Gastrointestinal complications of oncologic therapy. ACTA ACUST UNITED AC. 2008;5:682-696. [PMID: 18941434 DOI: 10.1038/ncpgasthep1277]

Antitumoral Agent-Induced Constipation: A Systematic Review

BACKGROUND

Constipation is a common symptom in patients receiving antitumoral treatment. The mechanisms underlying antitumoral agent-induced constipation (ATAIC) are poorly defined. This systematic review aimed to analyze and synthesize the available information related to the prevalence, etiology, and treatment of ATAIC.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted. The review included human studies written in English, French, or Spanish involving patients with cancer and containing information about the prevalence, etiology, and treatment of ATAIC.

RESULTS

A total of 73 articles were included. The reported prevalence ranged from 0.8% to 86.6%. Six studies reported an ATAIC prevalence of over 50%. The prevalence rates of constipation of grades 3 and 4 ranged between 0 and 11%. The importance of enteric neuronal integrity in gastrointestinal function was reported. The articles with the highest levels of evidence in relation to ATAIC treatment obtained in this systematic review studied treatments with acupuncture, sweet potato, osteopath, probiotics, and moxibustion.

CONCLUSIONS

The prevalence of constipation in patients undergoing antitumoral treatment is very diverse. Studies specifically designed to report the prevalence of antineoplastic treatment-induced constipation are needed. The importance of enteric neuronal integrity in gastrointestinal function was described. Thus, neuroprotection could be an area of research for the treatment of chemotherapy-induced gastrointestinal disorders.

Probiotic OMNi-BiOTiC® 10 AAD Reduces Cyclophosphamide-Induced Inflammation and Adipose Tissue Wasting in Mice

Cancer therapy is often associated with severe side effects such as drug induced weight loss, also known as chemotherapy-induced cachexia. The aim of this study was to investigate the effects of a multispecies probiotic (OMNi-BiOTiC® 10 AAD) in a chemotherapy mouse model. A total of 24 male BALB/c mice were gavage-fed with the probiotic formulation or water, once a day for 3 weeks. In the third week, the mice received intraperitoneal cyclophosphamide. At euthanasia, the organs were dissected, and serum was sampled for cytokine analysis. Tight junction components, myosin light chain kinase, mucins, and apoptosis markers were detected in the ileum and colon using histological analyses and qRT-PCR. Lipolysis was analyzed by enzymatic activity assay, Western blotting analyses, and qRT-PCR in WAT. The fecal microbiome was measured with 16S-rRNA gene sequencing from stool samples, and fecal volatile organic compounds analysis was performed using gas chromatography/mass spectrometry. The probiotic-fed mice exhibited significantly less body weight loss and adipose tissue wasting associated with a reduced CGI58 mediated lipolysis. They showed significantly fewer pro-inflammatory cytokines and lower gut permeability compared to animals fed without the probiotic. The colons of the probiotic-fed animals showed lower inflammation scores and less goblet cell loss. qRT-PCR revealed no differences in regards to tight junction components, mucins, or apoptosis markers. No differences in microbiome alpha diversity, but differences in beta diversity, were observed between the treatment groups. Taxonomic analysis showed that the probiotic group had a lower relative abundance of Odoribacter and Ruminococcus-UCG014 and a higher abundance of Desulfovibrio. VOC analysis yielded no significant differences. The results of this study indicate that oral administration of the multispecies probiotic OMNi-BiOTiC® 10 AAD could mitigate cyclophosphamide-induced chemotherapy side effects.

Small Bowel Lymphoma Complicated With Ischemic Colitis: A Case Report

Ischemic colitis is thought to be an injury to the colon as a result of reduced blood flow. Certain infectious diseases such as the Epstein-Barr virus can aid in the reduction of blood flow. The insult can range from inflammation and superficial injury to full-thickness necrosis. The typical regions affected are the "watershed" areas of the colon: the splenic flexure, the rectosigmoid junction, and the right colon. Because patients can present with a wide spectrum of symptoms from vague abdominal discomfort to complete abdominal catastrophe, the diagnosis of ischemic colitis is sometimes challenging to make. Patients typically present with the acute onset of crampy abdominal pain and usually pass blood mixed with stool within 24 hours. Endoscopically, ischemia is suspected in the presence of bluish hemorrhagic nodules from submucosal bleeding, cyanotic or necrotic mucosa with bleeding ulcerations, or a segmental distribution with an abrupt transition point between injured and normal mucosa. We present a case of an 80-year-old male with a history of hypertension, hyperlipidemia, and basal cell carcinoma of the scalp diagnosed with ischemic colitis associated with positive Epstein-Barr virus B cell lymphoma.

Neutropenic Enterocolitis: An Uncommon, but Fearsome Complication of Leukemia

Neutropenic enterocolitis (NEC) is a life-threatening condition occurring in severely neutropenic patients, following intensive chemotherapy for leukemia. Its pathogenesis is not entirely understood and believed to be multifactorial, including mucosal injury as a result of cytotoxic drugs, profound neutropenia, impaired host defense and possibly microbiota changes. Establishing an early diagnosis is key. The management of NEC remains undefined due to lack of high-quality clinical data. With a better understanding of the disease, a more conservative approach is preferred over surgical intervention. The involvement of a multi-disciplinary team, consisting of the oncologist, infectious diseases specialists and surgeons is highly recommended. This review aims to delineate insights into the pathophysiology and clinical presentation of NEC and to emphasize the diagnostic and therapeutic approach to this condition.

Probiotic Supplementation Attenuates Chemotherapy-Induced Intestinal Mucositis in an Experimental Colorectal Cancer Liver Metastasis Rat Model

The use of chemotherapeutic agents is of paramount importance when treating colorectal cancer (CRC). Unfortunately, one of the most frequent chemotherapy (CTx) side effects is intestinal mucositis (IM), which may present with several clinical symptoms such as nausea, bloating, vomiting, pain, and diarrhea and even can result in life-threatening complications. There is a focused scientific effort towards developing new therapies to prevent and treat IM. The aim of this study was to assess the outcomes of probiotic supplementation on CTx-induced IM in a CRC liver metastasis rat model. Six-week-old male Wistar rats received either a multispecies probiotic or placebo mixture. On the 28th experiment day, rats received FOLFOX CTx, and afterwards, the severity of diarrhea was evaluated twice daily. Stool samples were collected for further microbiome analysis. Additionally, immunohistochemical stainings of ileum and colon samples with were performed with MPO, Ki67, and Caspase-3 antibodies. Probiotic supplementation alleviates the severity and length of CTx-induced diarrhea. Additionally, probiotics significantly reduced FOLFOX-induced weight and blood albumin loss. Furthermore, probiotic supplementation mitigated CTx-induced histological changes in the gut and promoted intestinal cell regeneration. This study shows that multispecies probiotic supplementation attenuates FOLFOX-induced IM symptoms by inhibiting apoptosis and promoting intestinal cell proliferation.

