Hypokalemia (Low Potassium) & Chronic Diarrhea

A&E of UMMC

Here I am again at the hospital taking care of mom. This is the second admission since last week's when mom was discharged after being hospitalized for 4 nights due to persistent diarrhea and total loss of body strength. It really scared the hell out of me. She looked as if she was paralysed and could not even sit up without assistance. It took us all energy and strength to transport her to the car and drove her to A&E of UMMC. She had 3 falls at home and her potassium level dropped to 2.1 when tested at the A&E. She was allowed home when her potassium level went up to 4.6 after few rounds of sodium and potassium drips although her diarrhea still persisted. The surgical doctor asked mom if she wanted to go home and of course she said yes! How wrong could that be.. because she was again readmitted 4 days later due to the same problems.. Loss of potassium and fluids from severe diarrhea.

Mom has been having diarrhea after 5th cycle of Folfox regimen and her renal function result wasn't satisfactory ever since due to low reading in potassium and high creatinine level. On her 6th cycle and onwards, the oncologist had dropped oxaliplatin for good and only proceeded with 5FU as they suspected it could be due to oxaliplatin that had caused her poor renal function. Mom's response to the chemo drugs had been excellent until post 5th cycle when she started to develop chronic diarrhea and it persisted till now. The oncologist prescribed Lomotil and later Imodium but it did not seem to help much.

This time she is readmitted to the surgical unit, they did all kinds of blood tests, urine tests, occult stool test to find out the cause of the chronic diarrhea and that mom would not get discharged unless the cause is identified. Mom developed UTI (Urinary Tract Infection) while in the ward and the surgical doctor put mom on antibiotic (Rocephin) drips. She urinated very often and could not hold her urine and most of the time she would wet the bed eventhough she was on diapers. I searched the internet and realised that when one has UTI, it is common not to be able to hold one's urine and that flow of urine would increase.

Mom was then wheeled down to the oncology unit to see Dr Ho, the oncologist in-charge of mom. I was told that mom would stop receiving chemotherapy for good after 8 cycles (5 cycles of FOLFOX, 2 5FUs and 1 De Gramont). He said as the initial plan was 8 to 12 chemo cycles, it would be good if the drugs are well tolerated and the 12 cycles be completed but it would not justified if the drugs had started to affect her quality of life. I told him that Imodium did not give the desired result and he wrote a prescription for octreotide injection (to slow down the bowel movement, well, supposedly) to be administered.

Today is the 6th day of admission and mom's diarrhea still did not see much improvement, she is still having an average of 6 times of diarrhea daily. The surgical team just came for their afternoon round and I could hear them discussing the possibility of tumour growth that caused the persistent diarrhea seeing the administration of Ostreotide by the oncologist. I did a search on the internet, apart from suppressing tumour growth, ostreotide also uses for side effects of 5FU. Hopefully it was the side effects that has caused the diarrhea and not the other way round. No, mom needs no more and could no longer tolerate anymore chemo cycles. God Bless Her.

Apart from getting persistent diarrhea, mom can eat and sleep really well. She wiped off the supper consists of kuey teow soup and dessert of sweet potatoes soup I bought for her as supper last night. She can walk with a walking stick now but still weak in body strength and stamina. Her feet swelled due to water retention from the drips and she is wearing TED stocking to prevent bood clot. She exercises her lung using the spirometer we bought during her post operation six months ago. They administered heparin jab on her this morning and she gets octreotide injection, supposedly to slow down the bowel movement once daily. The surgical team has started giving mom 4mg tds of Imodium and lomotil once daily today. I asked the doctor if it was alright to have octreotide, Imodium and lomotil at the same time and he explained due to the different mode of actions of each drug, so it would be fine.

To be continued........

Confused

I accompanied mom to the Oncology Unit this morning for her 5th cycle of chemotherapy. The uncle I met and chatted with two weeks ago was there too to take his 8th cycle. He has been having problems with low platelet counts since his 3rd cycle and now that the doctor has decided to reduce his dosage from 3 to 2 bottles, same chemo regimen as mom's though mom's FBC (Full Blood Count) is still okay to take the full dose. I hope mom would be able to sail through and complete the whole cycle without any major problems.

