Quimioterapia: complicaciones gastroinstestinales

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Náusea y vómito

• Es un problema frecuente
• 70 a 80% han tenido náusea y vómito
• 10 a 44% vómito anticipado
• Es prevenible
• Calidad de vida
• Costo

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Etiología

• Drogas
• Obstrucción intestinal
• Carcinoma gástrico
• Infecciones
• Vértigo
• Alteraciones metabólicas
• Factores psicológicos
• Radioterapia
• Toxinas
• Incremento de la PIC

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Grados de Náusea y Vómitos

Grados	Manifestaciones
Grado 0	Normal
Grado 1	Transitoria
Grado 2	Controlable
Grado 3	Requiere terapia
Grado 4	Incontrolable

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Regimen antiemético para emesis tardía

Riesgo	Regimen antiemético	Dosis y esquemas
Riesgo severo	Esteroides VO+metoclopra, Mida VO + 5HT3 VO	Dexametasona 8mg C/24 horas 3 a 4d
Riesgo moderado	Esteroides VO+metoclopra, Mida VO + 5HT3 VO	Metoclopramida 30mg O 0.5 mg/kg 2 a 4 v/d por 2 a 4 días
Riesgo bajo y muy bajo	No se dan antieméticos preventivos

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Complicaciones orales

• Dentales
• Caries
• Tejidos blandos
• Mucositis
• Pericorinitis
• Gingivitis
• Periodontitis
• Queilosis angular
• Epulis fissuratum
• Xerostomía

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Factores de riesgo para complicaciones orales

• Debilidad
• Sequedad de boca
• Quimioterapia
• Pobre ingesta
• Radiación local
• Deshidratación

British Medical Journal 315 (7114) 1002-1005

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Mucositis

• Es una complicación frecuente de la quimioterapia
• Se presenta en un 40%  bajo quimioterapia
• Comunicación, estado nutricional y sueño
• Costos elevados
• Prevención

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Grados de Mucositis (WHO)

Grados	Síntomas
0	Ninguno
I	Ulceras no dolorosas, eritema o dolor leve
II	Eritema doloroso, o úlceras pero puede comer
III	Eritema doloroso, edema o úlceras pero no puede comer
IV	Requiere apoyo nutricional

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Mucositis (Tratamiento)

• Clorhexidina 0.1% (4/día)
• Peróxido de hidrógeno 6% (3/día)
• Floruro de sodio gel 1% (2/día)
• Acido ascórbico 250 mg (3/día)
• Nicotinamida 75 a 100 mg C/24hs
• Nistatina 100,000 UI/ml 4ml (4/día
• Pilocarpina 5g C/24 hs

Semin Oncol 2000;27:24-33

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Diarrea

• 8% enfermedad avanzada
• Menos del 10% son hospitalizados
• 5FU e irinotecan
• 3 mecanismos: 1) Osmótico, 2) Alteración en el balance secreción/absorción, 3) Motilidad
• Esquema semanal

Semin Oncol 2000; 27, 24-33

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Grados de diarrea

Grados Manifestaciones Grado 0 Normal Grado 1 Transitoria Grado 2 Transitorio controlable Grado 3 Requiere terapia IV Grado 4 Deshidratación y Hemorragia

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Constipación

• Mas frecuente en enfermedad avanzada
• Se presenta en 80% hasta 50% requieren tratamiento
• Síntomas asociados (flatulencia, borborigmoa, dolor abdominal, tenesmo)
• Complicaciones (anorexia, diarrea, confusión, náusea y vómito, alteraciones urinarias)

Britihs Medical Journal 1997; 315, 1293-96

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Constipación - Etiología

• Causados por tratamiento (opiodes, antieméticos, antiespasmódicos, antidepresivos, AINES.
• Obstrucción intestinal
• Problemas neurológicos
• Quimioterapéuticos
• Cáncer (hipercalcemia, masas intrabdominales, compresión espinal, Sx cauda equina, depresión)
• Asociados a debilidad

Britihs Medical Journal 1997; 315, 1293-96

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Risk factors for complications of mouth

• Weakness
• Dry Mouth
• Chemotherapy
• Poor intake
• Local radiation
• Dehydration

   
British Medical Journal 315 (7114) 1002-1005

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Mucositis

• In some cases, chemotherapy can cause pain and inflammation of the soft layer of tissue that lines the digestive system from the mouth to the anus (the mucous membrane). This is known as mucositis.
• The severity of your symptoms usually depends on the strength of your medication. People having high-dose chemotherapy usually have ore severe symptoms.
• The symptoms of mucositis usually begin 7 to 10 days after you start chemotherapy.

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Mucositis NCI-CTCAE Grading Scale

Grade	Symptoms
Grade 0 (none)	None
Grade 1 (mild)	Painless ulcers, erythema in the absence of lesions
Grade 2 (moderate)	Painful erythema, oedema, or ulcers but eating or swallowing possible
Grade 3 (severe)	Painful erythema, oedema, or ulcers requiring IV hydration
Grade 4 (life-threatening)	Severe ulceration or requiring parenteral or enteral nutritional support or prophylactic intubation
Grade 5 (death)	Death related to toxicity

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Mucositis (Treatment)

• Chlorhexidine (4 / day)
• Hydrogen peroxide (3 / day)
• Sodium fluoride gel 1% (2 / day)
• Ascorbic acid (3 / day)
• Nicotinamide 75-100 mg C / 24h
• Nystatin 100,000 IU / ml 4ml (4 / day)
• Pilocarpine

Semin Oncol 2000;27:24-33

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Diarrhea

• The GI tract is susceptible to chemotherapy toxicity because of the rapid turnover of the mucosal cells.
• The agents most commonly associated with diarrhoea are capecitabine, 5-fluorouracil (especially in high dose or in combination with leucovorin or oxaliplatin), irinotecan,methotrexate and topotecan. Irinotecan is specifically associated with early (within 24 hours) and late onset (3 to 11 days post therapy) diarrhoea.
• Early onset diarrhoea, often preceded by diaphoresis and/or abdominal cramping, can be ameliorated by the administration of atropine.

Semin Oncol 2000; 27, 24-33

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Diarrhea NCI-CTCAE Grading Scale

Grade	Symptoms
Grade 0	None
Grade 1	Increase of <4 stools per day over baseline; mild increase in ostomy output compared to baseline
Grade 2	Increase of 4 - 6 stools per day over baseline; moderate increase in ostomy output compared to baseline not interfering with ADLs
Grade 3	Increase of >=7 stools per day over baseline; incontinence; hospitalization indicated; severe increase in ostomy output compared to baseline; limiting self care ADLs
Grade 4	Life-threatening, consequences; urgent intervention indicated
Grade 5	Death

 

British Medical Journal 1997; 315, 1293-96

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Constipation

A condition in which stool becomes hard, dry, and difficult to pass, and bowel movements don’t happen very often. Other symptoms may include painful bowel movements, and feeling bloated, uncomfortable, and sluggish.
Most people need to drink at least 8 cups of liquid every day. Water is a good choice. So are fruit and vegetable juices, such as prune juice.

Britihs Medical Journal 1997; 315, 1293-96

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Constipation, Etiology

• Caused by treatment (opioids, antiemetics, antispasmodics, antidepressants, NSAIDs.
• Intestinal obstruction
• Neurological problems
• Chemotherapeutic
• Cancer (hypercalcemia, intra-abdominal mass, spinal compression, cauda equina Sx, depression)
• Associated with weakness

Britihs Medical Journal 1997; 315, 1293-96

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