Factors associated with long-term gastrointestinal symptoms in colorectal cancer survivors in the women's health initiatives (WHI study)

PURPOSE

Colorectal cancer (CRC) survivors often experience long-term symptoms after cancer treatments. But gastrointestinal (GI) symptom experiences are under-investigated in CRC survivors. We described persistent GI symptoms after cancer treatments in female CRC survivors and assessed GI symptoms' risk and life-impact factors.

METHODS

A cross-sectional study utilized data from the Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) study that recruited postmenopausal women. Correlation analyses and multivariable linear regression models were used.

RESULTS

CRC survivors after cancer treatments were included (N = 413, mean age 71.2 years old, mean time since diagnosis = 8.1 years). 81% of CRC survivors experienced persistent GI symptoms. Bloating/gas was the most prevalent (54.2%± 0.88) and severe GI symptom, followed by constipation (44.1%±1.06), diarrhea (33.4%±0.76), and abdominal/pelvic pain (28.6%±0.62). Significant risk factors for GI symptoms include time since cancer diagnosis (<5 years), advanced cancer stage, high psychological distress, poor dietary habits, and low physical activity. Fatigue and sleep disturbance were the most significant risk factors for long-term GI symptoms (β = 0.21, t = 3.557; β = 0.20, t = 3.336, respectively, Ps < .001). High severity of GI symptoms was positively associated with poor quality of life (QOL), increased daily life interferences (social and physical functions), and low body image satisfaction (Ps < .001).

CONCLUSIONS

Women CRC survivors experience a high GI symptom burden, highlighting the need to inform policy and improve the QOL of cancer survivors. Our findings will aid in identifying those more vulnerable to symptoms, and inform future survivorship care interventions (i.e., community-based cancer symptom management) by considering multiple risk factors (e.g., psychological distress).

Outcome and Determinants of Neutropenic Enterocolitis in Pediatric Cancer Patients

BACKGROUND

Neutropenic enterocolitis (NEC) is a dreaded complication of chemotherapy. There is scant literature regarding incidence, clinical features, and determinants. The understanding of gut dysbiosis in NEC and pediatric cancer is evolving.

METHODS

Pediatric cancer patients with neutropenia and gastrointestinal symptoms were evaluated for NEC with contrast-enhanced computed tomography abdomen. Clinical, imaging, and laboratory features were analyzed. Fecal samples were analyzed for fecal calprotectin by sandwich enzyme-linked immunoassay and gut microbiota by conventional culture and compared with healthy controls and children without NEC.

RESULTS

NEC was diagnosed in 44 children based on clinical and imaging features with incidence of 7.4% (4 had recurrent episodes). Common manifestations included fever (98%), pain abdomen (88%), and diarrhea (83%). Hypoalbuminemia was observed in 78% of patients. Large bowel involvement (94%) with diffuse bowel involvement (63%) and pancolitis (64%) were common. Fecal calprotectin was significantly elevated in NEC group than non-NEC group and healthy controls (median: 87, 53, and 42 µg/g, respectively). A higher degree of gut dysbiosis was observed in children with NEC with higher isolation of Bacteroides and infrequent isolation of Lactobacilli. Mortality rate of 23% was observed. Only the presence of free fluid predicted higher mortality. Though levels of fecal calprotectin and gut dysbiosis were higher in NEC, they did not increase mortality. Isolation of Bacteroides and absence of Lactobacilli predicted a longer duration of intravenous alimentation.

CONCLUSIONS

NEC caused significant morbidity and mortality in pediatric cancer patients. Gut dysbiosis was significantly higher in NEC group suggesting a role in pathogenesis and influencing outcome. This highlights the role of targeted interventions towards gut dysbiosis like prebiotics and probiotics.

A Review of Potential Role of Capsule Endoscopy in the Work-Up for Chemotherapy-Induced Diarrhea

Chemotherapy-induced diarrhea (CID) is a common, severe side effect of chemotherapy, immunotherapy, and targeted therapy. Because patients are more prone to continuing chemotherapy if they do not suffer from CID, appropriate diagnosis and monitoring of this disease are essential. However, suitable monitoring methods are yet to be developed. To date, several studies have shown that small-bowel capsule endoscopy (SBCE) is useful in visualizing the entire small intestinal mucosa and detecting small intestinal abnormalities, including bleeding, malignant tumors, and mucosal injury, associated with the use of nonsteroidal anti-inflammatory drugs and low-dose aspirin. Currently, limited studies have evaluated the small intestinal mucosa using SBCE in patients receiving fluoropyrimidine-based chemotherapy or immune checkpoint inhibitors. These studies have reported that small intestinal mucosal injury is common in patients with severe fluoropyrimidine-induced diarrhea. SBCE might be a useful screening method for the early detection of enterocolitis induced by immune checkpoint inhibitors. SBCE may be a powerful tool for the diagnosis and monitoring of CID, and understanding its indication, contraindication, and capsule-retention risk for each patient is important for clinicians.

A Smartphone-Based Decision Support Tool for Predicting Patients at Risk of Chemotherapy-Induced Nausea and Vomiting: Retrospective Study on App Development Using Decision Tree Induction

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) are the two most frightful and unpleasant side effects of chemotherapy. CINV is accountable for poor treatment outcomes, treatment failure, or even death. It can affect patients' overall quality of life, leading to many social, economic, and clinical consequences.

OBJECTIVE

This study compared the performances of different data mining models for predicting the risk of CINV among the patients and developed a smartphone app for clinical decision support to recommend the risk of CINV at the point of care.

METHODS

Data were collected by retrospective record review from the electronic medical records used at the University of Missouri Ellis Fischel Cancer Center. Patients who received chemotherapy and standard antiemetics at the oncology outpatient service from June 1, 2010, to July 31, 2012, were included in the study. There were six independent data sets of patients based on emetogenicity (low, moderate, and high) and two phases of CINV (acute and delayed). A total of 14 risk factors of CINV were chosen for data mining. For our study, we used five popular data mining algorithms: (1) naive Bayes algorithm, (2) logistic regression classifier, (3) neural network, (4) support vector machine (using sequential minimal optimization), and (5) decision tree. Performance measures, such as accuracy, sensitivity, and specificity with 10-fold cross-validation, were used for model comparisons. A smartphone app called CINV Risk Prediction Application was developed using the ResearchKit in iOS utilizing the decision tree algorithm, which conforms to the criteria of explainable, usable, and actionable artificial intelligence. The app was created using both the bulk questionnaire approach and the adaptive approach.

