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Mucositis - Esophageal and Gastrointestinal Problems and Solutions
Ernest H Rosenbaum, MD, Sol Silverman, MA, DDS, Bernadette Festa, MS, RD, Isadora R. Rosenbaum, MA, Julie Matel, MS, RD, Rosemary Elliott-Snow, RDH, and Robert J. Ignoffo, Pharm D

Dry Mouth (Xerostomia)
What You Can Do If You Have Dry Mouth

Tips for Foods and Hydrating the Mouth
Swallowing Difficulties
Positioning of Body and Head
Feeding Methods
Heartburn, Reflux and Indigestion
Early Filling and Bloating

Diarrhea Medications for Radiation Therapy
Milk (Lactose) Intolerance
Mucositis Table of Contents

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A normal high-protein, high-calorie diet with supplements as needed will help your sore mouth or tongue heal faster. Drinking lots of fluids will also help with healing as well as making your mouth sores more comfortable.

A high-calorie, high-protein diet includes scrambled eggs, custards, milkshakes, malts, gelatins, creamy hot cereals, macaroni and cheese and blenderized or pureed foods. Commercial supplements such as Ensure®, Boost®, and Carnation Instant Breakfast Drink® can be helpful.

Until your mouth sores heal, you should avoid:
- Very cold foods

- Tomatoes and citrus fruits such as grapefruit, lemons and oranges, which can burn your mouth, and salty foods, which can cause a burning sensation

- Hot, spicy, coarse or rough foods, including toast, dry crackers and potato chips

- Alcoholic beverages and tobacco, which irritate the lining of the mouth

- Any medications that contain alcohol, such as mouthwashes or cough syrups

Your diet should consist of soft, bland foods. Solid foods should be soft or cooked until tender. A liquid diet or a pureed diet may be needed if you find solid food too irritating. Frequent small meals served warm or at room temperature will be more tolerable.

Foods especially well tolerated are: applesauce, cool or room temperature drinks, cooked cereal, strained cream soup, custard and puddings, eggs, plain ice cream, sherbet, Jell-O, milkshakes, mashed potatoes and popsicles.

Dry Mouth (Xerostomia)
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Saliva serves many functions. It initiates the digestion of starch. It mixes with food to form a bolus that can be swallowed, and it is the first line of defense to protect the teeth and mucosa from oral bacteria and fungus. Radiation therapy to the head and neck area affects the salivary glands by destroying gland acini and creating hyposalivation (decreased salivary flow). Saliva production is decreased, and saliva becomes thicker, resulting in a dry mouth, a condition called xerostomia. This can interfere with chewing, swallowing, speech and hygiene. It is an uncomfortable sensation and a major complaint that often persists for prolonged periods.

What You Can Do If You Have Dry Mouth
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Dry mouth (xerostomia) can occur in certain patients and can be managed with drinking fluids, sugar-free sodas, sucking ice chips, eating fresh fruits or sugarless chewing gum and sugarless lozenges/candies. Preparations containing alcohol or glycerin should not be used because they may irritate or aggravate dryness. Dryness should not be overlooked, as it may predispose to ulcers and infections. (See Radiation Effects under Radiation Effects)

Tips for Foods and Hydrating the Mouth
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- Choose foods with a high liquid content, such as: Applesauce,custard, puddings,ice cream, sorbet,most fruits,water (add lemon juice),yogurt, and cottage cheese.

- Add gravies, sauces, melted butter or margarine, broth or salad dressing.

- Dunk breads or other baked goods in your beverage.

- Drink generous amounts of nutritious liquids with meals. You may find that you eat less because you fill up on the liquid. Add lemon juice to water.

- Suck on sugar-free hard candy (such as Tic Tacs®), lemon drops or chew sugar-free gum. This may help to stimulate saliva production. Avoid sweet products, since your teeth have lost the natural protection that saliva provides. You can also suck on popsicles or flavored or plain ice cubes.

A dry mouth can make it difficult and even impossible to swallow. There are a few tricks to hydrate, or moisten, the mouth and increase saliva. Use popsicles, hard sugarless candy or crushed ice or take frequent sips of water throughout the day. You can buy over-the-counter artificial saliva at a drugstore. When saliva production is a problem, choose sour foods, which may increase saliva; avoid sweet foods that may be cariogenic.

If there are remaining functional cells in the major salivary glands, systemic salivary gland stimulants (sialogogues) may help. Pilocarpine (Salagen®) solution (1 mg/cc-5mg/teaspoon {15-20 mg/D} 3-4 teaspoons or 5 mg tablets)and cevimeline (Evoxac®) may help. These must be prescribed, with average doses of pilocarpine being 15-30 mg/d, and Cevimeline being 30 mg t.i.d. Doses are adjusted to balance beneficial and undesirable effects. Caution must be used in patients with asthma, gastrointestinal ulcers, narrow angle glaucoma Salivary Function

- Artificial saliva products may be helpful. Ask your physician, dentist or speech therapist about these. Commercial preparations such as MoiStir® and MouthKot®, an oral saliva substitute, or Oral Balance®, a moisturizing gel, may help.

