財團法人天主教聖馬爾定醫院
安寧療護暨癌症照護研習會
癌末病患常見之症狀困
擾與處置
蕭士銓 主任
Mucositis
蕭士銓
開場白
黏膜炎為化療以及放射線治療在腸胃道，特別
是口腔或口咽腔的黏膜所引起的傷害。
一般而言發生率約40% 。
高劑量化療或頭頸部癌症放射線治療的病人是
高危險群 。
黏膜炎會帶給病人痛苦疼痛，無法飲食，妨礙
說話，造成感染，甚至造成治療中斷影響治療
結果。
Causes of Mucositis in Cancer
Patients
Radiation therapy :
Mucositis usually appears by second week of
radiation therapy (at dose of 2000 rad)
Mucositis intensifies may persist 2 to 3 weeks
after completion of radiation.
Chemotherapy :
Early symptoms : increased sensitivity to
hot/cold foods; intolerance to citrus fruits.
Oral mucositis may indicate ulceration of entire
GI tract.
GVHD
Chemotherapeutic Agents with a High
Potential to Cause Stomatitis(I)
Antimetabolites
Cyclocytidine
Cytosine arabinoside
5-Fluorouracil
Floxuridine
6-Mercaptopurine
Methotrexate
6-Thioguanine
Antibiotics
Actinomycin D
Doxorubicin
Bleomycin sulfate
Daunomycin
Mithramycin
Mitomycin C
Mitoxantrone
Chemotherapeutic Agents with a
High Potential to Cause Stomatitis(II)
Plant Alkaloids
Etoposide
Vinblastine sulfate
hydrochloride
Vincristine sulfate
Taxanes
Paclitaxel
Taxotere
Miscellaneous
Hydroxyurea
Procarbazine
過程
1.分四個時期
2.約在7天後開始
3.化療引起的潰爛90%侷限在非角質化黏膜
放射線引起的黏膜炎則不會
4.黏膜炎在化療結束後約二到三週會修復而
放射線治療引起的粘膜炎可能延遲到六週
才修復
黏膜炎病理機轉之1
黏膜炎病理機轉之2
黏膜炎病理機轉之3
黏膜炎病理機轉之4
Grading system for mucositis :
Stage
Signs and Symptoms
0
None
I
Pain
II
Ulcers, but able to eat
III
Ulcers; can take liquids only
(I)
(II)
Management of
Mucositis
Management of Mucositis
General measures :
Serve food at room temperature, not hot.
 Avoid heavily seasoned or acid foods (or
any foods that trigger pain).
 Avoid alcohol and tobacco.
 Moisten foods with sauces; dry foods may
be difficult for patient to swallow.
 Chilled or frozen yogurt soothes oral
mucosa and provides a high-protein snack.
MAINTAIN CLEANLINESS AND PREVENT INFECTION
MAINTAIN INTEGRITY AND PROMOTE HEALING
Mouth care every 4 hours around the clock
Remove patient’s dentures, if present.
Brush the teeth with a soft-bristle nylon brush
and a fluoridated sodium bicarbonate dentifrice
within 30 minutes after eating and at bedtime.
Brushing before meals can help stimulate the
appetite.
Clean and massage the tongue and oral mucosa
with a soft-bristle brush and sodium bicarbonate
dentifrice after brushing or removing dentures. A
sponge-tipped applicator can be used to clean
the teeth and the tongue if brushing causes
discomfort or bleeding.
MAINTAIN CLEANLINESS AND PREVENT INFECTION
MAINTAIN INTEGRITY AND PROMOTE HEALING
Rinse the mouth with one ounce of saline, salt
and soda, tap water or 1.5% hydrogen peroxide
for 1 to 2 minutes. If saline or peroxide is used,
rinse with water to enhance mechanical
cleansing and minimize aftertaste.
Remove and brush dentures within 30 minutes
after eating and at bedtime, then soak dentures
in 1.5% hydrogen peroxide for several minutes.
MAINTAIN CLEANLINESS AND PREVENT INFECTION
MAINTAIN INTEGRITY AND PROMOTE HEALING
Floss the teeth once daily after brushing. Omit
flossing if it causes pain, if the platelet count is
less than 40,000/mm3, or if the leukocyte count
is less than 1500/mm3.
