1)
I always assume that something can be changed to reduce or eliminate
the diarrhea, even if the doctors seem to think the diarrhea is a
"given".
2)
Try to change only one aspect of treatment or care at a time to evaluate
what works and what doesn't.
3)
As the patient's RD, I always try to work with the patient and his/her
doctor to determine if there are any medications that might be helpful,
i.e., H2 blockers, anti-motility agents, and bile acid sequestrants.
4)
I ask patients to keep a detailed diet diary (all foods and beverages),
what food is eaten, portion sizes, if foods are hot or cold, are foods
eaten in a restaurant, take out food, or home made, time of day food
is eaten, and also a detailed symptom diary. Discuss the food and
symptom diary with the RD who will try to determine if the symptoms
are related to the food intake or even the timing of the food consumption.
This process may take several weeks to evaluate and see patterns!
5)
Never assume what bothers one person will bother the next person.
Everyone is soooo different! Example: One of my patients could not
tolerate any leftover foods or foods served from a salad bar. I think
this might be due to higher bacterial contents of these foods.
6)
If a patient cannot tolerate whole fruits and vegetables, try either
baby foods (can even buy organic baby foods) or juicing.
7)
One caveat, avoid "gassy" vegetables at all times, even
when juicing (i.e., all members of the broccoli family, onions).
8)
Encourage intake of yogurt with active cultures or kefir - approximately
8 ounces per day. Use a lactase tablet. Also consume lactase treated
milk and use lactase tablets for other dairy products.
9)
Consider use of a probiotic supplement. (Probiotics and benefits with
radiation diarrhea. Eur J Gastroenterol Hepatol 2001; 13: 391-396)
One supplement of this type is called Culturell.
Take 2 capsules twice daily for a month (available over the counter
at most pharmacies).
10)
Start psyllium three times/day or Benefiber right from the start.
11)
Use soluble fiber foods like oatmeal or oat bran bread while avoiding
insoluble fiber foods like whole wheat, whole rye products or other
whole grains.
12)
Avoid hard-to-digest foods like corn, gassy vegetables like Brussels
sprouts and other cabbage family foods, all fatty foods, caffeine,
alcohol, and spicy foods.
13)
Some patients will have diarrhea no matter what fruits, vegetables,
and other foods are eliminated. Patients may find the use of Imodium
will control the diarrhea without needing to be so restrictive with
the diet.
14)
Review all herbs and other dietary supplements with your RD for possible
side effects like diarrhea. One case report in the medical literature
has shown that unexplained diarrhea resolved upon discontinuing the
herb milk thistle (Adverse Drug Reactions Advisory Committee. An adverse
reaction to the herbal medication milk thistle (Silybum marianum).
Med J Aust 1999;170:218-9.)
15)
Avoid foods high in in-soluble fiber, which are foods made from whole
grains. Also avoid raw whole fruits and vegetables, nuts, beans and
legumes.
16)
Consider adding 400 IU of vitamin E and 500 mg vitamin C three times
daily. ("Successful and sustained treatment of chronic radiation
proctitis with antioxidant vitamins E and C", Kennedy M, et al.
Am J of Gastroenterology 2001;96:1080-1084) Try for 8 weeks to see
if diarrhea is reduced or eliminated. (This study used these anti-oxidant
supplements after radiation was completed, not during therapy.)
17)
"Rice Congee" may really help! Combine 1 cup long-cooking
WHITE rice with 6-7 cups of water and one-tablespoon of salt; cook
this according to package directions (usually ~ 40 minutes); this
will be a 'sticky, soupy' mixture; eat and drink mixture. If broth
is used instead of water, omit the salt.
18)
Many RD's use glutamine therapy to help those people with chronic
diarrhea that does not resolve with other dietary changes. Use 10
gm three times per day mixed with clear juice or water. (Do not use
without consulting your RD or MD. Do not use if you have decreased
liver or kidney function.) If glutamine is going to work, you should
see results in three days. Two brands that have been used in research
studies are:
(a)
Cambridge
Sympt-X marketed by Baxter
(b)
GlutaSolve
by Novartis.
19)
Be sure to have "C. diff" (clostridium difficiles) ruled
out. C. diff is an overgrowth of normally present GI bacteria that
can produce loose and crampy stools.
20)
To compensate for any possible vitamin and mineral malabsorption due
to the diarrhea, one RD recommends a Flintstones Chewable complete
vitamin twice daily for a month then go to one daily or switch to
a Centrum Silver type if the diarrhea has lessened or stopped.
21)
Have your doctor and dietitian order blood work to evaluate levels
of fat-soluble vitamins and vitamin B12. In addition, a stool sample
should be checked for bile salt malabsorption with a bile acid sequestrant
like cholestyramine added if needed.
22)
See the following web site for even more additional helpful information
regarding management of diarrhea. www.cancernutritioninfo.com,
click on Treatment Symptom Management, then click on diarrhea.
23) I have heard of several recently reported cases of patients developing intractable diarrhea after cancer therapy who were finally tested and found to have previously undiagnosed celiac disease (gluten intolerance). Counseling from a Registered Dietitian and adherence to a strict gluten-free diet completely eliminated the chronic diarrhea.
24) Some RDs are reporting that a few patients have had successful resolution of long-standing diarrhea by the use of either acupuncture or massage.
25) Words of wisdom from a very experienced dietitian:
For
one specific patient, it helped her just to have the knowledge of
what she could and could not tolerate. Prior to working with her,
she felt completely out of control, not knowing if eating would
precipitate diarrhea or not. This knowledge was empowering in and
of itself. Although she has to avoid some foods high in insoluble
fiber, she was able to systematically try different foods to learn
her own tolerances.
26)
Lastly, if all of these efforts fail, consider the observation of
another very experienced dietitian:
I
have had several patients with long standing diarrhea, bowel urgency
and incontinence after treatment. I tried everything from glutamine,
paregoric, high soluble fiber, and anything else that the MD would
agree to try. I kept coming across a common problem; they had very
low re-anastamosis surgeries. There was a surgeon in town that tried
to save many patients from the humiliation of a colostomy by "doing
them a favor" and reattaching them even if there was precious
little rectum or sphincter tone. All of our patients regained a
normal life after getting an ostomy. I know that this is not the
answer many patients are looking for, but these people were truly
happy with the results and not having to wear diapers or being afraid
of having an accident.
