Medical management includes treating diarrhea, dehydration, malabsorption, and abdominal or rectal discomfort. Symptoms usually resolve with medications, dietary changes, and rest. If symptoms become severe despite these measures, a treatment break may be warranted.
Medications may include the following:
Kaopectate, an antidiarrheal agent. Dose: 30 cc to 60 cc by mouth after each loose bowel movement.
Lomotil (diphenoxylate hydrochloride with atropine sulfate). Usual dose: One or two tablets by mouth every 4 hours as needed. Dose can be adjusted to individual patients and patterns of diarrhea. For example, one patient may achieve control of diarrhea with one tablet 3 times a day, while another patient may require two tablets every 4 hours. Patients are not to take more than eight tablets of Lomotil within a 24-hour period.
- Paregoric, an antidiarrheal agent. Usual dose: 1 teaspoon by mouth 4 times a day as needed for diarrhea. Paregoric may also be alternated with Lomotil.
Cholestyramine, a bile salt sequestering agent. Dose: one package by mouth after each meal and at bedtime.
Donnatal, an anticholinergic antispasmodic agent to alleviate bowel cramping. Dose: One or two tablets every 4 hours as needed.
Imodium (loperamide hydrochloride), a synthetic antidiarrheal agent. Recommended initial dose: two capsules (4 mg) by mouth every 4 hours, followed by one capsule (2 mg) by mouth after each unformed stool. Daily total dose should not exceed 16 mg (eight capsules).
In addition to these medications, opioids may offer relief from abdominal pain. If proctitis is present, a steroid foam given rectally may offer relief from symptoms. Finally, if patients with pancreatic cancer are experiencing diarrhea during radiation therapy, they should be evaluated for oral pancreatic enzyme replacement, as deficiencies in these enzymes alone can cause diarrhea.
The role of nutrition
Damage to the intestinal villi from radiation therapy results in a reduction or loss of enzymes, one of the most important of these being lactase. Lactase is essential in the digestion of milk and milk products. Although there is no evidence that a lactose-restricted diet will prevent radiation enteritis, a diet that is lactose free, low fat, and low residue can be an effective modality in symptom management.[Level of evidence: I]
Foods to avoid
- Milk and milk products. Exceptions are buttermilk and yogurt, which are often tolerated because lactose is altered by the presence of Lactobacillus. Processed cheese may also be tolerated because the lactose is removed with the whey when it is separated from the cheese curd. Milkshake supplements such as Ensure are lactose free and may be used.
- Whole-bran bread and cereal.
- Nuts, seeds, and coconuts.
- Fried, greasy, or fatty foods.
- Fresh and dried fruit and some fruit juices such as prune juice.
- Raw vegetables.
- Rich pastries.
- Popcorn, potato chips, and pretzels.
- Strong spices and herbs.
- Chocolate, coffee, tea, and soft drinks with caffeine.
- Alcohol and tobacco.