RESULTS

The decision tree performed well in both phases of high emetogenic chemotherapies, with a significant margin compared to the other algorithms. The accuracy measure for the six patient groups ranged from 79.3% to 94.8%. The app was developed using the results from the decision tree because of its consistent performance and simple, explainable nature. The bulk questionnaire approach asks 14 questions in the smartphone app, while the adaptive approach can determine questions based on the previous questions' answers. The adaptive approach saves time and can be beneficial when used at the point of care.

CONCLUSIONS

This study solved a real clinical problem, and the solution can be used for personalized and precise evidence-based CINV management, leading to a better life quality for patients and reduced health care costs.

The Impact of Probiotics on Intestinal Mucositis during Chemotherapy for Colorectal Cancer: A Comprehensive Review of Animal Studies

Colorectal cancer (CRC) is the second most commonly diagnosed cancer in females (incidence 16.4/10,000) and the third in males (incidence 23.4/10,000) worldwide. Surgery, chemotherapy (CTx), radiation therapy (RTx), or a combined treatment of those are the current treatment modalities for primary CRC. Chemotherapeutic drug-induced gastrointestinal (GIT) toxicity mainly presents as mucositis and diarrhea. Preclinical studies revealed that probiotic supplementation helps prevent CTx-induced side effects by reducing oxidative stress and proinflammatory cytokine production and promoting crypt cell proliferation. Moreover, probiotics showed significant results in preventing the loss of body weight (BW) and reducing diarrhea. However, further clinical studies are needed to elucidate the exact doses and most promising combination of strains to reduce or prevent chemotherapy-induced side effects. The aim of this review is to overview currently available literature on the impact of probiotics on CTx-induced side effects in animal studies concerning CRC treatment and discuss the potential mechanisms based on experimental studies’ outcomes.

The Superoxide Dismutase Mimetic M40403, Improves 5-Fluorouracil-induced Small Intestinal Mucositis in a Mouse Model

BACKGROUND/AIM

Intestinal mucositis with diarrhea is a dose-limiting toxicity of 5-fluorouracil (5-FU). M40403, a superoxide dismutase mimetic, was evaluated on whether it improves the mucositis with diarrhea.

MATERIALS AND METHODS

BALB/c mice were treated with daily intraperitoneal injections of 5-FU±M40403 for five consecutive days. Following treatment, light microscopy (apoptosis), electron microscopy (autophagy), and analyses for the expression of apoptosis/autophagy-related proteins were performed in analysing small intestinal samples. Body weight, diarrhea score, blood cytokine levels, complete blood count, and blood chemistries were measured. The in vivo anti-tumor activity of 5-FU±M40403 was also evaluated.

RESULTS

M40403 improved 5-FU-induced intestinal mucositis (apoptosis and autophagy) and attenuated 5-FU-induced changes in the expression of apoptosis/autophagy-related proteins, weight loss, diarrhea score, and serum TNF-α levels. M40403 neither added further adverse effects nor compromised the anti-tumor activity during 5-FU treatment.

CONCLUSION

M40403 can be useful in improving 5-FU-induced intestinal mucositis with diarrhea.

Gut Microbiota as a Positive Potential Therapeutic Factor in Carcinogenesis: an Overview of Microbiota-Targeted Therapy

Cancer therapeutic methods comprising chemotherapy, radiotherapy, and surgery are so routine in cancer treatment. Remarkably, there are several personal features which affect the effectiveness of such treatments including nutrition, microbiome diversity, and physical activity which has distinct significant roles during and after therapies along with their bilateral connections. In this way, the ability of gut microbiota36 in modulating the efficacy of chemotherapeutic medications in cancer and other types of disorders is of great importance. In addition, the role of dietary, probiotic, and synthetically engineered bacteria in manipulating and optimizing the gut microbiota is of interest. Conspicuously, the correlation between the commensal microbiota and also host can regulate the physiological activities comprising the immunity system and inflammatory agents and it is scanned in the category of cancers. Bacterial species have been employed in cancer therapy; commensal microbes posse a key beneficial role in this field. Practically, the microbiota has this potential to accelerate and modulates a certain response by priming in order to release the pro-inflammatory agents. We would like to discuss these vital factors in this review as gut microbiota has the potential to be the main option for personalized cancer treatment strategies in the future. Meaning, this novel data present clinical promising feasibilities of modulating cancer therapy with using microbiota.

Assessment of diarrhea as side effect of oral targeted antineoplastic agents in clinical practice

BACKGROUND

Diarrhea is one of the most frequent class adverse events associated with targeted oral antineoplastic agents (OAAs). Our objective was to analyze the incidence, characteristics, and severity of diarrhea in cancer patients in clinical practice.

METHODS

An observational, longitudinal, and prospective study of cancer outpatients treated with targeted OAAs was carried out in a tertiary hospital. Targed OAAs analyzed were anaplastic lymphoma kinase inhibitors, BCR-ABL inhibitors, cyclin-dependent kinase inhibitors, epidermal growth factor receptor inhibitors, mTOR inhibitors, poly (ADP-ribose) polymerase inhibitors, and vascular endothelial growth factor receptor inhibitors. Patients were given a data collection form to record daily the number, severity (CTCAE version 5.0), and characteristics of stools during the first 30 days of treatment with OAAs. Multivariate analysis was performed to identify risk factors associated with the incidence of diarrhea.

RESULTS

We analyzed 240 patients, of whom 28.7% experienced diarrhea (25.4% grades 1-2 and 3.3% grades 3-4). Patients treated with EGFR and VEGFR inhibitors had a higher incidence of diarrhea. The multivariate analysis revealed that taking the OAA with food was associated with a lower risk of diarrhea (OR = 0.404 [0.205-0.956], p = 0.038).

CONCLUSIONS

More than a third of patients in treatment with OAAs presented diarrhea (any grade), and 22.1% of stools were semi-liquid/liquid. In multivariate analysis, taking the OAA on an empty stomach was associated with a statistically significant increase in the incidence of diarrhea.

