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1 劉狀行率 7-10% 寧療見狀不不良降不不寧療 (06) EXT (06) m @yahoo.com.tw 342 寧療年 11

2 行率 Conill 9.1% Sykes 寧 7-10% Solano 3-29% 1, 2 見狀不不良降識不異力流量不理 59 () 糖尿行寧 7-8 寧 ( ) 力 ( 便 ) (loperamide 4mg/day 8mg/day 2 + Omeprazole 20mg 1 + Durogesic patch 25µg/h + morphine(10mg) 1#q8h + Levofloxacin (500 mg) qd/ac) 理 ( 流料 ) 便數便 4 / 了便 () 便 7 糖 79mg/dl 識不降不臨理便數便狀便量 (pseudodiarrhea) 便便量數便不便數寧療年

3 2 4 3 例療塞不良 4 類見狀 70% 5 療塞不良療 5-fluorouracil, Irinotecan, and Docetaxel 類 mefenamic acid, diclofenac, indomethacin Mitomycin 糖療惡便塞 (narcotic bowel syndrome) 切切切類糖尿狀量離泌離不 5 1. 量 (1) (osmotic) 泌 (secretory) 泌便離離度 2( 離 + 離 ) 50mmole/l 若 50mmole/l 泌 6 () 不良 (carbohydrate malabsorption) ( 例糖不 ) (poorly absorbed carbohydrate) ( 例 lactulose, sorbitol, polyethyleneglycol ) 離不良離 ( 例硫 ) 344 寧療年 11

量 (1) (osmotic) 泌 (secretory) 泌便離離度 2( 離 + 離 ) 50mmole/l 若 50mmole/l 泌 6 () 不良 (carbohydrate

4 泌便度泌 24 便量便 (mosm/kg) Na (meq/liter) K (meq/liter) (Na + K) 2 (mosm/kg) * * = (Na + K) 2 泌泌 (secretagogues) ( 例 ) 泌 ( 例 ) 塞便塞 (Addison s disease) ( 例切 ) 泌來刺泌 serotonin, substance P, gastrin, calcitonin 泌類見狀 (2) 不良 (malabsorption) 不良例淋塞不良切不良刺 2. 離泌離 (1) 90% Salmonella spp. E.coliShigella spp.campylobacter jejuni Yersinia spp.vibrio spp.aeromonas spp. Clostridium difficlerotavirusgiardiae. histolytica 7 臨狀數例 Salmonella spp. E.coliShigella spp.giardia Vibrio spp Clostridium difficle 2000 年 Clostridium difficle 2000 年 2005 年率 3 寧療年

離泌離 (1) 90% Salmonella spp. E.coliShigella spp.campylobacter jejuni Yersinia spp.vibrio spp.aeromonas spp. Clostridium difficlerotavirusgiardiae.

5 6.9% 率 Clostridium difficle Clostridium difficle (pseudomembranous colitis) 見 Clostridium difficle 療療量殺 Clostridium difficle 不 (toxic megacolon) () 8 療 Clostridium difficle Metronidazole 250mg ( 不 ) Vancomycin125mg ( ) 療 Clostridium difficle 不 (2) ( 例隆 (Crohn s disease)) 淋 (Lymphocytic and collagenous colitis) ( 例 (eosinophilic gastroenteritis) (graft-vs-host disease) 3. 不不 dumping 切 (ileocecal valve) 切惡類 (carcinoid syndrome) 狀糖尿不了 (steatorrhea) 便量便 3 量便便 6 /24 若 ( 例 ) 列來 ( 量便量 100 / 量 ) 數 95% 6 不良不良 (intraluminal malabosrption) 346 寧療年 11

(Lymphocytic and collagenous colitis) ( 例 (eosinophilic gastroenteritis) (graft-vs-host disease) 3.

