficiency together with anaemia - discuss urgently If suggesting iron overload - discuss urgently Thyroid function tests If suppressed TSH: 1. Recheck result once with thyroid auto antibodies 2. Ask GP to arrange radiological imaging and arrange treatment If elevated TSH: 1. Recheck result once 2. Check morning cortisol if any possibility of Addison s disease (ie symptoms of weakness/ tiredness/ dizziness or serum sodium is at or below lower end of normal, serum potassium is at or above the upper limit of normal, or urea or creatinine are raised). 3. Start on thyroid replacement, ask GP to monitor long-term 4. Review bowel function after 6-8 weeks Version 7. January

5 Abnormal urea and electrolytes, and calcium Abnormal liver functions Will need liver screen and liver ultrasound Haemoglobin <12.5g/L If unexplained, consider OGD + Colonoscopy If iron deficient, consider iron supplements If Haemoglobin <10g/L, consider transfusion Glucose 1. If between 7.8 and 11 and no history of diabetes refer to GP 2. If > 11 and no history of diabetes discuss urgently 3. If known diabetic and >11 but < 20 inform GP 4. If >20 discuss urgently Fat soluble Vitamin and trace element levels including Vitamin A, Vitamin D, Vitamin E, INR (for Vitamin K) selenium and zinc 1. If any borderline, prescribe multivitamin + trace element supplement (eg Forceval) daily and ask GP to recheck in 12 months and monitor long-term 2. If any deficient, ask GP to prescribe replacement, monitor long-term (minimum annually) and suggest additional Forceval one daily long-term Elevated triglyceride levels Discuss Version 7. January

6 Bleeding - bright red +/- clots Check haemoglobin Check clotting and haematinics if heavy bleeding is occurring Flexible sigmoidoscopy Abnormal Radiation proctopathy with bleeding from telangiectasia Follow treatment abnormal blood results pg. 4, 5 1. No treatment if minor (give written information) 2. If significant bleeding affecting quality of life, topical therapy using sucralfate enemas +/- 4 weeks of metronidazole 3. Discuss for hyperbaric oxygen or endoscopic therapy 4. Discuss experimental agents (eg. Vitamin A, thalidomide, clot stabilizing agents) Haemorrhoidal bleeding Consider local treatment of haemorrhoids (diet, creams etc); if 3 rd degree surgical referral Primary inflammatory bowel disease 1. Send stool culture 2. Diverticular bleeding Newly diagnosed neoplasia 2nd primary / tumour recurrence / advanced polyp Viral infection (eg. CMV) If all tests are negative, but symptoms persist Consider colonoscopy Bleeding - dark bleeding Routine blood screen AND OGD + colonoscopy Abnormal Radiation induced telangiectasia in the colon or terminal ileum Follow treatment abnormal blood results pg. 4, 5 1. No treatment if minor (give written information) 2. Discuss hyperbaric oxygen or endoscopic therapy 3. Discuss experimental agents (eg. Vitamin A, thalidomide, clot stabilizing agents) Version 7. January

7 Bleeding - dark bleeding cont'd Newly diagnosed neoplasia 2nd primary / tumour recurrence / advanced polyp Primary inflammatory bowel disease Diverticular bleeding Upper GI source for bleeding 1. Send stool culture 2. Bloating / cramping. This is also the Algorithm guideline for Abdominal pain If steatorrhoea is present, or possible, also follow Algorithm Steatorrhoea 1st line: Routine blood screen AND Additional blood screen AND Abdominal X-ray Careful dietary history Careful drug history If all tests are negative, but Consider capsule endoscopy / enteroscopy symptoms persist Abnormal results Follow treatment abnormal blood results pg. 4, 5 Faecal loading (with overflow diarrhoea) Appropriate fluid and fibre intake Excessive sorbitol Excessive caffeine Bulking agent / laxatives +/- stimulant rectal enema 1. Written advice 2. Simple dietary advice 3. Referral to dietician Consider stopping opiate drugs / metformin / non steroidal anti-inflammatory drugs 2nd line: OGD and duodenal aspirate and glucose hydrogen methane breath tests SIBO (Small Intestinal Bacterial Overgrowth) Treatment for SIBO 1. Written Information Sheet AND one 7-10 day course of broad spectrum oral antibiotics 2. No improvement / rapid recurrence further 7-10 day course of second antibiotic treatment 3. If rapid recurrence discuss cyclical antibiotics / low dose continuous /intermittent antibiotics Version 7. January