Paclitaxel-Induced Bowel Perforation: A Rare Cause of Acute Abdomen

Paclitaxel, a chemotherapeutic agent, is routinely administered for the treatment of various solid organ malignancies. In rare instances, patients receiving infusions of paclitaxel may present with signs of an acute abdomen. Ischemia and necrosis of the bowel wall from chemotherapy-induced neutropenia and direct toxic effects of the drug have been implicated as the cause. We present a case of necrotizing small and large bowel perforation in a patient with breast cancer, 2 weeks after paclitaxel administration.

A dynamic prediction engine to prevent chemotherapy-induced nausea and vomiting

BACKGROUND

Cancer remains the second major cause of death in the United States over the last decade. Chemotherapy is a core component of nearly every cancer treatment plan. Chemotherapy-Induced Nausea and Vomiting (CINV) are the two most dreadful and unpleasant side-effects of chemotherapy for cancer patients. Several patient-specific factors affect the risk of CINV. However, none of the guidelines consider those factors. Not all of the patients have the similar emetic risk of CINV. Despite the improvements in CINV management, as many as two-thirds of chemotherapy patients still experience some degree of CINV. As a result, physicians use their personal experiences for CINV treatment, which leads to inconsistent managements of CINV.

OBJECTIVE

The overall objective of this study is to improve the prevention of CINV using precise, personalized and evidence-based antiemetic treatment before chemotherapy. In CINV prediction, one of the interesting factors is that CINV has two distinct and complex pathophysiologic phases: acute and delayed. In addition, the risk factors and their associations are different for different emetogenic chemotherapies (e.g., low, moderate, and high). There are six contexts considering the combination of phases and emetogenicity levels. This will require the creation of six different models. Instead, our objective was to describe a single framework named "prediction engine" that can perform prediction query without losing the sensitivity to each context. The prediction engine discovers how the patient-related variables and the emetogenecity of chemotherapy are associated with the risk of CINV for each phase.

METHODS

This was a single-center retrospective study. The data were collected by retrospective record review from the electronic medical record system used at the University of Missouri Ellis Fischel Cancer Center. An association rule-based dynamic and context-sensitive Prediction Engine has been developed. Physicians receive feedback about CINV risks of patients from the CINV decision support system based on patient-specific factors.

RESULTS

The prediction performance of the system outperformed many popular prediction methods and all the results of CINV risk prediction published in the literature. Best prediction performance was achieved using the rule-ranking approach. The accuracy, sensitivity, and specificity were 87.85 %, 87.54 %, and 88.2 %, respectively.

CONCLUSIONS

The system used the patient-specific risk factors for making personalized treatment recommendations for CINV. It solved a real clinical problem that will shorten the gap between clinical practices and evidence-based guidelines for CINV management leading to the practice of personalized and precise treatment recommendation, better life quality of patient, and reduced healthcare cost. The approach presented in this article can be applied to any other clinical predictions.

Consumption of Lactose, Other FODMAPs and Diarrhoea during Adjuvant 5-Fluorouracil Chemotherapy for Colorectal Cancer

Chemotherapy-induced mucosal injury of the small intestine may interfere with the enzymes and transporters responsible for the hydrolysis and absorption of dietary carbohydrates causing diarrhoea, abdominal discomfort and pain. The aim of this study was to investigate the association between the consumption of foods rich in FODMAPs (fermentable oligo-, di- and monosaccharides and polyols) and gastrointestinal symptoms in patients receiving adjuvant therapy for colorectal cancer. The patients (n = 52) filled in a 4-day food diary at baseline and during therapy and kept a symptom diary. The intakes of FODMAP-rich foods were calculated as portions and the intakes were divided into two consumption categories. Patients with high consumption of FODMAP-rich foods had diarrhoea more frequently than those with low consumption (for lactose-rich foods the odds ratio (OR) was 2.63, P = 0.03; and for other FODMAP-rich foods 1.82, P = 0.20). Patients with high consumption of both lactose-rich and other FODMAP-rich foods had an over 4-fold risk of developing diarrhoea as compared to those with low consumption of both (OR, 4.18; P = 0.02). These results were confirmed in multivariate models. Conclusion: Consumption of lactose-rich foods results in an increased risk of diarrhoea during adjuvant therapy for colorectal cancer, especially when the consumption of other FODMAP-rich foods is also high.

Pathogens causing diarrhoea among Bangladeshi children with malignancy: Results from two pilot studies

BACKGROUND

Diarrhoea is a frequent symptom in children with cancer, and occurs due to a composite effect of underlying disease and immunosuppression consequent to therapy, malnutrition, and non-infective aetiologies such as mucositis. In a large proportion of cases, the aetiology of diarrhoea remains unknown but is often attributed to multiple pathogens including parasites.

AIM

To identify and describe the pathogens causing diarrhoea in Bangladeshi children with cancer.

METHODS

Two cross-sectional pilot studies were conducted involving paediatric oncology patients with diarrhoea. Stool samples were collected from children who were hospitalised with or without being treated with chemotherapy during the study period, and had diarrhoea at any stage during their admission. In the first study, stool samples were tested by conventional microbiological methods and by polymerase chain reaction for parasites, and by immunoassays for Clostridium difficile. In the second study, conventional microbiology was conducted for bacteria and parasites including an enzyme-linked immunosorbent assay for Cryptosporidium antigen, and in a subset, immunoassays for Clostridium difficile.

RESULTS

In the first study Giardia lamblia was detected in 68.5% of samples, Entamoeba histolytica in 13%, Cryptosporidium in 5.6%, non-toxigenic C. difficile in 22.4%, and other bacteria in 5.2%. In the second study, E. histolytica was detected in 10% of samples, Cryptosporidium in 4.3%, G. lamblia in 1.4%, C. difficile in 5.1%, and other bacteria in 5.7% of samples.

CONCLUSION

These pilot data suggest that parasites are important aetiologies of diarrhoea in Bangladeshi children with malignancy. While molecular diagnostic tools detect an array of stool pathogens with greater sensitivity, conventional diagnostic methods are also useful.

SCID/NOD mice model for 5-FU induced intestinal mucositis: Safety and effects of probiotics as therapy

BACKGROUND

For chemotherapy patients, intestinal mucositis is a frequent complication. Previously, we evaluated the beneficial effect of oral probiotics in 5-Fluorouracil (5-FU) induced mucositis in BALB/c mice. Here, we used SCID/NOD mice instead to simulate the immunodeficiency of chemotherapy patients: first, to evaluate the safety of probiotic supplementation and second, to determine the probiotic effect in response to 5-FU intestinal mucositis.

