epecepecepecepec gi symptoms module 10a the education in palliative and end-of-life care program at...
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EEPPEECC
GI SymptomsModule 10a
The Education in Palliative and End-of-life Care program at Northwestern University Feinberg School of Medicine, created with the support of the American Medical Association and the Robert Wood Johnson Foundation
Nausea / vomiting ...
Definitionnausea is an unpleasant subjective sensation of being about to vomit
vomiting is the reflex expulsion of gastric contents through the mouth
Pathophysiology …
Nausea subjective sensation (easily learned)stimulation from
gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex (ICH, anticipatory, psychogenic), vagal reflex
Vomitingneuromuscular reflex
… Pathophysiology
Cortex
Vestibular apparatus
GI tract
ChemoreceptorTrigger Zone (CTZ)
Neurotransmitters Serotonin Dopamine Acetylcholine Histamine
Vomiting center
Assessment
Timing Acute versus chronic Intermittent or constant Associated with sights or smells Eating patterns Bowel patterns Medications
Management Dopamine
antagonists Antihistamines Anticholinergics Serotonin
antagonists Neurokinin
antagonists
Prokinetic agents
Antacids Cytoprotective
agents Other
medications
Medications …
Dopamine antagonistsHaloperidolMetoclopramideProchlorperazinePromethazine
Histamine antagonistsDiphenhydramineMeclizineHydroxyzine
… Medications …
Acetylcholine antagonistsScopolamine
Serotonin antagonistsGranisetronOndansetron
… Medications Prokinetic agents
Metoclopramide Antacids
H2 receptor antagonistsProton pump inhibitors
Dexamethasone 6-20 mg PO daily Tetrahydrocannabinol 2.5-5 mg PO
tid Lorazepam 0.5-2 mg PO q 4-6 h
Constipation ...
Straining Hard stool Sensation of
incomplete evacuationanorectal obstruction
Pathophysiology Medications
opioidscalcium-channel
blockersanticholinergicsondansetron
Pathophysiology Decreased
motility Ileus Mechanical
obstruction Metabolic
abnormalities
Malignancy Dehydration Spinal cord
compression Autonomic
dysfunction
Management
General measuresregular toileting gastrocolic
reflexactivity
Specific measuressofteners osmoticsstimulants lubricantsenemas
Stimulant laxatives
Prune juice Senna Bisacodyl
Osmotic agents
Lactulose or sorbitol Milk of magnesia (other Mg salts) Magnesium citrate Polyethylene glycol
Opioid constipation ...
Occurs with all opioids Up to 80 % of patients Pharmacological tolerance
develops slowly, or not at all Dietary interventions alone usually
not sufficient Avoid bulk-forming agents in
debilitated patients
... Opioid constipation
Combination stimulant / softeners are useful first-line medications
senna + docusate sodium Bisacodyl Opioid antagonists
Bowel obstruction ...
Definition: mechanical or functional obstruction of the progress of food and fluids through the GI tract
Impact: misery from nausea, vomiting and abdominal pain
Epidemiology Prevalence
range from 6% (ovarian cancer) to 48% (colorectal cancer)
Prognosis – poor if inoperable
... Bowel obstruction
Pathophysiology Intraluminal mass Carcinomatosis/infiltration External compression Adhesions
Assessment Symptoms
distension pain 92%intestinal colic 72-76%nausea/vomiting 68-100%
Abdominal radiographdilated loops, air-fluid levels
CT scanstaging, treatment planning
Surgical management
Surgical evaluation Standard
intravenous fluidsnasogastric tube - intermittent suction
Inoperablestent placement
Analgesicsopioids
Antiemeticshaloperidol
Steroidsdexamethasone
Pharmacological management
Antisecretory agentsDrug Dose Notes
Octreotide 10 mcg/h SQ/IV cont. infusion or 100 mcg SQ q 8 h
Minimal adverse effects; titrate daily
Scopolamine (hyoscine hydrobromide)
10 mcg/h SQ/IV cont. infusion or 0.1 mg SQ q 6 h
Anticholinergic effects may be dose-limiting; titrate daily
Glycopyrrolate
0.2 to 0.4 mg SQ q 2 to 4 h; titrate
Anticholinergic effects possible
Anticholinergics Antispasmodic and antisecretory Scopolamine
10 to100 mcg/h SC/IV0.1 mg sc q 6 h and titrate
Glycopyrrolate0.2-0.4 mg sc q 2 to 4 h and titrate
Octreotide ...
Polypeptide analog of somatostatinserum half-life = 2 h
Relieves symptoms of obstruction
... Octreotide Octreotide 10 mcg/h continuous
infusion or 100 mcg sq tid Titrate to complete control of n/v If NG tube in place, clamp when
volume diminishes to 100 cc and remove if no n/v
Try convert to intermittent sc Continue until death
Summary
Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve end-of-life care