8 Bloating / cramping cont'd Stool for faecal elastase Pancreatic insufficiency Treatment for pancreatic insufficiency 1. Written information AND 2. Pancreatic enzyme supplements +/- PPI 3. Refer to dietician: low fat predominant diet 4. Annual monitoring of fat soluble vitamins and trace elements by GP 5. Consider long-term multi vitamin + trace element supplement Dietary history +/- challenge test for carbohydrate malabsorption Ultrasound of biliary tree (+ small bowel if no recent CT scan of abdomen and pelvis) Carbohydrate intolerance Suggestive of gallstones or inflammatory bowel disease If all tests are negative, but symptoms persist Treatment for carbohydrate malabsorption Dietetic advice (eg. FODMAPS or specific carbohydrate exclusion diet) 1. Reassure 2. Antispasmodic 3. Low dose anti-depressants 4. Referral for acupuncture 5. Agent for neuropathic pain if pain severe 6. Refer to pain clinic if pain severe Borborygmi 1st line: Routine blood screen AND additional blood screen Abnormal results Follow treatment abnormal blood results pg. 4, 5 AND OGD and duodenal aspirate and biopsies and/or glucose hydrogen methane breath tests SIBO Enteric infection Treatment plan for SIBO (see 'Bloating') Treat as recommended by microbiologist Version 7. January

9 Borborygmi Cont. Carbohydrate challenge Carbohydrate malabsorption Treatment plan for carbohydrate malabsorption (see 'Bloating') 2nd line: Chromogranin A&B + Gut hormones+ Urinary 5HIAA Carcinoid syndrome If all tests are negative, but symptoms persist Reassure Change in Bowel Habit Most patients will have change in their bowel habit from preradiotherapy, but this section is to help investigate those with a sudden recent change Routine blood screen AND additional blood screen AND colonoscopy Non GI causes for symptoms Newly diagnosed neoplasia Newly diagnosed IBD If all tests are negative, but symptoms persist Reassure Version 7. January

10 Constipation This is also the Algorithm guideline for 'Evacuation difficulty' Abdominal / rectal examination AND routine blood screen AND additional blood screen Dietary/ lifestyle assessment Constipation / Evacuation disorder SIBO Dietary / lifestyle advice 1. Correct positioning +/- rectal evacuant 2. Bulk laxative +/-rectal evacuant 3. Refer for biofeedback therapy if refractory Treatment plan for SIBO (see Bloating ) Abdominal X-ray Upper GI endoscopy with duodenal aspirate and biopsies and/or glucose hydrogen (methane) breath test Non GI causes for symptoms Newly diagnosed neoplasia Newly diagnosed IBD Diarrhoea - loose / semi formed stool. Colonoscopy Routine blood screen AND additional blood screen Abnormal results Follow guidelines for abnormal blood results pg. 4, 5 See also the guideline for 'Diarrhoea watery stool' (except here colonoscopy is performed in preference to flexi sigmoidoscopy) AND serum Mg2+ Mg2+ low Coeliac screen Coeliac disease 1. If IgA deficient, request IgG Coeliac screen 2. Confirm with duodenal biopsy 3. Refer to dietician / GP for gluten free diet and annual monitoring including bone densometry Stool sample for microscopy, culture + Clostridia Difficile toxin Stool contains pathogen Treat as recommended by the microbiologist Version 7. January