Use special precautions to prevent aspiration in
the person with a compromised gag reflex.
Eat a high-protein diet with vitamin
supplements.
MAINTAIN CLEANLINESS AND PREVENT INFECTION
MAINTAIN INTEGRITY AND PROMOTE HEALING
Apply agents to protect the mucosa and promote
healing, such as substrates of antacids or sucralfate.
Orabase applied pen pc and hs to ulcerated areas.
Sucralfate 1-gm tabs : Crush and spread through
mouth.
Sucralfate suspension : Swish for 2 minutes and
swallow, pc and hs. (To prepare: Dissolve eight 1-gm
sucralfate tabs in 40 ml of sterile water; add 40 ml of 70%
sorbitol and shake; in a separate container,dissolve 3
Ensure falvor packs in 10 ml of water; add to drug mixture;
water qs to 120ml.)
Vitamin E: Puncture capsule and apply directly on
lesion.
MAINTAIN CLEANLINESS AND PREVENT INFECTION
MAINTAIN INTEGRITY AND PROMOTE HEALING
Maintain optimal fluid and nutritional
intake while avoiding foods that are
irritating.
Consult with the physician and
nutritionist regarding the need for
enteral or parenteral nutrition.
PROMOTE COMFORT AND MINIMIZE PAIN(I)
Use topical anesthetics such as benzocaine or
diclonine before eating and as needed to control
pain.
Avoid irritants (e.g., alcohol and tobacco)
Use analgesics to control pain: 1.5 hours before
meals; at regular intervals around-the-clock if pain
is constant.
Xylocaine viscous 2% solution: Swish 15ml for
30 seconds, then spit out (q3h maximum).
PROMOTE COMFORT AND MINIMIZE PAIN(II)
Analgesic cocktail: 1 to 2 tbsp 15 minutes ac
and hs; hold for 2 minutes in mouth, then spit
out. (To prepare: Maalox (antacid), 345 ml;
xylocaine viscous, 79 ml; Benadryl Elixir, 47 ml.)
Choline salicylate (Teejel) or benzydamine
HCl 5% (NSAID) applied to affected area
(benzydamine is not currently available in the
United States).
Avoiding thermally, mechanically, or chemically
irritating foods.
MANAGE INFECTION(I)
Monitor the patient’s temperature every 4 hours
and report any elevation over 38°c.
Use local or systemic antibiotics,antifungals,and
antiviral agents as prescribed.
Infections of the oral cavity can be bacterial,
fungal, or viral in origin, and the antibiotic should
be selected based on the causative organism.
Antibiotics can be applied topically in ointments
(e.g., bacitracin or acyclovir), swishes or pastilles
(e.g., nystatin), or troches (e.g.,clotrimazole).
MANAGE INFECTION(II)
Sensitive,systemic antibiotics may also be
indicated,
especially in the immunocompromised
individuals.
The prophylactic use of the antiviral agent
acyclovir or antifungal agents is recommended
in individuals who are seropositive to the
herpes simplex virus and at high risk for
immunosuppression, such as prior to a bone
marrow transplant.
Note: It is critical to perform an oral culture to
identify the causative organism in
immunosuppressed individuals.
CONTROL BLEEDING
Monitor vital signs every 4 hours.
Assess platelet function from a complete blood
count (CBC).
Inspect mucosa and report any bleeding.
Rinse mouth with ice water and/or apply
pressure to an area of uncontrolled bleeding
using a piece of gauze dipped in ice water or
a wet tea bag that has been frozen.
Consult with the physician regarding the need
for thrombin or aminocaproic acid (use with
caution in persons with thrombocytopenia as
disseminated intravascular coagulation may
result).
總結
黏膜炎在癌症治療中常見，常帶來不良併發症，
延長住院時間，增加醫療支出，甚至造成醫療
中斷，病人死亡。
黏膜炎是一個上皮幹細胞複雜的生理病理交復
作用的動態過程。
目前預防與治療上並沒有特別有效的方 法，不
過許多的治療藥物正在進行臨床試驗。
單一藥物或單一處理步驟並不能滿足黏膜炎的
病人必需事先歸劃針對個人需求處理