6 ( 例泌不路塞 (cystic fibrosis) 泌 (somatostatinoma) 度塞 ) 不良 (mucosal malabsorption) ( 例 celiac sprue, Whipple s disease, ) 塞 (post-mucosal obstruction) ( 例淋塞 ) 切切切 (Bariatric surgery) (fundoplication) 見 (National Cancer Institute Common Toxicity Criteria, NCICTC) 療度 0 1 ( 度 ) ( 度 ) 4-6 度 3 ( 度 ) 7-9 便 4 () 10 便便數便量便便量狀狀不見便數量便降兩便不良便塞便塞律 dumping 臨暈糖療療狀 10 糖尿 ( 老年 ) 狀理便塞寧療年

Cancer Institute Common Toxicity Criteria, NCICTC) 療度 0 1 ( 度 ) 2-3 2 ( 度 ) 4-6 度 3 ( 度 ) 7-9 便 4 () 10 便便數

7 狀狀淋例良療類良療不良淋 AIDS 糖尿 Zollinger-Ellison 類 (carcinoid syndrome) (blind loop syndrome) Addison s disease 度狀類 (carcinoid syndrome) 泌 gastrin 便便 ( ) 良 60-80% 11 便蘭 (Gram s stain) 來 Staphylococcus, Campylobacter Candida 類狀 () 了狀了 X 流寧療年 11

syndrome) 泌 gastrin 便便 ( ) 良 60-80% 11 便蘭 (Gram s stain) 來

8 理度度度便便不老便 ** * metronidazole 療 ** quinolone 療療療流寧療年

9 狀 3 例不來 3 便不良便便不良便便 (functional diarrhea) 切切 lactose, sorbitol 流 350 寧療年 11

10 Hb, Alb 降 MCV, MCH 不便 K + 降類療切便量切 48 便 PH 量便量便量異行行療流了不糖糖不不療列類泌類便 Shigella C. difficile 惡 Shigella C. difficile 寧療年

11 1. (absorbent agents) (bulk-forming agents) 例 (methyl cellulose) (pectin) 狀便度更說便 48 不不便 (42 )(187 ) kaopectin 2. (adsorbent agents) 例 (kaolin)(chalk) attapulgite 量率 (kaolin) (chalk) attapulgite 1.2 立 (hydrated aluminum silicate)attapulgite 力 attapulgite 33 療力 attapulgite 量量不寧療 3. 列 (mucosal prostaglandin inhibitors) 例 aspirin, 量 4 bismuth subsalicylate, 量 5 mesalazine, 列泌列 ( mefenamic acid indomethacin ) Mesalazine 5-amino-salicylic acid 列 bismuth subsalicylate 了列 Escherichia coli 12 bismuth subsalicylate 異列異 aspirin 療 mesalazine 4. 類例 codeineloperamide diphenoxylate 量率 codeine loperamide diphenoxylate 類類類 352 寧療年 11

4 (hydrated aluminum silicate)attapulgite 力 attapulgite 33 療力 attapulgite 量量不寧療 3. 列 (mucosal prostaglandin inhibitors) 例 aspirin, 4 300 量 4 bismuth subsalicylate, 0.

12 泌來 loperamide 離流類力便 codeine loperamide 便不 diphenoxylate 不 13 loperamide 類不 (blood-brain barrier) loperamide 量不良類 codeine 5.24diphenoxylate 23.7 loperamide 552 loperamide 類 loperamide 4mg/day codeine 200mg/day diphenoxylate 10mg/day 類療 loperamide ( 量 ) 度 loperamide 不良例塞不類 Codeine 類 () 便寧療 5. 泌類 (somatostatin analogues) 例 octreotidelanreotide 量率 octreotide mcglanreotide 泌 D 泌來泌 octreotide 療 carcinoid Zollinger-EllisonVerner-Morrison 泌類列療 octreotide haloperidol midazolam hyoscine 不 cyclizine octreotide, mcg/24h 85% 惡塞狀療 octreotide 2400mcg/24h 14 Lanreotide 數便來寧療年

泌類 (somatostatin analogues) 例 octreotidelanreotide 量率 octreotide 24 300-600mcglanreotide 14 30 泌 D 泌來泌 octreotide 療 carcinoid

13 療 fluoroquinolones ( (1) ciprofloxacin, 500mg 12 1 (2) ofloxacin, 400mg 12 1 (3) pefloxacin, 400mg 12 1 ) pefloxacin fluoroquinolones 7 療 4 療療 Pancreatin( 若 H 2 更 ) cholestyramine, (chologenic diarrhea) 療 cholestyramine, aspirin Zollinger-Ellison H 2 ranitidine, 類 (carcinoid syndrome) cyproheptadine, 12 methysergide, (pseudomembranous colitis) metronidazole 療 7-14 vancomycin125 4 療 7-14 vancomycin 15 mesalazine (ulcerative colitis) 例 Calcium carbonate5-ht P (substance P) Calcium carbonate 5-HT P (neurohumoral) 5-hydroxy-tryptamine (5-HT), P vasoactive intestinal peptide (VIP) 16 狀寧寧療年 11