METHODS

Thirty-six SCID/NOD mice were injected with saline (three control groups) or 5-FU (three experimental groups) intraperitoneally daily for five days. Mice were given either oral saline daily, probiotic suspension of Lactobacillus casei variety rhamnosus (Lcr35, Antibiophilus™, France) or Lactobacillus acidophilus and Bifidobacterium bifidum (LaBi, Infloran™, Italy). Blood, liver, spleen, and lymph node tissue samples were evaluated for probiotic translocation via culture and Q-PCR. Weight change, diarrhea score, jejunal villus height (VH) and crypt depth (CD), and serum cytokine levels of TNF-α, IFNγ, IL-1β, IL-6, IL-4, IL-10, IL-13, and IL-17 were also assessed.

RESULTS

No weight loss was found in the SCID control group. Mean weight loss of 10.63 ± 0.87% was noted by day five in 5-FU group without probiotics but it was only 6.2 ± 0.43% if mice were given Lcr35 (p < 0.01) and 7.1 ± 1.80% (p < 0.01) if they were given LaBi. Diarrhea score of 5-FU group without probiotics was 2.0 ± 0.0 by day five, which dropped to 1.33 ± 0.17 (p < 0.05) and 1.42 ± 0.24 (p < 0.05) with Lcr35 and LaBi, respectively. Average VH significantly decreased and CD significantly increased in SCID mice given 5-FU. With probiotics, average CD improved (p < 0.05) while VH lengthened as well. Besides IL-13, all cytokine levels increased in 5-FU SCID mice. Both Lcr35 and LaBi significantly inhibited serum cytokines (p < 0.05). No probiotic strains were detected in blood cultures of any mice.

CONCLUSION

Using SCID/NOD mice as a novel model for 5-FU induced intestinal mucositis, we find that probiotics Lcr35 and LaBi do not lead to bacteremia, can improve diarrhea and body weight, can restore jejunal crypt depth, and significantly inhibit cytokines TNF-α, IL-1β, IFNγ, IL-6, IL-4, IL-10, and IL-17.

Targeted Therapies: Immunologic Effects and Potential Applications Outside of Cancer

Two pharmacologic approaches that are currently at the forefront of treating advanced cancer are those that center on disrupting critical growth/survival signaling pathways within tumor cells (commonly referred to as "targeted therapies") and those that center on enhancing the capacity of a patient's immune system to mount an antitumor response (immunotherapy). Maximizing responses to both of these approaches requires an understanding of the oncogenic events present in a given patient's tumor and the nature of the tumor-immune microenvironment. Although these 2 modalities were developed and initially used independently, combination regimens are now being tested in clinical trials, underscoring the need to understand how targeted therapies influence immunologic events. Translational studies and preclinical models have demonstrated that targeted therapies can influence immune cell trafficking, the production of and response to chemokines and cytokines, antigen presentation, and other processes relevant to antitumor immunity and immune homeostasis. Moreover, because these and other effects of targeted therapies occur in nonmalignant cells, targeted therapies are being evaluated for use in applications outside of oncology.

Biliary and pancreatic complications of molecular targeted therapies in cancer imaging

The purpose of this review is to familiarize radiologists with the different imaging manifestations of biliary and pancreatic toxicity of molecular targeted therapies. The advent of molecular targeted therapies for cancer treatment has prompted radiologists to be familiar with these new molecules, their patterns of response, and their class-specific toxicities. While liver and bowel toxicities have been extensively reported in literature, less is known about the pathogenesis and imaging of toxicity involving the pancreatobiliary system. Biliary and pancreatic toxicity of molecular targeted therapies present with variable manifestations and varying degrees of severity, from asymptomatic liver function tests elevation to acute pancreatitis or cholecystitis. Management of these conditions depends on the clinical scenario and the severity of the findings. In this article, we will (1) present the various classes of molecular targeted therapies most commonly associated with biliary and pancreatic toxicity; (2) illustrate imaging findings of drug-associated biliary and pancreatic injuries and their possible differential diagnosis; and (3) provide a guide for management of these conditions.

Esophagitis and its causes: Who is “guilty” when acid is found “not guilty”?

Esophagitis is mainly a consequence of gastroesophageal reflux disease, one of the most common diseases affecting the upper digestive tract. However the esophageal mucosa can also be targeted by some infectious, systemic or chemical conditions. Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory disease, characterized by eosinophilic infiltration in the mucosa. Esophageal localization of Crohn’s disease is not very common, but it should always be considered in patients with inflammatory bowel disease complaining of upper digestive tract symptoms. There are also forms of infectious esophagitis (e.g., Herpes simplex virus or Candida albicans) occurring in patients with a compromised immune system, either because of specific diseases or immunosuppressive therapies. Another kind of damage to esophageal mucosa is due to drug use (including oncologic chemotherapeutic regimens and radiotherapy) or caustic ingestion, usually of alkaline liquids, with colliquative necrosis and destruction of mucosa within a few seconds. Dysphagia is a predominant symptom in EoE, while infectious, drug-induced and caustic damages usually cause chest pain and odynophagia. Endoscopy can be useful for diagnosing esophagitis, although no specific pattern can be identified. In conclusion when a patient refers upper gastrointestinal tract symptoms and the diagnosis of gastro-esophageal reflux disease is not convincing we should always carefully investigate the patient’s clinical history to consider possibilities other than the gastric refluxate.

The clinical characteristics and manifestations of cytomegalovirus esophagitis

Esophagitis is the second most common gastrointestinal manifestation of cytomegalovirus (CMV) infection after colitis. CMV esophagitis has been reported in patients who have undergone transplantation, are on long-term renal dialysis, or who have the human immunodeficiency virus infection. This study aimed to investigate the clinical characteristics and manifestations of CMV esophagitis in patients who underwent diagnostic endoscopy. A total of 16 patients with histologically proven CMV infection were identified from 1539 patients with esophageal ulcers and analyzed retrospectively (January 2006 to December 2013). Patients' personal data (age, smoking, and alcohol consumption), underlying systemic diseases (diabetes mellitus, end-stage renal disease, and chronic obstructive pulmonary disease), malignancy, indication for esophagogastroduodenoscopy, endoscopic characteristics, and diagnostic methods (pathological or serological findings) were collected for further analysis. Among the patients with CMV esophagitis, the mean age was 59.94 years (range, 23-84 years). The male : female ratio was 1.67:1. Odynophagia and epigastralgia were common symptoms. Of the 16 patients, 3 (18.75%) were infected with the human immunodeficiency virus and 9 (56.25%) had an underlying malignancy, including lung cancer (6 patients), esophageal cancer (2 patients), gastric cancer (1 patient), ampulla of Vater cancer (1 patient), and lymphoma (1 patient). Six of the 9 patients (66.7%) with malignancy had been administered concurrent chemoradiotherapy (CCRT). In this study, patients with malignancy who had been administered CCRT were at increased risk for CMV esophagitis, which had not been reported before in the literature. CMV esophagitis should be considered as a potential treatment-related complication of CCRT.