- Make your own mouthwash with liquid lidocaine (Xylocaine®), baking soda and salt dissolved in 1 quart (1L) of water, or mix 1 quart water and 1 tsp. (5mL) salt and 1 tbsp. (15mL) baking soda.

- Use lip balms, lanolin-based products, chapsticks or lipstick if your lips are dry. Avoid petroleum based products that could promote microbial growth. Vitamin E oil is also a good product to use when lips are chapped or cracked.

Swallowing Difficulties
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Completely swallow each bite before taking another bite. Feel or look to see if the food has cleared the mouth. Sense whether food has cleared the throat. Do you feel or see any food in the mouth? Do you feel food stuck in your throat? If you answer yes to either of these questions, attempt dry swallows until no food pieces can be seen or felt.

Positioning of Body and Head
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The proper position can often markedly reduce swallowing difficulties. In the beginning, eat without the distraction of conversation or noise so that you can concentrate on the swallowing process. The standard position for swallowing is sitting as upright as possible with the hips at a right angle to the body. Sit in a firm chair, preferably one with a high back, so you can place a pillow behind your head. Place your feet on the floor or another firm surface.

After you swallow, tilt your chin down toward the chest to close off the trachea (windpipe) and help prevent food moving into the lungs, which can cause pneumonia.

If you have to eat in bed, sit up and use a wedge-shaped cushion behind your back to achieve as upright a position as possible. If you are in a hospital bed, put the head of the bed in a full upright position. Never eat lying down or in a reclining position unless your swallowing therapist has suggested these positions.

The position of your head is also important to effective and safe swallowing. Your swallowing therapist will prescribe the best head position for your particular situation.

Feeding Methods
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The following feeding methods may be helpful while you are learning to swallow and to manipulate foods of different consistencies. Be patient with yourself during all stages of your swallowing rehabilitation.

- Never rush feeding. Time and patience are needed on your part and the part of your caregiver.

- Always make sure your mouth, tongue and teeth are brushed and clean before you start to eat.

- After eating, sit upright for at least 20 minutes.

- Do the exercises for lips, tongue, jaw and swallow response that may be prescribed by your swallowing therapist. Do these four to eight times a day. The more frequently you do them, the faster you will recover.

You may wish to keep a record of your progress. The goal of your training program is to be able to swallow safely and enjoy your normal diet. By achieving this goal, you will help achieve another vital goal, a highly nutritious diet, which is crucial to your healing and well-being.

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Esophatigitis or inflammation of the lining of the esophagus (the tube leading from the throat to the stomach) may be a side effect of chemotherapy or radiation therapy to the head and neck area. It may occasionally occur because of an infection.

The recommended dietary approach is similar to that used with a sore or ulcerated mouth or throat (see above). In general, eat slowly and only small amounts at a time.


- Any medications should be prescribed by your physician. You might ask your doctor about gargling with and swallowing an analgesic solution such as liquid or viscuous Xylocaine® gel before meals to lessen irritation. A similar solution may be made by dissolving 1 tbsp. (15mL) baking soda and 1 tsp. (5mL) salt in 1 quart (1L) warm water. Use 2 to 4 tbsp. (25mL to 50mL) before each meal. Systemic analgesics such as Tylenol® or codeine my be needed to relieve pain. Carafate ®(sucralfate) suspension may reduce symptoms and discomfort and help healing by coating the esophagus.

- If symptoms persist, a candida (monilial fungal) infection may be present, which can be effectively treated with ketoconazole (Nizoral®), nystatin (Mycostatin®), fluconazole (Diflucan®), amphotericin (Fungizone®), itraconazole (Sporanox®) or Mycelex®.

Heartburn, Reflux and Indigestion
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Over one million people experience heartburn, which is commonly caused by acid reflux (the movement of acid from the stomach into the esophagus). Heartburn is a sensation of burning or pressure in the upper stomach and the esophagus. It can cause an inflammation of the esophagus called esophagitis.

Indigestion, an uncomfortable feeling in the abdomen after eating, is usually caused by eating too much or by eating foods that are too spicy or too fatty. Indigestion may also accompany stress, constipation, bloating or eating when you have no appetite.

What You Can Do about Heartburn

- Avoid spicy, acidic, tomato-based or fatty foods such as citrus fruits, fruit juices and chocolate.

- Limit your intake of regular tea, alcohol, colas and coffee, including decaffeinated versions of these.

- Stop or at least reduce smoking.

- Watch your weight. Obesity causes an increase in intra-abdominal pressure, which can aggravate reflux.

- Eat small frequent meals.