11 Diarrhoea - loose / semi formed stool cont'd Upper GI endoscopy with duodenal aspirate and biopsies and/or glucose hydrogen (methane) breath test SIBO Treatment plan for SIBO (see Bloating ) This is also the guideline for 'Frequency of defaecation' and Nocturnal defaecation Lactose challenge ie. remove lactose from diet for one week and then reintroduce and/or lactose hydrogen breath test Lactose Intolerance Treatment for lactose intolerance 1. Written Information Sheet AND 2. Long term lactose free diet AND 3. Refer to dietician: diet and calcium intake Flexible sigmoidoscopy with biopsies from non-irradiated bowel (being careful to avoid biopsies from areas obviously irradiated in sigmoid and rectum) Radiation proctopathy & frequency of defaecation Radiation proctopathy and loose stool 1. Pelvic floor & toileting exercises - min. 6 weeks (Info Sheet) 2. Add stool bulking agent to pelvic floor exercise regimen 3. Anti-diarrhoeal +/- stool bulking agent +/- stimulant laxative suppository / enema 4. Low dose anti-depressant Anti-diarrhoeal +/- stool bulking agent +/- pelvic floor & toileting exercises SeHCAT scan Bile acid malabsorption Treatment for bile acid malabsorption 1. Written information and 2. Bile acid sequestrant + annual monitoring of fat soluble vitamin levels, triglycerides and trace elements 3. Add an anti-diarrhoeal agent 4. Low fat diet 5. MCT predominant diet with dietician supervision Dietary history Excess / inadequate fibre Excessive caffeine/alcohol 1. Simple advice (eg Fibre Information Sheet) 2. Dietetic review Version 7. January

12 Diarrhoea - loose / semi formed stool cont'd If all tests are negative, but symptoms persist If borderline or below normal Vitamin B12 level consider treatment for SIBO even in the absence of positive duodenal aspirate culture and negative breath test and see if Vitamin B12 corrects after treatment. Otherwise consider 1. 2nd line investigations: gut hormones / chromogranin A&B +/- urinary 5HIAA 2. Symptomatic treatment with anti-diarrhoeal agent Diarrhoea - watery stool Follow guidelines for Diarrhoea loose / semi formed stool Follow guidelines for 'Diarrhoea / loose stool' BUT as1st line: perform colonoscopy with biopsies rather than flexible sigmoidoscopy Macroscopic or microscopic colitis Organic cause Discuss results If all tests are negative, but symptoms persist Evacuation difficulty Flexible sigmoidoscopy Evacuation disorder 1. Correct positioning on lavatory +/- rectal evacuant 2. Biofeedback 3. Discuss specialist referral / specialist tests eg defaecating proctogram or balloon expulsion test Version 7. January

13 Faecal incontinence (Includes soiling, protective liners, pads) Routine blood screen AND additional blood screen Rectal examination Anoscopy Flexible sigmoidoscopy 2nd line: Endo anal ultrasound AND anorectal physiology Abnormal results Radiation proctopathy and faecal incontinence / leakage or Anal sphincter injury Loose stool Follow treatment abnormal blood results pg. 4, 5 1. Pelvic floor & toileting exercises - minimum 6 weeks (Info Sheet) 2. Stool bulking +/- anti-diarrhoeal agent 3. Anti-diarrhoeal agent +/- stimulant laxative suppositories / enemas 4. Topical sympathomimetic agent (eg. phenylephrine) 5. Referral for biofeedback 6. Discuss consideration of defunctioning surgery / sphincter repair Treatment plan for 'Diarrhoea / soft stool' Mucus discharge Treatment plan for mucus 1. Fibre Information Sheet. 2. Pelvic floor & toileting exercises minimum 6 weeks + fibre 3. Stool bulking agent and / or 4. Anti diarrhoeal agent Radiation proctopathy Mucosal prolapse Treatment plan for Faecal incontinence Discuss Unrelated to radiotherapy Discuss Version 7. January