[Ipilimumab-induced colitis: A new challenge for gastroenterologists]

Many drugs can produce enterocolitis and they should always be included in the differential diagnosis of this clinical picture. Entities such as antibiotic-associated colitis and neutropenic colitis have been known for some time and recently a new type of drug-induced colitis has emerged due to monoclonal antibodies. Ipimumab is a humanized monoclonal antibody against the CTLA4 molecule that is involved in the maturation and regulation of T lymphocyte activation. This drug causes immune activation and has an immune-mediated antitumor effect with excellent results in tumours such as melanoma. However, several immune-related adverse effects may occur in different organs. The most frequently involved site is the gastrointestinal tract, with adverse effects ranging from mild diarrhoea to colitis with systemic involvement, intestinal perforation, and even death. Although no similarities have been found in the pathogenesis with inflammatory bowel disease, treatments have been used in correlation with its autoimmunological profile: anti-TNF alpha corticosteroids have shown clinical efficacy in moderate to severe disease. However the use of anti-TNF treatment has not been defined and the safety profile is unknown. The inclusion of these new therapies in the treatment of several tumours requires familiarity with these entities and their management should be approached as a new challenge for the gastroenterologist. For that reason, we conducted a review of ipilimumab-induced colitis, evaluating essential features of its symptoms, diagnosis and treatment.

ErbB small molecule tyrosine kinase inhibitor (TKI) induced diarrhoea: Chloride secretion as a mechanistic hypothesis

Diarrhoea is a common, debilitating and potentially life threatening toxicity of many cancer therapies. While the mechanisms of diarrhoea induced by traditional chemotherapy have been the focus of much research, the mechanism(s) of diarrhoea induced by small molecule ErbB TKI, have received relatively little attention. Given the increasing use of small molecule ErbB TKIs, identifying this mechanism is key to optimal cancer care. This paper critically reviews the literature and forms a hypothesis that diarrhoea induced by small molecule ErbB TKIs is driven by intestinal chloride secretion based on the negative regulation of chloride secretion by ErbB receptors being disrupted by tyrosine kinase inhibition.

Assessment and management of gastrointestinal toxicities and lab abnormalities related to targeted therapy

OBJECTIVES

To identify the most common gastrointestinal toxicities and laboratory abnormalities associated with targeted therapies, as well as the assessment and management necessary to minimize adverse events related to these side effects.

DATA SOURCES

Peer-reviewed articles and national guidelines for oncology practice.

CONCLUSION

Common toxicities of diarrhea, mucositis, and laboratory abnormalities are often associated with the use of targeted agents and require skilled assessment and early management interventions to prevent severe complications or treatment interruption.

IMPLICATIONS FOR NURSING PRACTICE

Emerging trends focused on targeted therapy increase the importance of the oncology nurse's role in assessment, education, and evidenced-based recommendations to meet patient needs.

Graft-versus-host disease in oncology nursing practice

INTRODUCTION

Gastrointestinal graft-versus-host disease (GI-GvHD) is extremely debilitating and is multifactorial in its causative factors, management and treatment. It is an exaggeration of normal physiological mechanisms wherein the donor immune system attempts to rid itself of the host. The inflammatory process that follows has the benefit of providing an anti-tumour effect for many diseases, but unfortunately in patients undergoing human stem-cell transplantation, the nature of the inflammation can result in disability, wasting and death.

AIM

The aim of this article is to discuss the pathophysiology of this often misunderstood or misdiagnosed condition, as well as its signs and symptoms, management and considerations for nursing care. Considerations for nursing practice: While the medical management is aimed at minimising GvHD through the reduction of T-cell production and proliferation and gastrointestinal decolonisation, the nursing care is often focused on the signs and symptoms that can have the most prominent impact on patients.

CONCLUSION

GI-GvHD has serious life-threatening complications, namely wasting syndrome, diarrhoea and dehydration. The basis of signs and symptomology is easily recognisable owing to the stages of progression through the human stem-cell transplantation process. Oncology nurses are in a prime position to identify these serious risks, initiate treatment immediately and collaborate effectively within the multidisciplinary team to minimise GvHD onset and provide expert support to patients, family and caregivers.

Targeted therapy-induced diarrhea: A review of the literature

PURPOSE OF RESEARCH

Revision of the literature on targeted therapy-induced diarrhea (TT-ID).

PRINCIPAL RESULTS

TT-ID is frequent; the mechanisms are mainly secretive, followed by ischemic or autoimmune ones. The duration of TT-ID is protracted over time. Its intensity is of grade G1-G3 but may be fatal in patients with diffuse colitis or on ipilimumab. However, no specific guidelines are available on management of different grades of TT-ID. Preventive measures with antibiotics, probiotics or activated charcoal should be further investigated. Loperamide is the first choice drug followed by octreotide. The role of corticosteroids is controversial.

CONCLUSION

Early assessment and management of TT-ID is essential to prevent the worsening of this side-effect, patients' hospitalization and dose reduction or oncological treatment discontinuation. Future research is needed to better understand the pathophysiological mechanisms of TT-ID and it should also be investigated whether a specific pharmacological and/or non pharmachological approach is indicated.

Chimonanthus nitens var. salicifolius Aqueous Extract Protects against 5-Fluorouracil Induced Gastrointestinal Mucositis in a Mouse Model

Gastrointestinal mucositis is a major side effect of chemotherapy, leading to life quality reduction in patients and interrupting the therapy of cancer. Chimonanthus nitens var. salicifolius (CS) is a traditional Chinese herb for enteral disease. Considering the protective effect of CS on intestine, we hypothesize that the aqueous extract of CS could be benefcial to gastrointestinal mucositis. To verify this, a mouse mucositis model was induced by 5-Fluorouracil (5-Fu). Male Balb/C mice were treated with CS aqueous extract (5, 10, and 20 g/kg) or loperamide (0.2 mg/kg) intragastrically for 11 days, and the severity of mucositis was evaluated. Furthermore, the chemical compounds of CS aqueous extract were also analysed by high-performance liquid chromatography (HPLC). Our results demonstrated that CS aqueous extract improved mice body weight, diarrhoea, and faecal blood, maintained the liver function and intestinal length, alleviated villus shortening, and suppressed the apoptosis and inflammation in small intestine. We concluded that CS could protect mice against 5-Fu induced mucositis by inhibiting apoptosis and inflammation, and this protective effect might be associated with the 3 flavonoids (rutin, quercetin, and kaempferol) identified in CS aqueous extract.