- Avoid exercising too soon after eating.

- Walk around after meals rather than sitting down.

- Avoid bedtime snacks. Eat meals at least three or four hours before lying down.

- Elevate the head of your bed with 4 to 6 in. (10 to 15 cm) of blocks to help gravity drain stomach and gastric acids. Or use several pillows to elevate your head when you are lying down or sleeping.

Medication for Heartburn
An antacid taken one or two hours after meals and at bedtime may provide relief. If heartburn is excessive or recurrent, consult your doctor about stomach-acid blocking medicines such as Tagamet®, Zantac®, Pepcid®, Axid®, Prilosec® and Prevacid®. Over-the-counter antacids include Maalox®, Mylanta®, Gaviscon®, Tums® and Gelucil®.

What You Can Do about Indigestion
Again, frequent small meals and a bland diet can be helpful. In general, avoid overeating and avoid foods you have found cause you indigestion.

Medication for Indigestion
An antacid taken one or two hours after meals may help relieve discomfort. Antispasmodic drugs such as Donnatal block help block acid production in the stomach.

Early Filling and Bloating
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A common problem during radiation therapy or chemotherapy is early filing-a feeling of being full after having taken only few bites of food. Bloating may be defined as an over-full feeling occurring after eating, often after just a few bites. Bloating is due to the inability of the stomach and intestines to properly digest the food you eat. It may also occur because of a slowdown of the passage of food from one part of the intestines to another, which may be caused by nervousness and tension, anticancer drugs, narcotics, strong pain relievers and other medications, lack of adequate exercise, or constipation. Bloating may also be related to the type of food you eat. Fatty, fried and greasy foods tend to remain in the stomach longer and may cause you to feel full. Carbonated drinks, gas-producing foods and milk may also cause bloating.

What You Can Do
Eat frequent small meals instead of three large meals a day and emphasize sweet or starchy foods and low-fat protein foods. Sit up or walk around after meals.

Avoid fatty, fried and greasy foods, gas-producing vegetables (such as dried beans and peas, broccoli, Brussel sprouts, cabbage, cauliflower, corn, cucumber, green peppers, sauerkraut, turnips and winter squash), carbonated drinks, chewing gum and milk. Stir carbonated drinks to remove gas bubbles.

Mylanta® Gas Tablets (simethicone) help relieve and reduce symptoms of excess gas.

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Several anti-cancer drugs can damage the digestive tract, at times leading to diarrhea. Specific drugs particularly associated with diarrhea are 5-FU, methotrexate, cytarabine, capecitabine (Xeloda®), and irinotecan (Camptosar®). Because it is difficult to predict which patients will develop diarrhea, prevention is not an effective management strategy and antidiarrheal therapy is the mainstay of treatment. In addition, adequate fluid intake is critical in order to prevent dehydration. Drinking water, soup or non-caffeinated beverage is adequate in mild diarrhea, and oral fluid replacement preparation (such as Gatorade®) is preferable in moderate losses. Intravenous fluid support might be required in a severe case of dehydration. Diarrhea can be controlled with Lomotil® or Imodium®, unless the diarrhea is caused by an infection.

Diarrhea is a condition marked by abnormally frequent bowel movements that are more fluid than usual. It is sometimes accompanied by cramps. You may get diarrhea because of chemotherapy, radiation therapy to the lower abdomen, malabsorption because of surgery to the bowel or sometimes a bowel inflammation (ileitis or colitis) or infection. Some antibiotics, especially-broad spectrum antibiotics, can cause diarrhea. Diarrhea may also develop because of an intolerance to milk (see Milk (Lactose) Intolerance below), difficulty absorbing fats, sensitivity to a specific food or group of foods, food allergy or emotional or psychological problems.


- Effective treatment depends on finding the cause. A general approach is to limit your diet solely to fluids to allow the bowel to rest. Drink plenty of mild liquids, such as fruit drinks and Gatorade, ginger ale, peach or apricot nectar, water and weak tea. Hot and cold liquids and foods tend to increase intestinal muscle contractions and make the diarrhea worse, so they should be warm or at room temperature. Allow carbonated beverages to lose their fizz or stir them before you drink them. Inform your physician, nutritionist or health care team if you are on this diet longer than one day.

- When you are feeling better, gradually add foods low in roughage and bulk. Examples include steamed rice, cream of rice, bananas, applesauce, mashed potatoes and dry toast and crackers. These foods should be eaten warm or at room temperature.

- As your diarrhea decreases, you may move on to a low-residue diet (see Chapter 33). Frequent small meals will be easier on your digestive tract.