14 Flatulence - excessive wind or can t control wind Dietary review to consider possible reduction in fibre intake Dietary - excess / deficiency of fibre - inadequate fluid intake Refer to dietician for detailed dietary review and advice Abdominal X-ray Faecal overload, constipation Stool bulking agent / laxatives if abdominal X-ray shows faecal loading (follow guidelines for 'Constipation') OGD + D2 Aspirate and/or Glucose hydrogen breath test SIBO Treat SIBO (see 'Bloating') Flexible sigmoidoscopy Organic cause - eg. IBD, neoplasia Lax sphincter muscle 1. Pelvic floor & toileting exercises - minimum 6 weeks (Info Sheet) 2. Stool bulking +/- anti-diarrhoeal agent 3. Anti-diarrhoeal agent +/- stimulant laxative suppositories / enemas 4. Referral for biofeedback Flatulence - oral (burping) Abdominal X-ray OGD +D2 asp. Glucose hydrogen/methane breath test Faecal loading See treatment plan Constipation SIBO If all tests are negative, but symptoms persist See treatment plan SIBO Bloating 1. Trial of a proton pump inhibitor 2. Discuss aerophagia with patient Version 7. January

15 Frequency of defaecation - follow guidelines for 'Diarrhoea/loose stool Loss of sensation unable to discriminate between need to defaecate and to pass urine Follow guidelines for 'Diarrhoea / loose stool' 1st line Routine blood screen AND additional blood screen AND flexible sigmoidoscopy Consider MRI pelvis Abnormal blood results Follow treatment abnormal blood results pg. 4, 5 Organic cause as above eg. IBD, neoplasia Tumour recurrence or other cause for neurological dysfunction Related to radiotherapy 1. Bulking agent + pelvic floor & toileting exercises 2. Biofeedback Mucus +/- leakage (excessive or wet wind ) Rectal examination Organic cause Trial of low fibre diet Flexible sigmoidoscopy If no improvement AND radiation proctopathy Treatment plan for mucus (see Faecal incontinence - soiling ) Version 7. January

16 Nausea Blood screen Metabolic abnormality Liver / biliary pathology Sepsis Antibiotics Urine analysis Metabolic abnormality eg glucosuria, ketonuria Infection Antibiotics Trial of proton pump inhibitor Inflammatory (acid related) Continue intermittent /lower dose proton pump inhibitor and reassess Trial of sucralfate suspension Inflammatory (acid/bile related) Continue intermittent /lower dose sucralfate suspension and reassess Endoscopy Inflammatory / ulcerative 1. Proton pump inhibitor 2. Sucralfate promotility agents 3. Promotility agents Duodenal aspirate/ glucose hydrogen methane breath test Hepatic and pancreatic ultrasound CXR/CT/MRI (including CNS) Small intestine bacterial overgrowth Biliary / hepatic/ pancreatic aetiology Local or distal infection Central nervous system pathology If all tests are negative, but symptoms persist Treatment plan for SIBO (see Bloating ) Treat appropriately Antibiotics Refer to neurology team Version 7. January

17 Nocturnal need to defecate follow guidelines for Diarrhoea Follow guidelines for 'Diarrhoea' Pain - abdomen/cramps follow guidelines for 'Bloating' Follow guidelines for 'Bloating' Pain - back (new onset) Routine blood screen AND additional blood screen Back X-ray CT/MRI/PET scan abdomen and pelvis (to restage patient) Consider a bone scan Abnormal results suggesting relapse Colonic faecal loading Consider referral back to oncologist See treatment plan for 'Constipation' Pain perineal - anal/rectal (typical proctalgia fugax) None needed for typical proctalgia fugax Rectal spasm Treatment for rectal spasm 1. Pelvic floor & toileting exercises 6 weeks 2. Inhaled beta 2 agonist 3. Low dose anti-depressants 4. Consider acupuncture Version 7. January

