Pediatric emergency medicine trisk 2737 2737
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HEPATIC AND GASTROINTESTINAL COMPLICATIONS OF
CANCER TREATMENT
Cancer treatment frequently affects the GI tract and liver. The majority of
complications are minor and fully reversible. A few complications are potentially
severe and/or have long-term consequences. Chemotherapy frequently impairs the
ability of the mucosal lining of the GI tract to regenerate itself. Severity varies with
different chemotherapy regimens. Time to occurrence is similar to the timing of
myelosuppression with onset 7 to 10 days after treatment and recovery by 14 days.
Radiation also causes temporary injury to any areas of mucosa included in the
radiation field. This injury becomes evident after several weeks of treatment and
will persist/worsen until treatment is complete.
Initial assessment must include a thorough oncology history to elicit
chemotherapy or radiation exposures as well as localizing symptoms and a complete
physical examination. Chemotherapy-induced mucositis can affect part of or the
entire GI tract from the oropharynx to the rectum and may manifest as oral
ulceration, throat pain, esophagitis, gastritis, enteritis, or rectal ulceration. Radiationinduced mucosal injury is often associated with skin manifestations in the treatment
field. Oropharyngeal involvement usually includes pain and visible mucosal injury
ranging from irregular mucosal surfaces to scattered ulcerations to severe diffuse
ulceration with swelling of the lips and inability to open the mouth. Esophagitis may
be evident only by refusal to swallow and/or retrosternal pain. Enteritis, common
with radiation fields that include the intestines, may be evident with crampy watery
diarrhea. Mucosal injury to the rectum leads to pain with defecation, tenesmus, or
rectal pain. There may be obvious perirectal erythema or ulceration. As discussed
elsewhere, avoid a digital rectal examination, which may cause an increased
likelihood of bacteremia.
Management of moderate to severe mucositis usually requires pain control with
parenteral narcotics. Cancer patients may require higher than standard starting
doses, especially if already on narcotics at home. Patients and their families should
be asked whether they have medication preferences based on prior episodes of pain.
PCA with both continuous and bolus dosing should be initiated in the ED if
available. Do not use NSAIDs for pain control since they usually have platelet
inhibitory effects and the development of thrombocytopenia frequently coincides
with mucositis. Avoid regular use of acetaminophen, which may mask fever since
neutropenia also often occurs at the same time. Assess hydration and administer
intravenous fluids as needed. Patients with adequate oral pain control and oral
hydration can be discharged to home. Others will need to be admitted for pain
control and/or hydration until the mucositis resolves.
