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


Introduction

Mucositis occurs when cancer treatments break down the rapidly divided epithelial cells lining the GI tract, particularly in the oral cavity, leaving the mucosal tissue open to ulceration and infection. Mucositis can occur anywhere along the digestive tract from the mouth to the anus. Oral Mucositis is probably the most common, debilitating complication of cancer surgery, chemotherapy and radiation. It occurs in 20-40% of patients treated with chemotherapy alone and up to 50% of patients receiving combination radiation and chemotherapy, especially those with head and neck cancer. Drugs such as doxorubicin, paclitaxel, and capecitabine are commonly used in breast cancer and frequently associated with oral and GI mucositis. The consequences of mucositis can be mild requiring little intervention to severe (hypovolemia, electrolyte abnormalities, and malnutrition) that may result in fatal complications.

Mucositis is further complicated by nausea and vomiting which often occurs with treatment. Chemotherapy and radiation therapy can affect the ability of cells to reproduce, slowing healing of the oral mucosa. Patients with damaged oral mucosa and reduced immunity are prone to opportunistic mouth infections.

Taste loss tends to increase in proportion to the aggressiveness of treatment. Nausea, pain, vomiting, diarrhea, a sore or dry mouth may make eating difficult. Thus maintaining adequate nutrition is a challenge for cancer patients. Reduction of caloric intake can lead to weight loss, loss in muscle mass strength and other complications, including a decrease in immunity. Cancer patient education must discuss the risks and the under-reporting of mucositis. Delayed or reduced medical treatment doses may reduce chances for cure. The potential impact of morbidity and mortality with oral Mucositis should not be underestimated and requires active treatment.

Maintaining adequate nutrition can be challenging for patients with cancer. Many problems-commonly loss of appetite-occur as side effects of cancer therapy. The foods you eat can affect these problems-they can make them worse or they can relieve them.

Physical problems may interfere with food intake and proper nutrition. Patients with head and neck tumors may have mouth or throat pain that can interfere with chewing and compound difficulties in swallowing. Tooth and gum disease further complicate the problem.

Radiation therapy to the head and neck area frequently results in a loss of taste perception, decreased production of saliva, along with inflammation of the mouth lining (mucositis), pain and difficulty swallowing. This suppresses the appetite and adds further to diminishing adequate nutrition and caloric intake. Radiation to the abdomen may cause some damage to the bowel, resulting in cramps, diarrhea, malabsorption or obstruction.

Chemotherapy can inhibit appetite by the same mechanisms as radiation. This is often worsened because of concomitant nausea. Decreased food intake is common for a short period around the time of treatment. It is important to try to compensate for weight loss during this time by making a conscious effort to eat more.

When you experience any of these problems, first consult your physician, nurse or the registered dietitian on your health care team. With their help and with the suggestions in the following articles, you should be able to plan a diet designed to minimize these problems. Prescription medications may be required. Your dentist, dental hygienist, nurse, dietitian, and pharmacist may also be of assistance.

Mucositis - Oral Problems and Solutions
Surgery To the Head And Neck Area
Radiation Effects
Mucocutaneous Changes and Mucositis
Loss of Taste
Salivary Function

Dental Caries
Candidiasis
Osteonecrosis
Osteoradionecrosis
Soft Tissue Necrosis
Dental Treatment Planning

Mucositis - Chemotherapy Problems and Solutions
Chemotherapy
Loss of Appetite (Anorexia)
Abnormalities in Taste Perception
What You Can Do If Foods Taste Too Bitter
What You Can Do If Foods Taste Too Sweet
What You Can Do If Foods Taste Off

What You Can Do In General
Nausea and Vomiting
Anticipatory Nausea and Vomiting What You Can Do
Medications for Nausea and Vomiting
Sore Mouth and Throat (Mucositis)

Corticosteroid Strategy
What You Can Do If You Have Mucositis
Infections
Antifungal Drugs
Herpes Simplex Virus Treatment

Mucositis - Esophageal and Gastrointestinal Problems and Solutions
Nutrition
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 Esophagitis
Heartburn, Reflux and Indigestion
Early Filling and Bloating
Diarrhea
Diarrhea Medications for Radiation Therapy
Milk (Lactose) Intolerance

Handout Mucositis: Problems and Solutions
Handout Mucositis: Problems and Solutions (PDF) - page 1
Handout Mucositis: Problems and Solutions (PDF) - page 2
It is important to know who is at risk of mucositis and to prevent complications to help improve quality of life and maximize your therapy. These risk factors include radiation to the head and neck, high dose chemotherapy, bone marrow transplantation, certain single agent anti-cancer drugs or a combination of these. Symptoms of mucositis should be treated as soon as they appear. It is important to be educated about proper nutrition and oral hygiene to help prevent or lessen these symptoms. Once you are aware of proper nutrition, you will be able to maintain adequate hydration, maintain your immunity and help prevent nausea as well as protecting your teeth

Mucositis and Targeted Therapies
New patient toxicities occur when targeted therapies usually monoclonal antibodies or small molecules such as tyrosine kinase inhibitors are given in conjunction with more traditional chemotherapy drugs. Mucosal injury can be a combination of either or both with mouth ulcers and diarrhea prominent.



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First appeared February 2, 2002; updated July 31, 2007; reviewed 2011-08-07