Diarrhea in neutropenic children with cancer: An Egyptian center experience, with emphasis on neutropenic enterocolitis

Background:

Diarrhea is a frequent complication in children with cancer who received intensive chemotheraputic regimens. It may be caused by several factors, neutropenic enterocolitis (NE) being the most serious.

Aim:

To study diarrhea in neutropenic cancer patients in the pediatric age group, with its underlying etiologies and risk factors, especially the bacterial causes, with special concern on NE.

Materials and Methods:

This study was carried out at the Pediatric Hematology and Oncology Units, Zagazig University Hospitals, Egypt, from January 2009 to September 2010. All children with malignant diseases who are ≤12 years of age were included. Patients who were neutropenic (<500/ mm³) on admission or who became neutropenic during their stay in the hospital were monitored regularly (daily) for diarrhea. Neutropenic cancer patients with diarrhea were grouped into two groups: Group 1, with NE, and group 2, with neutropenic diarrhea rather than NE. On the first day of diarrhea, patients were subjected to complete blood count, blood cultures, stool microscopy and culture. Abdominal ultrasonography was carried out within 3 days of diarrhea.

Results:

A total of 200 children ≤12 years old, suffering from different malignancies, with a total of 180 neutropenic episodes were followed. Diarrhea was observed in 100 episodes (55.5%). NE constituted 16% of these diarrheal episodes. All patients with NE had significantly more severe neutropenia, and this was of longer duration than the other group. All patients with NE were febrile, with 100% positive blood culture. Stool analysis diagnosed giardiasis in 4.8% of the non-NE patients and in none of the NE patients, while stool culture was positive in 75% of the NE patients compared with 40.5% of the other group.

Conclusions:

Diarrhea is a common complication in neutropenic cancer children. Gram negative bacteria and Candida are the most incriminated pathogens. Duration and severity of neutropenia carry a great risk for the development of NE.

[Esophageal toxicity of radiation therapy: clinical risk factors and management]

Acute radiation-induced esophagitis includes all clinical symptoms (odynophagia, dysphagia) occurring within 90 days after thoracic irradiation start. Its severity can be graded using RTOG and CTCAE scales. The clinical risk factors are: age, female gender, initial performance status, pre-therapeutic body mass index, pre-therapeutic dysphagia, tumoral and nodal stage, delivered dose, accelerated hyperfractionned radiotherapy, concomitant association of chemotherapy to radiotherapy and response to the treatment. The dosimetric parameters predictive of esophagitis are: mean dose, V(20Gy), V(30Gy), V(40Gy), V(45Gy) and V(50Gy). Amifostine is the only drug to have a proven radioprotective efficacy (evidence level C, ESMO recommendation grade III). The medical management of esophagitis associates a diet excluding irritant food, medication against gastroesophageal reflux, analgesic treatment according to the WHO scale and management of dehydration and denutrition by enteral feeding.

Chemotherapy-induced diarrhea: pathophysiology, frequency and guideline-based management

Diarrhea is one of the main drawbacks for cancer patients. Possible etiologies could be radiotherapy, chemotherapeutic agents, decreased physical performance, graft versus host disease and infections. Chemotherapy-induced diarrhea (CID) is a common problem, especially in patients with advanced cancer. The incidence of CID has been reported to be as high as 50-80% of treated patients (≥30% CTC grade 3-5), especially with 5-fluorouracil bolus or some combination therapies of irinotecan and fluoropyrimidines (IFL, XELIRI). Regardless of the molecular targeted approach of tyrosine kinase inhibitors and antibodies, diarrhea is a common side effect in up to 60% of patients with up to 10% having severe diarrhea. Furthermore, the underlying pathophysiology is still under investigation. Despite the number of clinical trials evaluating therapeutic or prophylactic measures in CID, there are just three drugs recommended in current guidelines: loperamide, deodorized tincture of opium and octreotide. Newer strategies and more effective agents are being developed to reduce the morbidity and mortality associated with CID. Recent research focusing on the prophylactic use of antibiotics, budesonide, probiotics or activated charcoal still have to define the role of these drugs in the routine clinical setting. Whereas therapeutic management and clinical work-up of patients presenting with diarrhea after chemotherapy are rather well defined, prediction and prevention of CID is an evolving field. Current research focuses on establishing predictive factors for CID like uridine diphosphate glucuronosyltransferase-1A1 polymorphisms for irinotecan or dihydropyrimidine-dehydrogenase insufficiency for fluoropyrimidines.

Clinically defined chemotherapy-associated bowel syndrome predicts severe complications and death in cancer patients

BACKGROUND

Neutropenic patients are at risk of abdominal complications and yet the incidence and impact of these complications on patients' morbidity and mortality have not been sufficiently evaluated. We aimed to assess a clinical rule for early detection of abdominal complications leading to death or transfer to intensive care in patients with chemotherapy-associated neutropenia.

DESIGN AND METHODS

This observational multicenter study was carried out in seven German hematology-oncology departments. For inclusion, neutropenia of at least 5 consecutive days was required. Risk factors for "transfer to intensive care" and "death" were assessed by backward-stepwise binary logistic regression analyses. Chemotherapy-associated bowel syndrome was defined as a combination of fever (T ≥37.8 °C) and abdominal pain and/or lack of bowel movement for 72 hours or more. Five hundred and twenty-one neutropenic episodes were documented in 359 patients.

RESULTS

The incidence of chemotherapy-associated bowel syndrome was 126/359 (35%) in first episodes of neutropenia. Transfer to intensive care occurred in 41/359 (11%) and death occurred in 17/359 (5%) first episodes. Chemotherapy-associated bowel syndrome and duration of neutropenia were identified as risk factors for transfer to intensive care (P<0.001; OR 4.753; 95% CI 2.297-9.833, and P=0.003; OR 1.061/d; 95% CI 1.021-1.103). Chemotherapy-associated bowel syndrome and mitoxantrone administration were identified as risk factors for death (P=0.005; OR 4.611; 95% CI 1.573-13.515 and P=0.026; OR 3.628; 95% CI 1.169-11.256).

