Symptom: Gas (Flatulence)

Initial Grading Reminder

CTCAE grading of gas:

Grade 1: Mild symptoms; intervention not indicated
Grade 2: Moderate; persistent; psychosocial sequelae

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had any problems with gas in the past? Is this a new or worsening symptom? When did it start or get worse? Were you gassy before? How much worse is it now? Has it developed gradually or suddenly?

“Suddenly” would be more consistent with peritoneal signs.

Grade the symptom

Ask the patient:

How frequently do you pass gas? Is it causing you any distress? Do you ever soil yourself with the passage of gas?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Normally, how many bowel movements do you have per day/week? How many bowel movements do you have now? Is there blood and mucus in your stool? Do you have any abdominal (belly) pain, bloating, nausea or fever?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Gaseousness itself is not a cause for an office visit but may be a marker of GI toxicity. If patients are incontinent, they should be seen.

    Patients with symptoms of GI toxicity or GI red flags should be seen.

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    Nursing Assessment of Potential Causes

    GI Toxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear weak?
    • Has the patient lost weight?
    • Does the patient appear dehydrated?
    • Does the patient appear in distress?
    • Quantity & quality of bowel movements (e.g., change in/increased frequency over baseline): solid, soft, or liquid diarrhea; dark or bloody stools; or stools that float
    • Fever
    • Abdominal pain or cramping
    • Increased fatigue
    • Upset stomach, nausea, or vomiting
    • Bloating/increased gas
    • Decreased appetite or food aversions
    • Serum chemistry/hematology abnormalities
    • Infectious vs immune-related adverse event causation
    • Peritoneal signs of bowel perforation (i.e., pain, tenderness, bloating)

    Hepatotoxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear fatigued or listless?
    • Does the patient appear jaundiced?
    • Does the patient appear diaphoretic?
    • Does the patient have any ascites?
    • Change in energy level?
    • Change in skin color? Yellowing?
    • Change in stool color (paler)?
    • Change in urine color (darker/tea colored)?
    • Abdominal pain: specifically, right upper quadrant pain?
    • Bruising or bleeding more easily?
    • Fevers?
    • Change in mental status?
    • Increased sweating?
    • Elevation in LFTs
      • AST/SGOT
      • ALT/SGPT
      • Bilirubin (total/direct)
    • Alteration in GI function
    • Symptoms such as abdominal pain, ascites, somnolence, and jaundice
    • Other potential causes (viral, drug toxicity, disease progression)

    Differential Diagnosis

    What do you suspect is the cause of the patient’s flatulence?