Do you have diet suggestions for someone who has diarrhea after radiation therapy for rectal cancer?
I recently had several people write me with this same question. Chronic radiation enteritis after radiation treatments for rectal cancer (or other cancers that have been treated with radiation to the abdominal area) can produce side effects like long-standing diarrhea, bowel urgency, and incontinence. Sometimes these side effects can even occur a year after therapy has been completed.
1) I always assume that something can be changed to reduce or eliminate the diarrhea, even if the doctors seem to think the diarrhea is a "given".
2) Try to change only one aspect of treatment or care at a time to evaluate what works and what doesn't.
3) As the patient's RD, I always try to work with the patient and his/her doctor to determine if there are any medications that might be helpful, i.e., H2 blockers, anti-motility agents, and bile acid sequestrants.
4) I ask patients to keep a detailed diet diary (all foods and beverages), what food is eaten, portion sizes, if foods are hot or cold, are foods eaten in a restaurant, take out food, or home made, time of day food is eaten, and also a detailed symptom diary. Discuss the food and symptom diary with the RD who will try to determine if the symptoms are related to the food intake or even the timing of the food consumption. This process may take several weeks to evaluate and see patterns!
5) Never assume what bothers one person will bother the next person. Everyone is soooo different! Example: One of my patients could not tolerate any leftover foods or foods served from a salad bar. I think this might be due to higher bacterial contents of these foods.
6) If a patient cannot tolerate whole fruits and vegetables, try either baby foods (can even buy organic baby foods) or juicing.
7) One caveat, avoid "gassy" vegetables at all times, even when juicing (i.e., all members of the broccoli family, onions).
8) Encourage intake of yogurt with active cultures or kefir - approximately 8 ounces per day. Use a lactase tablet. Also consume lactase treated milk and use lactase tablets for other dairy products.
9) Consider use of a probiotic supplement. (Probiotics and benefits with radiation diarrhea. Eur J Gastroenterol Hepatol 2001; 13: 391-396) One supplement of this type is called Culturell. Take 2 capsules twice daily for a month (available over the counter at most pharmacies).
10) Start psyllium three times/day or Benefiber right from the start.
11) Use soluble fiber foods like oatmeal or oat bran bread while avoiding insoluble fiber foods like whole wheat, whole rye products or other whole grains.
12) Avoid hard-to-digest foods like corn, gassy vegetables like Brussels sprouts and other cabbage family foods, all fatty foods, caffeine, alcohol, and spicy foods.
13) Some patients will have diarrhea no matter what fruits, vegetables, and other foods are eliminated. Patients may find the use of Imodium will control the diarrhea without needing to be so restrictive with the diet.
14) Review all herbs and other dietary supplements with your RD for possible side effects like diarrhea. One case report in the medical literature has shown that unexplained diarrhea resolved upon discontinuing the herb milk thistle (Adverse Drug Reactions Advisory Committee. An adverse reaction to the herbal medication milk thistle (Silybum marianum). Med J Aust 1999;170:218-9.)
15) Avoid foods high in in-soluble fiber, which are foods made from whole grains. Also avoid raw whole fruits and vegetables, nuts, beans and legumes.
16) Consider adding 400 IU of vitamin E and 500 mg vitamin C three times daily. ("Successful and sustained treatment of chronic radiation proctitis with antioxidant vitamins E and C", Kennedy M, et al. Am J of Gastroenterology 2001;96:1080-1084) Try for 8 weeks to see if diarrhea is reduced or eliminated. (This study used these anti-oxidant supplements after radiation was completed, not during therapy.)
17) "Rice Congee" may really help! Combine 1 cup long-cooking WHITE rice with 6-7 cups of water and one-tablespoon of salt; cook this according to package directions (usually ~ 40 minutes); this will be a 'sticky, soupy' mixture; eat and drink mixture. If broth is used instead of water, omit the salt.
18) Many RD's recommend glutamine therapy to help those people with chronic diarrhea that does not resolve with other dietary changes. Use 10 gm three times per day mixed with clear juice or water. (Do not use without consulting your RD or MD. Do not use if you have decreased liver or kidney function.) If glutamine is going to work, you should see results in three days. Two brands that have been used in research studies are:
(a) Cambridge Sympt-X marketed by Baxter19) Be sure to have "C. diff" (clostridium difficiles) ruled out. C. diff is an overgrowth of normally present GI bacteria that can produce loose and crampy stools.
(b) GlutaSolve by Novartis.
20) To compensate for any possible vitamin and mineral malabsorption due to the diarrhea, one RD recommends a Flintstones Chewable complete vitamin twice daily for a month then go to one daily or switch to a Centrum Silver type if the diarrhea has lessened or stopped.
21) Have your doctor and dietitian order blood work to evaluate levels of fat-soluble vitamins and vitamin B12. In addition, a stool sample should be checked for bile salt malabsorption with a bile acid sequestrant like cholestyramine added if needed.
22) See the following web site for even more additional helpful information regarding management of diarrhea. www.cancernutritioninfo.com, click on Treatment Symptom Management, then click on diarrhea.
23) I have heard of several recently reported cases of patients developing intractable diarrhea after cancer therapy who were finally tested and found to have previously undiagnosed celiac disease (gluten intolerance).
Counseling from a Registered Dietitian and adherence to a strict gluten-free diet completely eliminated the chronic diarrhea.
24) Some RDs are reporting that a few patients have had successful resolution of long-standing diarrhea by the use of either acupuncture or massage.
25) Words of wisdom from a very experienced dietitian:I hope some of these ideas are helpful to you, as you try to regain a sense of control and also normalcy during your cancer recovery journey.
For one specific patient, it helped her just to have the knowledge of what she could and could not tolerate. Prior to working with her, she felt completely out of control, not knowing if eating would precipitate diarrhea or not. This knowledge was empowering in and of itself. Although she has to avoid some foods high in insoluble fiber, she was able to systematically try different foods to learn her own tolerances.26) Lastly, if all of these efforts fail, consider the observation of another very experienced dietitian:
I have had several patients with long standing diarrhea, bowel urgency and incontinence after treatment. I tried everything from glutamine, paregoric, high soluble fiber, and anything else that the MD would agree to try. I kept coming across a common problem; they had very low re-anastamosis surgeries. There was a surgeon in town that tried to save many patients from the humiliation of a colostomy by "doing them a favor" and reattaching them even if there was precious little rectum or sphincter tone. All of our patients regained a normal life after getting an ostomy. I know that this is not the answer many patients are looking for, but these people were truly happy with the results and not having to wear diapers or being afraid of having an accident.
Be sure to discuss all of these concerns and possible solutions with both your doctor and dietitian. I have heard of one oncologist who says that since hiring a dietitian for his practice, he no longer needs to spend one single minute of his precious face-to-face time discussing diarrhea with his patients. Now that is one terrific example of teamwork and true comprehensive cancer care!
I send all my best wishes for health, healing, and hope!
Diana Dyer, MS, RD
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