CONCLUSIONS

The occurrence of chemotherapy-associated bowel syndrome has a significant impact on patients' outcome. In future interventional clinical trials, this definition might be used as a selection criterion for early treatment of patients at risk of severe complications.

Chemotherapy-Induced Ischemic Colitis in a Patient with Jejunal Lymphoma

The occurrence of acute ischemic colitis may be associated with the intake of various drugs. However, colitis during antineoplastic chemotherapy usually is due to toxic effects or neutropenia and not caused by ischemia. We describe a 51-year-old man with jejunal B-cell lymphoma who developed recurrent episodes of ischemic colitis following chemotherapy with cyclophosphamide, vincristine, doxorubicine and prednisolone plus rituximab (R-CHOP). After switching chemotherapy to bendamustin plus rituximab no further episodes of colonic ischemia occurred during the following cycles of chemotherapy. In conclusion, chemotherapy of lymphoma using a standard protocol with CHOP and rituximab may cause ischemic colitis.

Esophageal involvement by extranodal natural killer T cell lymphoma, nasal type, mimicking Ebstein Barr viral esophagitis in a tonsillar lymphoma patient undergoing chemoradiation therapy

Esophageal involvement by extranodal natural killer (NK)/T cell lymphoma, nasal type, is rare. As a result, esophageal symptoms in these patients might at first be thought to originate from a benign condition, such as viral esophagitis. It is important to note, however, that benign conditions may mask esophageal involvement by lymphoma. Until now, there has been no report documenting esophageal involvement by lymphoma mimicking viral esophagitis in an extranodal NK/T cell lymphoma patient undergoing active treatment. Here, we report a case of esophageal involvement by extranodal NK/T cell lymphoma, nasal type, initially misdiagnosed as Ebstein Barr virus esophagitis. Lymphoma invasion of the esophagus should be considered if esophageal symptoms do not respond to usual medical esophagitis therapy in an extranodal NK/T cell lymphoma, nasal type, patient undergoing chemoradiation.

Incidence and risk factors for lower alimentary tract mucositis after 1529 courses of chemotherapy in a homogenous population of oncology patients: clinical and research implications

BACKGROUND

Lower alimentary tract mucositis is a serious complication of chemotherapy. The aim of the study was to determine the incidence, risk factors, and mortality of lower alimentary tract mucositis in a homogeneous population of patients with newly diagnosed myeloma receiving similar antineoplastic therapy and standardized supportive care.

METHODS

Lower alimentary tract mucositis was evaluated among 303 consecutive patients with myeloma (2004-2007) enrolled in a clinical trial consisting of induction chemotherapy, tandem melphalan-based autologous stem cell transplantation (ASCT), and consolidation. Lower alimentary tract mucositis was defined as neutropenia-associated grade II-IV enteritis/colitis. Pretreatment risk factors were examined including body surface area (BSA), serum albumin (albumin), and estimated creatinine clearance (CrCl). Multiple logistic regression model was used to compute adjusted odds ratio (OR) and 95% confidence intervals (CI).

RESULTS

Forty-seven (15.5%) patients developed lower alimentary tract mucositis during 1529 courses of chemotherapy (including 536 melphalan-based ASCT). Pre-enrollment BSA <2 m² (OR, 2.768; 95% CI, 1.200-6.381; P = .0169) increased the risk for lower alimentary tract mucositis, whereas higher albumin was protective (OR, 0.698; 95% CI, 0.519-0.940; P = .0177). Pretransplant variables associated with lower alimentary tract mucositis were BSA <2 m² (OR, 4.451; 95% CI, 1.459-13.58, P = .0087) and estimated CrCl <60 mL/min (OR, 3.493; 95% CI, 1.173-10.40; P = .0246). Higher albumin level conferred protection (OR, 0.500; 95% CI, 0.304-0.820; P = .0061). No lower alimentary tract mucositis-related death was observed.

CONCLUSIONS

Lower alimentary tract mucositis is not uncommon among a homogenous population of oncology patients undergoing sequential courses of chemotherapy including melphalan-based ASCT but does not contribute to mortality. Lower BSA, renal function, and albumin are associated with increased risk for lower alimentary tract mucositis.

The gastrointestinal complications of oncologic therapy

A spectrum of oncologic treatments including chemotherapy, radiotherapy, and molecular targeted therapies is available to combat cancer. These treatments are associated with adverse effects in several organ systems including the gastrointestinal (GI) tract. The immunocompromised state induced by oncologic therapy is also an important contributing factor underlying GI complications. This review discusses common GI complications that can result from cancer therapy. The pathologic mechanisms underlying each complication and the pharmacology of the agents used to treat these complications are discussed.

Recurrent spontaneous gastrointestinal graft-versus-host disease in autologous hematopoietic stem cell transplantation

Acute graft-versus-host disease (GVHD) is a major complication after allogeneic stem cell transplantation (SCT). A similar manifestation involving skin, gastrointestinal (GI) mucosa, and liver can occur after autologous hematopoietic SCT (autoHSCT), either spontaneously or after treatment with cyclosporine or interferon. Severity of spontaneous GI GVHD among patients treated with autoHSCT is variable. Recurrent spontaneous GI GVHD induced by succeeding cycles of chemotherapy has rarely been reported and is poorly understood. Enteric-coated budesonide has been studied extensively in Crohn's disease, and beclomethasone has been studied in GI GVHD. There are no comparative studies between these drugs for GI GVHD. Furthermore, GI GVHD has to be considered when microbiologic workup remains negative during the workup of persistent diarrhea in autoHSCT. Endoscopic appearances can be normal, and pathologic diagnosis is essential. Further research into risk factors involving type of chemotherapy, interval between chemotherapies, and gene polymorphisms have to be considered for better understanding of autologous GVHD. We report for the first time a patient with spontaneous recurrent GI GVHD after autoHSCT for multiple myeloma with predominant lower GI symptoms and excellent response to enteric-coated budesonide therapy.

Diarrhea and malabsorption in the elderly

Acute and chronic diarrheal disorders are common problems at all ages. It has been estimated that 5% to 7% of the population has an episode of acute diarrhea each year and that 3% to 5% have chronic diarrhea that lasts more than 4 weeks. It is likely that the prevalence of diarrhea is similar in older individuals. This article reviews the impact of diarrhea in the elderly, many of whom are less fit physiologically to withstand the effect of diarrhea on fluid balance and nutritional balance.