Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer

Andreyev, H Jervoise N; Davidson, Susan E; Gillespie, Catherine; Allum, William H; Swarbrick, Edwin

doi:10.1136/gutjnl-2011-300563

Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer

OPEN ACCESS

¹Pelvic Radiation Disease and GI Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
²Clinical Oncology, Christie Hospital NHS Foundation Trust, Manchester, UK
³Cancer and Palliative Care, Chelsea and Westminster Hospital, London, UK
⁴Surgery, Royal Marsden NHS Foundation Trust, London, UK and National Clinical Advisor for Upper Gastrointestinal Cancer, NHS Improvements, UK
⁵Gastroenterology, The Royal Wolverhampton NHS Trust, UK

Correspondence to Dr Jervoise Andreyev, Consultant Gastroenterologist in Pelvic Radiation Disease, Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; j{at}andreyev.demon.co.uk

Contributors All authors met before the guidance was written and discussed the format of the guidance, its content and what should not be included. Sections of the guidance were given to each author to research and write. JA edited the initial submissions which were further edited by ES. The writing committee reviewed this completed draft, suggestions were discussed and a further major revision of the manuscript was undertaken by JA and edited a second time by ES. This second major revision was sent out for comments to the four collaborating societies (the Association of Colo-Proctology of Great Britain and Ireland, the Association of Upper Gastrointestinal Surgeons, the British Society of Gastroenterology and the Royal College of Radiologists). These societies all commissioned at least two reviewers to read and comment on the manuscript. In addition, JA and ES sent copies of the manuscript to known specialists with expertise in this field as listed in the acknowledgements and asked them for comments. The penultimate draft of the manuscript was produced after taking all comments into account by JA and ES, circulated around the members of the writing committee and a final agreed version was produced which is the submitted version.

Revised 19 September 2011
Accepted 29 September 2011
Published Online First 4 November 2011

Abstract

Backgound The number of patients with chronic gastrointestinal (GI) symptoms after cancer therapies which have a moderate or severe impact on quality of life is similar to the number diagnosed with inflammatory bowel disease annually. However, in contrast to patients with inflammatory bowel disease, most of these patients are not referred for gastroenterological assessment. Clinicians who do see these patients are often unaware of the benefits of targeted investigation (which differ from those required to exclude recurrent cancer), the range of available treatments and how the pathological processes underlying side effects of cancer treatment differ from those in benign GI disorders. This paper aims to help clinicians become aware of the problem and suggests ways in which the panoply of syndromes can be managed.

Methods A multidisciplinary literature review was performed to develop guidance to facilitate clinical management of GI side effects of cancer treatments.

Results Different pathological processes within the GI tract may produce identical symptoms. Optimal management requires appropriate investigations and coordinated multidisciplinary working. Lactose intolerance, small bowel bacterial overgrowth and bile acid malabsorption frequently develop during or after chemotherapy. Toxin-negative Clostridium difficile and cytomegalovirus infection may be fulminant in immunosuppressed patients and require rapid diagnosis and treatment. Hepatic side effects include reactivation of viral hepatitis, sinusoidal obstruction syndrome, steatosis and steatohepatitis. Anticancer biological agents have multiple interactions with conventional drugs. Colonoscopy is contraindicated in neutropenic enterocolitis but endoscopy may be life-saving in other patients with GI bleeding. After cancer treatment, simple questions can identify patients who need referral for specialist management of GI symptoms. Other troublesome pelvic problems (eg, urinary, sexual, nutritional) are frequent and may also require specialist input. The largest group of patients affected by chronic GI symptoms are those who have been treated with pelvic radiotherapy. Their complex symptoms, often caused by more than one diagnosis, need systematic investigation by gastroenterologists when empirical treatments fail. All endoscopic and surgical interventions after radiotherapy are potentially hazardous as radiotherapy may induce significant local ischaemia. The best current evidence for effective treatment of radiation-induced GI bleeding is with sucralfate enemas and hyperbaric oxygen therapy.

Conclusions All cancer units must develop simple methods to identify the many patients who need help and establish routine referral pathways to specialist gastroenterologists where patients can receive safe and effective treatment. Early contact with oncologists and/or specialist surgeons with input from the patient's family and friends often helps the gastroenterologist to refine management strategies. Increased training in the late effects of cancer treatment is required.

Footnotes

Produced on behalf of the British Society of Gastroenterology, the Association of Colo-Proctology of Great Britain and Ireland, the Association of Upper Gastrointestinal Surgeons and the Faculty of Clinical Oncology Section of the Royal College of Radiologists.
The President of the British Society of Gastroenterology commissioned this document following a request from Professor Sir Mike Richards, National Cancer Director, and Professor Jane Maher, Chief Medical Officer of Macmillan Cancer Support and Chair of the National Cancer Survivorship Initiative's Consequences of Treatment Group.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.

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