18 Pain perineal - anal/rectal (related to defaecation) 1st line: Anoscopy and flexible sigmoidoscopy 2nd line: MRI Fistula in ano / abscess Fissure 1. If abscess / fistula, antibiotics and surgical referral 2. If fissure, topical agent eg. diltiazem and analgesia to reduce anal spasm (8 weeks) AND consider stool bulking / softening agent +/- short term topical local anaesthetic 3. If not healed after 2 months, refer for surgical opinion Complex haemorrhoids Surgical review Ano-rectal ulceration Treat the cause, if radiation related 1. Sucralfate enemas 2. Antibiotics 3. Pentoxifylline + Vitamin E 4. Consider stool bulking / softening agent 5. Hyperbaric oxygen Pain perineal - anal/rectal (unrelated to defaecation) Also pruritis (below) 1st line: Anoscopy and flexible sigmoidoscopy Possible diagnoses as above Pain related to defaecation 2nd line: MRI No physical cause identified 1. Pelvic floor & toileting exercises minimum 6 weeks + Information Sheet 2. Low dose anti-depressants 3. Acupuncture 4. Agent for neuropathic pain 5. Consider urological/gynaecological opinion Version 7. January

19 Pruritis (perianal) If loose stool / diarrhoea is present, also see guidance for diarrhoea especially SeHCAT scan Steatorrhoea (see guidelines for 'Diarrhoea - loose stool' re prescription of anti-diarrhoeal) Visual assessment Changes of radiotherapy 1. If soiling see guidance for faecal incontinence p Topical barrier agent 3. Topical corticosteroids (trimovate) 4. No improvement - refer to dermatologist No changes of radiotherapy Refer to dermatologist Stool for faecal elastase Pancreatic insufficiency 1. Written information AND 2. Pancreatic enzyme supplements +/- PPI 3. Refer to dietician: low fat predominant diet 4. Multi vitamin and trace elements supplement 5. Annual monitoring of trace elements by GP Routine blood screens AND additional blood screen AND fat soluble vitamin levels and trace elements Addison's disease / coeliac disease / thyroid dysfunction / Vitamin B12 deficiency Follow treatment abnormal blood results pg. 4, 5 Glucose / hydrogen/ methane breath test for bacterial overgrowth and / or OGD + D2 asp and biopsies Small Intestine Bacterial Overgrowth See treatment plan SIBO Bloating' SeHCAT scan Bile acid malabsorption Treatment for Bile acid malabsorption See Diarrhoea/loose stool Tenesmus Flexible sigmoidoscopy Radiation proctopathy and tenesmus 1. Pelvic floor & toileting exercises - 6 weeks (Information Sheet) and stool bulking agent 2. Low dose anti-depressants 3. Consider acupuncture 4. Biofeedback Version 7. January

20 Urgency of defaecation - follow guidelines for diarrhoea/ loose stool Routine blood screen, AND additional blood screen Flexible sigmoidoscopy Any blood test abnormality Follow treatment abnormal blood results pg. 4, 5 Radiation proctopathy and urgency of defaecation 1. Pelvic floor & toileting exercises - 6 weeks (Information Sheet) 2. Stool bulking agent 3. Anti-diarrhoeal agent 4. Low dose anti-depressants 5. Biofeedback Vomiting Blood screen 1. Drug / medication related 2. Alcohol related 3. Metabolic 4. Endocrine Urine analysis + culture Infective Follow recommendations of microbiologist Trial of proton pump inhibitor Trial of Sucralfate suspension Endoscopy (+ duodenal aspirate) Glucose hydrogen / methane breath test / trial of antibiotics Metabolic Inflammatory (acid related) Inflammatory (acid/bile related) Inflammatory/ ulceration Small intestinal bacterial overgrowth Continue intermittent / lower dose proton pump inhibitor and reassess Continue intermittent / lower dose Sucralfate suspension and reassess Proton pump inhibitor Sucralfate Promotility agents See treatment plan for SIBO 'Bloating' Version 7. January

21 Vomiting cont'd CT/MRI Bowel obstruction Admit to hospital Consider CT MRI head Neurological disease Weight loss - unexplained Dietary review Routine blood screen AND additional blood screen OGD AND Colonoscopy CT chest abdomen and pelvis Abnormal results Organic cause No organic cause Follow treatment abnormal blood results pg. 4, 5 Refer for expert advice Refer to dietician and review regularly Any of the above symptoms requiring hospital admission Discuss Any symptoms not covered in the management plan Discuss Clinical depression Discuss Version 7. January