Question 13

Causes

Drugs: promotility agents, antibiotics
Infection – multiple possible organisms
Radiation
Neutropenic enterocolitis
VHD

Outline your assessment and management

ABC

History:

Details of the indication for and type of transplant – esp. HLA matching etc.
Details of pre-transplant chemo/radiation etc.

Course and complications post-transplant
Whether engraftment has occurred
Medication history – esp. antibiotics

Details related to diarrhoea – associated with pain, blood etc,

Examination:

General physical with specific attention to Volume status

Abdominal examination – signs of peritonitis Signs of GVHD: rash, liver tenderness

Investigations:

Standard blood tests -FBC, Electrolytes, LFT’s, Cultures Stool culture including C difficile PCR

Plain AXR CT abdomen

Sigmoidoscopy +- biopsy

Discussion

Management

Fluid resuscitation – volume loss replaced by saline or balanced salt solution
Electrolyte replacement – as required but particularly potassium and magnesium

Nutrition – general enteral nutrition is satisfactory but TPN may be required where whole bowel rest is required

Antidiarrheal – loperamide can be used once infectious cause has been excluded
Anti-secretory – octreotide – particularly in early GvHD

Infection control, contact proportions

Treatment of underlying cause e.g. GVHD, C Diff.

Discussion

This question is functionally quite similar to Question 11 from the first paper of 2014, except in 20144 this patient was a 65-year-old male, 18 days following BMT for multiple myeloma, and who clearly has some serious abdominal pathology.

The causes of diarrrhoea in a bone marrow transplant recipient are so vastly numerous that they require a table to manage them:

Causes of Diarrhoea in the Bone Marrow Transplant Recipient

Infectious	Non-Infectious
Viruses Rotavirus Norovirus Adenovirus Cytomegalovirus Bacteria: Clostridium difficile Shigella Salmonella Campylobacter E.coli Aeromonas Parasites Giardia Cryptosporidium Microsporidium Fungi Candida	Immunosuppressant therapy Cytotoxic drugs Tacrolimus Whole-body irradiation Consequences of BMT Neutropenic enterocolitis Graft vs host disease ICU therapy Pro-motility agents High caloric feeds Lactulose Opioid withdrawal Broad spectrum antibiotics

Assessment:

• Supportive assessment:
  • A) - assessment of the urgent need for intubation
  • B) - Support of ventilation:
         - may be tachypnoeic if compensating for a metabolic acidosis
  • C) - Haemodynamic assessment: fluid resuscitation +/- vasopressors
  • E) - investigation of electrolyte abnormalities: EUC, CMP, ABG
  • F)- Monitoring of urine output and renal function; CRRT support as indicated
  • G)- assessment of the need for surgical consultation (is there peritonitis?)
    Also, assessment of the patient's nutritional state
• Specific investigations:
  • Blood cultures
  • Stool sample for
    • Culture
    • Ova/cyst/parasite microscopy
    • C.difficile toxin PCR
  • CT abdomen (looking for evidence of colitis): it will reveal such nasties as neutropenic enterocolitis (in the BMT recipient) as well as the pneumatosis of C.difficile infection and gut ischaemia. A plain abdominal xray is almost never useful. Hamdeh et al (2016) report a false negative rate of 48%.
  • CMV quantitative titer (perhaps this is CMV colitis?)
  • Colonoscopy and biopsy

Management:

• Supportive management
  • Fluid resuscitation, electrolyte replacement and haemodynamic control with vasopressors as needed
  • TPN if enteral nutrition is clearly inadequate
• Specific management:
  • Antibiotics empirically
  • Loperamide if the diarrhoea is not infectious
  • Octreotide if it is definitely secretory
• Targeted therapy for cause of diarrhoea:
  • Metronidazole for C.difficile, etc
  • High dose steroids for GVHD
  • Albendazole or ivermectin for parasitic infections