It was a long wait before mom was called to the day care room due to staff shortage and quite a few of the staff were still on their Raya holidays. We arrived at 8.15am and mom got her turn only at 9.45am. As the whole session would last for 4 hours, I brought along my notebook and updated on my blog to keep busy.

I needed a hair cut desperately and had not got around doing it. I know I must make effort to prioritize and change my lifestyle and focus on being mom's caregiver and not going on wasting my time justifying and pondering on the issue of fairness or otherwise. Everytime when I feel down, hubby would say something like this: Just take the task with a noble mind without thinking about getting any returns. Fei Lou, easier said than done, I am trying very hard and have had struggles within myself for god knows, umpteen times.

The uncle that I met this morning praised me for being such a filial and good daughter as I keep mom company wherever mom goes in the hospital as I have to be there to be her interpreter, she speaks no other languages or dialects, only Cantonese. Only God knows if I am even qualified to be “shortlisted” as a filial daughter. I know by transferring mom back to Sabah, I would get all the freedom that I have been wanting and without having to worry about cooking, dealing with mom's fluctuating emotions, her side effects from chemo, keeping track on mom's doctor appointments, going out and working on my assignments without feeling any guilt that someone ill is left behind unattended.

But on the other hand, I would not trust the doctors here in KL, let alone those in Sandakan! Would I blame myself or get blamed for the rest of my life should anything happened to mom due to negligence by any parties? I think I just have to learn to let go....

Chemotherapy Induced Constipation

Mama experienced constipation right after her 1st chemo cycle's drug infusion and from taking of pre and post chemo anti-nausea drugs such as Granisetron (Kytril), Ondansetron (Zofran) and Dexamethasone (Decadron). The first two anti-nausea drugs could well be the culprit for the constipation as this was one of the common side effects.

Mama did not have bowel movement until the next day when she noticed bright red blood in her stool. That scared the hell out of us as she told us that the toilet bowl was actually all red when she looked into it.

I have added a lot of high fibre food in mom's daily diet and kept reminding her to take lots of fluids as constipation was anticipated in patients undergoing chemotherapy but blood in the stool was not common though.

I quickly looked up on the internet and found some useful information:

1. 
   
   Hemorrhoids (also called piles) - Enlarged veins in the lower part of the rectum or anus
2. 
   
   Anal fissures - Small cracks or tears around the anus which can be caused by forceful or large bowel movements
3. 
   
   Infection or disease in the GI (gastrointestinal tract) - Bacterial infections, stomach ulcers, or inflammatory bowel disease (IBD).
4. 
   
   Tumors or cancer of the GI tract - Polyps or colon cancer. Cramps in relation to bright red rectal bleeding are suggestive of a partial colonic obstruction and especially suggest cancer.

Passing bright red blood usually suggests that the blood is coming from the large bowel or the rectum.

Hemorrhoids can be internal or external and are often caused by struggling when trying to defecate. You can't always feel them, and they don't always hurt when you sit. Mom felt straining around the anus during bowel movement and this suggested hemorrhoid.
Point 3 was ruled out because mom did not have any pain or dizziness from the bleeding.

I took mom back to the oncology clinic and Dr Lim, the MO on duty, performed a anoscopy on her. During the anoscopy, the doctor used a short, rigid, hollow tube (anoscope) and a nurse assisting him holding a torch light to look at the last 2" of mom's colon (anal canal). According to the dr, anoscopy can be done at any time because it does not require any special preparation (enemas or laxatives) to empty the colon.

The doctor told me that he noticed some enlarged veins in the lower part of mom's rectum and it could be due to internal hemorrhoid where the patient herself could not feel and did not even realise its presence. He wanted me to mention this during the follow-up appointment with mom's surgeon in two weeks' time to perform another anoscope to confirm his findings.