14 1-2 (loperamide 4 便 ofloxacin 療 cholestyramine) 度度 ( 量 (gluten-free) ) 例療 1. Conill C, Verger E, Henriquez I, Saiz N, Espier M, Lugo F, et al. Symptom prevalence in the last week of life. J Pain Symptom Manage 1997; 14: Solano JP, Gomes B, Higginson IJ.A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006; 31: Camilleri M, Murray JA. In: Fauci AS, Braunwald E, Kasper DL, Hauser Longo SL, Jameson JL, Loscalzo J (eds). Harrison s principles of internal medicine. 17th edition. McGraw-Hill Companies Press, 2008; Sykes N. Constipation and diarrhea. In: Hanks G, Cherny NI, Christakis NA, Fallon M, Kassa S, Portenoy RK(eds). Oxford Textbook of Palliative Medicine, 4th edition. New York: Oxford University Press, 2010; Mercadante S. Diarrhea, malabsorption. In: Ripamonti C, Bruera E. Gastrointestinal symptoms in advanced cancer patients. Oxford University Press, 2002; Monroe LS. Fecal analysis. In: Berk JE, Haubrich WS, Kalser MH, Roth JLA (eds). Bockus Gastroenterology. 14th edition. W. B. Saunders Company, 1987; 祿臨北 Dudukgian H, Sie E, Gonzalez-Ruiz C, Etzioni DA, Kaiser AM. C. Difficile colitis predictors of fatal outcome. J Gastrointest Surg 2010; 14: Mercadante S. Diarrhea, malabsorption, and constipation. In: Berger AM, Portenoy RK, Weissman DE. Principles 寧療年

A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006; 31: 58-69. 3. Camilleri M, Murray JA.

15 and practice of palliative care and supportive oncology 2nd edition. Maple Press, 2002; Merrouche Y, Extra JM, Abigerges D, Bugat R, Catimel G Suc E, et al. High dose-intensity of irinotecan administered every 3 weeks in advanced cancer patients: a feasibility study. J Clin Oncol 1997; 15: Reference b. Sack BR, Tilton RC, Weissfeld AS. Laboratory Diagnosis of Bacterial Diarrhea. (Cumitech 12.) Washington DC: American Society for Microbiology, Graham DY, Estes MK, Gentry LO. Double-blind comparison of bismuth subsalicylate and placebo in the prevention and treatment of enterotoxigenic Escherichia coli-induced diarrhea in volunteers. Gastroenterology 1983; 85: Palmer KR, Corbett CL, Holdsworth CD. Double-blind cross-over study comparing loperamide, codeine and diphenoxylate in the treatment of chronic diarrhea. Gastroenterology 1982; 79: Harris AG, O'Dorisio TM, Woltering EA, Anthony LB, Burton FR, Geller RB, et al. Consensus statement: octreotide dose titration in secretory diarrhea. Diarrhea Management Consensus Development Panel. Dig Dis Sci 1995; 40: Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007; 45: Farthing MJ. Novel targets for the pharmacotherapy of diarrhoea: a view for the millennium. J Gastroenterol Hepatol 2000; 15(Suppl): G 寧療年 11

Laboratory Diagnosis of Bacterial Diarrhea. (Cumitech 12.) Washington DC: American Society for Microbiology, 1980. 12. Graham DY, Estes MK, Gentry LO.

16 CME Management of Diarrhea in Patients with Terminal Cancer Yee-Hsin Kao 1 Mei-Ling Ko 2 Ying-Hui Su 2 ABSTRACT The prevalence rate of diarrhea in patients with terminal is about 7-10%. Although diarrhea is less common symptom in hospice care, the consequences of it can be troublesome, that can causes dehydration, malnutrition, risk of bedsores, or systemic infection. Moreover, diarrhea not only induces loss of comfort and dignity to the patients, but also causes additional work to the family. Therefore, the management of diarrhea in patients with terminal is a very important issue. (Taiwan J Hosp Palliat Care ) Key Wordsterminal cancer, diarrhea 1 Department of Family Medicine. Tainan Municipal Hospital. Tainan. Taiwan 2 Department of Nursing. Tainan Municipal Hospital. Tainan. Taiwan 寧療年

Moreover, diarrhea not only induces loss of comfort and dignity to the patients, but also causes additional work to the family.