Foods to Avoid Many types of foods are likely to aggravate your diarrhea and should be avoided. These include:

- Fatty, greasy and spicy foods

- Coffee, regular (not herbal) teas and carbonated drinks containing caffeine

- Citrus fruits such as oranges and grapefruit

- Popcorn, nuts and raw vegetables and fruits (except apples)

- Drinks and foods that are served too hot or too cold

What You Can Do

- Talk to your physician and other health team members to determine the cause of the problem. It may be due to a variety of causes as mentioned above, including an intestinal blockage, antibiotics or the cancer.

- Diarrhea can cause dehydration, so you will have to drink plenty of fluids (see Clear Liquid Diet). When you have diarrhea, food passes through the gut more quickly, so many nutrients are not absorbed. You also lose electrolytes, which are vital to the fluid balance of your body. To replace the fluid, sugar and salt you will lose, a good general formula is: 1 quart (1 L) boiled water, 1 tsp. (5 mL) salt, 1 tsp. (5 mL) baking soda, 4 tsp. (20 mL) sugar and flavor to your taste. As with any specially prepared concoction, however, check with your dietitian or doctor to make sure you can tolerate the ingredients.

- Potassium is lost in diarrhea. It is a necessary mineral and must be replaced. Foods high in potassium include bananas, apricot and peach nectars, tomatoes, potatoes, broccoli, asparagus, citrus juices and milk. A potassium supplement may be needed if diarrhea persists.

- Gatorade® may be useful for replacing fluid, potassium and electrolytes.

- Try the BRAT diet: bananas, rice, applesauce, tea and toast.

- Eat foods that are high in protein and calories.

- Reduce your intake of foods that are high in roughage and residue.

- Talk with your dietitian about ways to improve your diet.

- Ileostomy and colostomy diarrhea may be severe enough to require specific medical and dietary treatment and food.

- An antidiarrhea medication such as Kaopectate®, Imodium® or Lomotil® may be prescribed.

Diarrhea Medications for Radiation Therapy
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Drug Name Usual Dose Side Effects Cost
Water, broth, no coffee or soda 8 to 10 glasses daily No Caffeine-containing liquids, as they can worsen diarrhea Minimal
Rehydration formulas As indicated Well tolerated $$
Loperamide (Imodium®) As indicated 2 capsules followed by 1 capsule after each loose stool, up to 8 capsules per day Sedation, drowsiness $$
Lomotil® 1 or 2 tablets 3 to 4 times per day Nervousness, drowsiness $$

Diarrhea caused by irinotecan (Camptosar®) {CPT-11}) is treated in a different manner. If diarrhea occurs during or less than 24 hours after the infusion, often before administering chemotherapy, IV atropine is given to control the symptoms. For late-onset diarrhea (more than 24 hours after infusion), the patient should take 2 caplets (4 mg) of Imodium loperamide after the first episode of loose stools, followed by one or two caplets (2mg-4mg) every 2 hours until diarrhea-free for 12 hours. During nighttime, the patient should take 2 caplets (4mg) every 4 hours. This regimen is tailored for irinotecan-treated patients and should not be used for others, unless indicated otherwise.

- Kaopectate® (30 cc to 60 cc after each loose bowel movement)

- Lomotil ®(one or two tablets every two to six hours as needed to a maximum of eight tablets a day. Most patients require only two or three tablets per day after the diarrhea has been controlled.)

- Imodium ®(loperamide) (two tablets initially followed by one tablet after each loose stool, not to exceed 16 tablets per day); Imodium is also available in liquid or tablet form without a prescription.

- Donnatal® (one or two tablets every four hours for abdominal cramping).

- Paregoric ®(1 tsp every four hours) (requires a physician?s triplicate prescription.)

- Tincture of opium is very successful for severe uncontrollable diarrhea (requires a physician's narcotic triplicate prescription)

- For severe diarrhea from drugs, infections or post-surgery, octreotide (Sandostatin®) injections can be helpful.

MilkLactose) Intolerance
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Lactose intolerance can sometimes develop after intestinal surgery, radiation therapy to the lower abdomen or chemotherapy. Some people are also born with lactose intolerance or develop it later. The intolerance results from a deficiency of lactase, an enzyme that digests milk sugar (lactose) in the intestine, and is marked by bloating, cramping and diarrhea.

- If your diarrhea is caused by lactose intolerance, avoid milk and milk products such as ice cream, cottage cheese and cheese. Depending on how sensitive you are to milk, you may also have to avoid butter, cream and sour cream.

- If you are very sensitive, use lactose-free, nonfat milk solids or soy milk.

- You can make your own lactose-free milk by adding Lactaid-a tablet containing lactase-to your milk and keeping it in the refrigerator for 24 hours before drinking it.

- You can use buttermilk and yogurt because the lactose in them has already been processed and is easily digested.

- You might tolerate some processed cheeses.

- Try Mocha-mix®, Dairy Rich® and other soy products, or some lactose substitutes like Imo ®(an imitation sour cream), and Cool Whip®.

- See the Lactose-Free/Lactose-Restricted Diet

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