I asked for some stool softeners to help mom in bowel movements and the doctor prescibed Lactulose. Lactulose works by increasing the water content and volume of the stools in the bowel, making them softer and easier to pass. It is made up of sugar molecules and is broken down by the bacteria that live in the lower part of the gut. This leads to the contents of the gut becoming more acidic, which reduces the absorption of a chemical called ammonia. The presence of ammonia in the gut causes water to be drawn into the lower bowel. This increases the amount of water in the stools, softening them and making them easier to pass, thus relieving constipation. It can take up to 48 hours for the lactulose to have an effect.

I bought a bottle of Del Monte prune juice just before mom started her 2nd chemo cycle. She has been taking half a cup of prune juice together with 1 teaspoonful of L-Glutamine powder (known for prevention of neuropathy which I intend to blog about it later) twice a day on empty stomach since a day prior to her 2nd cycle and it has been a week now and the result was fantastic. She has not missed her daily bowel movement and has not have blood in her stool till now (knock on wood). She also took two teaspoonfuls of psyllium husk with her whey protein powder twice daily to prevent constipation even before the start of the 1st chemo cycle but it did not help as much.

We now swear by prune juice for mom's constipation and she now takes it obediently without much grumbles despite initially complaint of its nasty taste.

L-Glutamine Powder For Neuropathy

Ambit Continuous Infusion Pump

We went back to the Oncology clinic on the 3rd day of mom's 1st chemotherapy to take the pump off and the process was a breeze! We reached there slightly before 2pm and paid RM10 for the service. Mom was called into the chemotherapy room soon after and by 2.30pm we were ready to go. The Ambit pump was the hospital's property and would be kept by them until the next cycle where it would be attached to mom again.

The operation of the pump is simple. There are only two buttons, the Run/Pause button and On/Off buttons. 2 AA batteries are used and they can usually last throughout the 46 hours of 5FU infusion. To replace batteries or upon infusion completion, press run/pause button to pause position before turning off the pump and removing batteries.

The pump is about the size of a TV remote controller and designed to accurately deliver a patient's drug therapy in the comfort of their own home. Mom would have had to get admitted to the hospital for 2 nights on every fortnightly chemo cycle should the pump and chemoport had not become available. It is meant to complement the patient's quality of life and support the oncologists / physicians in prescribing the best and most affordable care.

Bard Chemo Port

Actual size of mom's Bard chemoport

(Mom's Model: M.R.I.* Plastic Single Lumen Port, Peel-Apart Percutaneous Introducter System

W/ Attachable Groshong* 8 French Catheter)

Larger image


The port is implanted completely beneath your skin, and the catheter is inserted inside a blood vessel. Ports are usually implanted on the upper chest, as in moms's case, on the left.



The port acts like an IV to the bloodstream. A special needle is inserted just below the surface of your skin and into the port so that medications and fluids can be given, and blood samples withdrawn.

What is a Bard Implanted Port?

A Bard Implanted Port is a device which is used to deliver medications into the bloodstream. The word implanted refers to the fact that the device is placed completely beneath the skin. The port will be visible merely as a small "raised area" beneath the skin. Daily care is generally not required and it does not affect your normal activities.

Visit To UMMC's Oncology Clinic

Dad and mom arrived at the hospital at 7.25am. I dropped them off and sent Ian to his kindy which was nearby. Ian's kindy opens at 8.00am so I parked my car by the roadside and let him catch up on his sleep till 8.00am. By the time I secured a parking and joined them at the oncology clinic, it was already 8.20am. We got a waiting number for blood tests on liver and kidney function and CEA level.

Dr Ros attended to us and when I told her that the chemo port was not implanted as yet due to the delay from the Surgery side, she tried calling them and fixed the appointment for us. She could not get through the right person so we had to wait for mom's name to be called again. I called Dr Tee immediately after I came out from the doctor's room. He told me he would call me by noon when the doctor who was incharged of roster of the operation theatres came back.

Not long after, mom was called in and Dr Ros told us the appointment for chemoport implantation had now been confirmed on this Friday and mom to get admitted a day before surgery. The 1st chemo cycle is now fixed on next Monday. Should there be any delay again in the surgery, mom must get admitted for two nights and would have to get the chemo through direct IV drips until she had the chemoport ready. Lets hope that there would not be anymore delays and all appointments fixed would be smooth sailing.

