High-potency sucralfate prevents and rapidly reverses chemo-radiation mucositis in a patient with stage 4b head and neck cancer

Table 1 Grade scales for the assessment of oral mucositis

World Health Organization Grade	Grade 1	Grade 2	Grade 3	Grade 4	Grade 5
Function	Painless ulcers, erythema or mild soreness	Painful erythema, edema, or ulcers but can eat solids	Painful erythema, edema, or ulcers and cannot eat solids	Alimentation is not possible; dependence on IV and feeding-tube
Clinical Exam	Erythema of the mucosa	Patchy ulcerations or pseudomembranes	Confluent ulcerations or pseudomembranes; bleeding with minor trauma	Tissue necrosis; significant spontaneous bleeding; life-threatening consequences	Death
Symptoms	Minimal symptoms, normal diet; minimal respiratory symptoms but not interfering with function	Symptomatic but able to eat and swallow modified diet; respiratory symptoms interfering with function but not with activities of daily living	Symptomatic and unable to adequately aliment or hydrate orally; respiratory symptoms interfering with activities of daily living	Symptoms associated with life-threatening consequences	Death

Table 2 European Organization for Research and Treatment of Cancer/Radiation Therapy Oncology Group and the World Health Organization toxicity criteria acute chemoradiation morbidity

	Scale for gastrointestinal toxicity
	Grade 0	Grade 1	Grade 2	Grade 3	Grade 4
Esophagus toxicity grade	None	Mild fibrosis; Slight difficulty in swallowing solids; No pain on swallowing	Unable to take solid food normally; Swallowing semi-solid food; Dilation may be indicated	Severe fibrosis; Able to swallow only liquids; May have pain on swallowing; Dilation required	Necrosis/Perforation Fistula
Small bowel toxicity grade	None	Mild diarrhea; Mild cramping; Bowel movement 5 times daily	Moderate diarrhea and colic; Bowel movement > 5 times daily	Obstruction or bleeding, requiring surgery	Necrosis/Perforation Fistula
Colorectal toxicity grade	None	Increased frequency or change in quality of bowel habits not requiring medication, rectal discomfort not requiring analgesics; Slight rectal discharge or bleeding	Diarrhea requiring parasympatholytic drugs, mucous discharge not necessitating sanitary pads, rectal or abdominal pain requiring analgesics; Excessive rectal mucus or intermittent bleeding	Diarrhea requiring parenteral support, severe mucous or bloody discharge necessitating sanitary pads/abdominal distension (flat plate radiograph demonstrates distended bowel loops)	Acute or subacute obstruction, fistula or perforation; gastrointestinal bleeding requiring transfusion; abdominal pain or tenesmus requiring tube decompression or bowel diversion
World Health Organization colorectal	None	Increase of 2-3 stools per day over pretreatment	Increase of 4-6 stools per day, or nocturnal stools, or moderate cramping	Increase of 7-9 stools per day, or incontinence, or severe cramping	Increase of > 10 stools per day or grossly bloody diarrhea, or need for parenteral support
Toxicity grade

Table 3 Modified naranjo probability of intervention-caused response

	Questions	Yes	No	Don’t know	Case report
1	Are there previous conclusive reports on this response?	1	0	0	0 don’t know
2	Did the response appear after the intervention was administered?	2	-1	0	+2 Yes
3	Did the response disappear when the intervention was discontinued?	+1	0	0	+1 Yes
4	Did the response reappear when the intervention was re-administered?	+2	-1	0	+2 Yes
5	Are there alternative causes that could on their own have caused the reaction?	-1	+2	0	+2 No
6	Did the reaction reappear when a placebo was given?	-1	+1	0	+1 No
7	Was the intervention detected in the blood in concentrations known to be toxic?	+1	0	0	0 No
8	Was the response more apparent when the dose was increased, or less apparent when the dose was decreased?	+1	0	0	0 No
9	Did the patient have a similar response to the same or similar intervention in any previous exposure?	+1	0	0	+1 Yes
10	Was the response confirmed by any objective evidence?	+1	0	0	+1 Yes
Patients total score					10