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 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