Selvi, the staff nurse gave mom and I a lengthy education session on FOLFOX regimen, its side effects, operation of AMBIT pump, telephone number to contact in case of emergency etc. I will write in more detail about this later.

Soon after we left the oncology clinic, I received a call from Dr Tee confirming the surgery on Friday. He has been very helpful from day one and we are really grateful and lucky to have him in mom's team of doctors.

Protein Powder

PROSURE
Per 100 g Protein 21.29 g, fat 8.2 g, carbohydrate 64.9 g, dietary fibre 3.1 g, fructo oligosaccharide 3.52 g, moisture 2.4 g, taurine 64.1 mg, carnitine 32 mg, vit A acetate 430 iu, β-carotene 2,241 iu, vit D3 218 iu, vit E 14.6 iu, vit K1 32 mcg, vit C 110.2 mg, folic acid 138 mcg, vit B1 0.81 mg, vit B2 0.92 mg, vit B6 1.09 mg, vit B12 1.58 mcg, niacin 7.99 mg-NE, pantothenic acid 3.52 mg, biotin 16 mcg, choline 163.4 mg, ash 3.2 g, Na 480 mg, K 640 mg, Cl 487 mg, Ca 474 mg, phosphorus 336 mg, Mg 90.6 mg, Fe 0.35 mg, Zn 7.99 mg, manganese 1.34 mg, copper 236 mcg, iodine 51.1 mcg, selenium 25.3 mcg, chromium 32 mcg, molybdenum 44.7 mcg. Energy: 392 kCal.

NESTLE NUTREN OPTIMUM
Per 100 g Fat 17.5 g, protein 18.4 g, carbohydrate 58.2 g, vit A 1,800 iu, vit D 130 iu, vit E 13 iu, vit K 23 mcg, vit C 65 mg, vit B1 0.92 mg, vit B2 1.1 mg, niacin 13 mg, vit B6 1.8 mg, folic acid 250 mcg, pantothenic acid 6.5 mg, vit B12 3.7 mcg, biotin 180 mcg, choline 210 mg, taurine 37 mg, carnitine 37 mg, Na 402 mg, K 573 mg, Cl 551 mg, Ca 307 mg, phosphorus 307 mg, Mg 123 mg, manganese 1,239 mcg, Fe 5.5 mg, iodine 46 mcg, copper 0.65 mg, Zn 6.5 mg, selenium 18 mcg, chromium 18 mcg, molybdenum 55 mcg. Energy: 461 kCal.

I got mom a tin of Nestle Nutren Optimum 400g after trying out few samples hubby brought back from a newly opened pharmacy in Puteri IOI, Puchong. I got the first tin from Guardian at Ikano Power for RM29.90. I then hopped over to Tesco nearby and was shocked to see the price tagged at RM36.80, if I remembered correctly. My impression was that prices at the supermarkets should be lower than that at the pharmacies, right, well, I was wrong.

While doing my marketing with papa at the Tropicana City, PJ the other day, I walked into Caring Pharmacy and the price gave me another shock, only RM19.90 per tin but that was a promotion pack larr. I quickly grabbed the 2 tins on the shelf and asked the shop assistant to check if they have any more stocks available. The remaining stock on the shelf was their last batch of stock available.

I initially wanted to get Prosure by Abbott but ended up with Nestle Nutren Optimum after comparing the ingredients, they were almost similar and Prosure had lighter weight content by 20gram and priced at RM45++ per tin, almost doubled the price of Nutren Optimum. Guess the higher price contribution was from branding and Abbot's aggressive advertisement and emphasis on special fomulation mainly for cancer patients.

