Because of the potentially life-threatening nature of diarrhea, rapid, yet thorough, assessment is imperative. Few standardized assessment tools are available, and studies suggest that, as a result, standardized assessment is rare in the clinical setting. For a complete assessment, one author suggests obtaining background information from the patient that includes the type and extent of the patient's cancer, anticancer treatment, comorbid factors, coexisting symptoms, patient and provider perceptions, as well as a thorough description of the diarrhea. Stringent monitoring conducted at least weekly is indicated during therapy using chemotherapeutic agents known to cause diarrhea. The NCI's Common Terminology Criteria for Adverse Events (Table 1) evaluate diarrhea by number of stools per day, incontinence, and increase in ostomy output compared to baseline.
The history also should include questions regarding the frequency of bowel movements during the past 24 hours, the character of the fecal material, and the time course of the development of diarrhea. One author has developed a visual tool to assist patients and families in characterizing the consistency of the stool. Six diagrams illustrate fecal material consistency ranging from well-formed, formed, and semiformed to loose, very loose, and liquid. Patients should be questioned regarding related symptoms that might indicate hemodynamic compromise or the underlying etiology. Specifically, questions should include information about dizziness, orthostatic symptoms, lethargy, cramping, abdominal pain, nausea, vomiting, fever, and rectal bleeding. These symptoms should be classified as complicated or uncomplicated, with therapy based on these classifications. Uncomplicated symptoms include grade 1 or 2 diarrhea with no other signs or symptoms. Management is conservative. Complicated symptoms include grade 1 or 2 diarrhea with any one of the following risk factors: moderate to severe cramping, grade 2 or higher nausea/vomiting (see Table 3), decreased performance status, fever, sepsis, neutropenia, frank bleeding, or dehydration. Grade 3 or 4 diarrhea is also classified as complicated. Thorough evaluation and close monitoring is warranted. The time course of diarrhea and concomitant symptom development are key to determining underlying etiology. Medication and dietary intake, as well as a history of recent travel, may provide additional clues regarding etiology. Weight loss and reduced urine output provide additional data regarding the severity of the effects of diarrhea.
Table 3. National Cancer Institute's Common Terminology Criteria for Adverse Events: Nausea and Vomitinga
TPN = total parenteral nutrition.
a Adapted from National Cancer Institute.
b Definition: A disorder characterized by a queasy sensation and/or the urge to vomit.
c Definition: A disorder characterized by the reflexive act of ejecting the contents of the stomach through the mouth.
|Nauseab||1||Loss of appetite without alteration in eating habits|
|2||Oral intake decreased without significant weight loss, dehydration, or malnutrition|
|3||Inadequate oral caloric or fluid intake; tube feeding, TPN, or hospitalization indicated|
|4||Grade not available|
|5||Grade not available|
|Vomitingc||1||1-2 episodes (separated by 5 min) in 24 h|
|2||3-5 episodes (separated by 5 min) in 24 h|
|3||?6 episodes (separated by 5 min) in 24 h; tube feeding, TPN, or hospitalization indicated|
|4||Life-threatening consequences; urgent intervention indicated|