1st Visit to UMMC's Oncology Clinic

We went for mom's 1st appointment at the Oncology Unit last Friday. We reached there around 8.30am, got a waiting number and filled up a form and mom's name was called not long after for taking of body weight. It was finally our turn after 2 hours waiting. Dr Ros, the MO under Dr Ho's team (the oncologist incharge of mom) attended to mom. Mom was asked to lie on the bed and had her wound checked. Dr Ros commented that mom's wound was healing well and I gave her the CT Scan for review. We were then asked to wait for mom's name to be called again while she discussed with Dr Ho and Prof. Dr Chin (the surgeon operated on mom). While waiting, I observed the patients around us. Most of them were seen wearing head scarves and hats to hide their balded head. I later found out they were mostly breast cancer patients and had undergone few chemotherapy cycles and the balding was due to its side effects and not all cancer patients undergoing chemo treatment would get the same side effects due to different types of drugs used.

There were three breast cancer patients seated a row behind us and they were discussing about life after getting this deadly disease and the dieting regimen they followed while on chemotherapy. I took life for granted and lightly and never bothered to get myself checked by the doctors before mom was admitted to the hospital and diagnosed with colon cancer even though I was previously in pharmaceutical sales for 5 years where I got to see doctors every day. During mom's twice admission to UMMC for a total of 10 days, I realised one could not take one's life lightly or ignorantly. In mom's case, should she had seek treatment when the symptoms like, dark coloured stool, abdominal pain, no appetite, fatigue arose three years ago, things would have been easier to manage today. But let bygone be bygone. The whole family had actually agreed not to ponder on this again as they would only make mom feel more guilty, the guilt of being a burden to the family.

Mom's name was called after another 1 hour waiting time. Dr Ros then told us that they had called Prof Dr Chin and he said that “almost” 100% of the tumour and infected colon were removed. Dr Ros briefed that due to the perforation (a tear or hole) of the tumour, they planned to put mom on a more powerful chemo drug called oxaliplatin combined with FU5 and Folinic Acid (a type of vitamin) also called FOLFOX regimen for 8 to 12 cycles every 2 weeks. The whole duration of chemotherapy would take at least 6 months depending on how well mom responded to the drugs. The cost of full cycle of FOLFOX regiment would be in the range of RM21,000 for the drugs alone and not included other expenses. She suggested a chemoport be implanted to reduce the pain mom had to endure everytime looking for veins for IV drips of the chemo drugs.

Dr Ho, the oncologist incharge of mom, came in and greeted us. I asked him about the side effects of this FOLFOX regimen and the possibility of moving mom back to Sandakan to continue with the treatment as mom has always wished to be to be in her hometown at this difficult part of her life journey. Dr Ho said some of the side effects would be neuropathy (tingling of the fingers and toes, nausea or feel like nauseating, touching or taking cold drinks would get an even worse effects to the nerves) though it would not cause hair loss due to the drugs used. He continued that he could refer mom to an Indian oncologist in KK but wasn't sure about any oncologist available in Sandakan.

He then observed mom and told me that mom looked very worried. I then asked Dr Ho if he could converse to mom in Cantonese and repeat what he had told me so that she could be more at ease than just staring at both of us not knowing what we said. He did that and mom looked very calm though a bit shocked and that gave me slight mental relief. All this while, I had been thinking chemotherapy would not be necessary on mom as one of the surgeons, Dr Tee reassured us that chemo might not necessarily come into the scene. I did not ask many questions as I was still recovering from the shock and wasn't prepared to this. I have had no idea what the hell this FOLFOX was and what damage it would bring to my already fragile mom with only 48kg left from the previous 60kg!

An appointment was fixed for blood test and day after, starting of chemotherapy on 20 & 21 July. I was then asked to get an appointment from Surgery Unit to have the Chemoport installed but due to the fact that I could not get a date as Prof Dr Chin's team would only be at the surgery clinic on Thursday, the oncology side postponed the dates to 27 & 28 July to allow sufficient time for chemoport implantation.

I told my sister about the oncologist's plan to put mom on chemotherapy and she was so upset over the fact that at this age mom would have to suffer yet again after the major surgery 3 weeks ago. Apparently, my sister has always been our messenger in the family to avoid having to repeat so many times on the same issues. My two elder brothers would always call should they want to know more about mom's case. I started my search on the FOLFOX regimen and my focus would definitely on its side effects.