gastrointestinal symptoms in palliative care dr peter nightingale macmillan gp
TRANSCRIPT
Introduction
Nausea and vomiting reported by 40-70%
Constipation reported by 50% of hospice inpatients
Dry mouth reported by over 75%
Overview Nausea and vomiting
Pathways and receptors Evaluation Causes Receptor-specific anti-emetics
Malignant intestinal obstruction Causes Clinical features management
Overview
ConstipationCausesAssociated symptomsManagement/laxative guidance
Mouth care Dry mouthOral candidiasis
Which of the following is true? A Cyclizine and metoclopramide is a logical
combination of drugs B Steroids are unhelpful in malignant bowel
dysfunction C Cyclizine and Haloperidol is a powerful
combination of antiemetics D Metoclopramide can help colicy pain in
malignant bowel dysfunction
Definitions Nausea
A feeling of the need to vomit May be accompanied by autonomic symptoms
Retching Rhythmic, laboured, spasmodic movements of the diaphragm
and abdominal muscles
Vomiting Forceful expulsion of gastric contents through the mouth
Table 2 Mechanism of action of drugs used in the treatment of nausea and vomiting1 2
Class Drug
Dopamine 2 receptor antagonist MetoclopramideDomperidoneHaloperidol
5-Hydroxytryptamine 3 antagonist OndansetronGranisetron
Antihistaminic antimuscarinic Cyclizine
Dopamine 2 antagonist, antihistaminic, antimuscarinic, 5-hydroxytryptamine 2 antagonist Levomepromazine
Antimuscarinic Hyoscine hydrobromide
Benzodiazepine Lorazepam
Cannabinoid Nabilone
Corticosteroid Dexamethasone
Prokinetic
5-hydroxytryptamine 4, D2 MetoclopramideDomperidone
Antisecretory
Antimuscarinic Hyoscine butylbromideGlycopyrronium
Somatostatin analogue Octreotide
Evaluation Establish a likely cause
Examination Thorough review of medication-do they need a PPI?(most do) Check bloods where appropriate
Treat anything reversible Non-drug measures Set realistic goals Identify the most likely pathway and receptors involved
Evaluation Choose the most potent antagonist Choose the most appropriate route of
administration Opt for regular rather than PRN dosing Titrate the drug dose accordingly Review regularly:
Have you identified the cause correctly?Consider combined therapy
Causes of Nausea and Vomiting Chemical
Drugs e.g. opioids Metabolic disturbanceCalcium and urea
Gastrointestinal Gastric stasis Stretch/distortion of GI
tract ?correctable bowel obstruction
Cranial Elevated ICP Meningeal irritation Skull mets
Other XRT Anticipatory and anxiety Movement Cough
Is a prokinetic (e.g.metoclopramide 10-20mg tds) indicated?
Promote gastric emptying Useful in gastric stasis (large volume vomits-late
in day-undigested food-little nausea-hiccoughs) If not settling in 2 or 3 days or happening 2-3
times daily consider using a syringe driver
Is vomiting due to opioids or chemical/metabolic factors?
Haloperidol 1.5mg is drug of choice for opioid induced vomiting (can usually be stopped after 10-14 days)
Some patients develop secondary gastric stasis so metoclopramide helps.
Alternative opioid indicated if nausea persists Haloperidol 1.5-3mg is indicated for uraemia or
hypercalcaemia
Is the patient still vomiting? With vomiting more than 2-3 times daily then consider a
syringe driver. Cyclizine (25-50mg tds) is broad spectrum but can cause
drowsiness and a dry mouth. Haloperidol and cyclizine is a potent combination Avoid cyclizine and metoclopramide (they oppose each
others action) Levomepromazine 3-25mg acts at multiple sites and is
sedating at higher doses. Dexamethasone 8mg daily has an anti emetic activity
Summary Points
Establish a cause Reverse anything reversible Choose the most appropriate receptor antagonist Choose the most appropriate route of
administration Review regularly
Incidence and Prognosis
Rates of up to 42% reported in ovarian cancer
Survival for several months without surgical intervention is possible
Causes of Obstruction Organic (mechanical)
Intraluminal IntramuralExtramuralMay be multiple sites of obstruction
Functional (pseudo-obstruction)Mesenteric or bowel muscle infiltrationCoeliac plexus infiltration
Clinical Features
Depends on level of obstruction Usually insidious onset Complete or partial (sub-acute)
Difficult to distinguish in practice Abdominal pain
Constant backgroundColic
Clinical Features
Vomiting +/- nausea Abdominal distension Absolute constipation Diarrhoea Borborygmi, normal or absent bowel sounds
Management
Try to anticipate and plan treatment in advance Surgical intervention should be considered in all
patients Radiological investigations
To distinguish between severe constipation and obstruction
In patients considered for surgery
Medical Management
Appropriate drug regimen can provide excellent symptom relief
CSCI is route of choice for most drugs IV fluids, NG tubes rarely needed Allow to eat and drink little and often Good mouth care vital Realistic goals
Pain
Background painOpioids
Colic May be relieved by opioidsMost need antispasmodic
Hyoscine butylbromide 20mg stat and PRNHyoscine butylbromide 60-120mg/24hrAlso has an antisecretory action
Nausea and Vomiting
If no colic and passing flatus try prokineticMetoclopramide 40-100mg/24hrStop if develop colic
If patient has colic prokinetics are contraindicatedCyclizine +/- haloperidol
Somatostatin Analogues
Octreotide inhibits secretion of numerous hormones
Resultant reduction in volume of GI secretions More rapidly effective than hyoscine Duration of action 8 hours Administer via CSCI or SC bolus Side effects: dry mouth and flatulence
Laxatives
Stop stimulant, osmotic or bulk-forming laxatives If likely to be constipated try phosphate enema and
a softener e.g. docusate sodium 100-200mg bd
Corticosteroids
Cochrane review 1999 (Feuer and Broadley) May relieve peri-tumour oedema Resultant improvement in symptom control Trial of dexamethasone
8mg daily SCReview after 5-7 daysStop or reduce dose according to response
Gastroduodenal Obstruction Duodenum
Often caused by pancreatic tumourUsually functionalTry metoclopramide first
PylorusAntisecretory drugs mainstay of treatmentSteroids
Consider NGT or venting gastrostomy
Definitions
The passage of small, hard faeces infrequently and with difficulty
The passage of hard stools less frequently than the patient’s own normal pattern
Prevalence in Palliative Care
A frequent cause of distress in terminally ill patients
50% of patients admitted to Palliative Care Units report constipation
80% require laxatives 90% of terminally ill patients on opioid analgesics
are constipated
Physiology Food residue usually in the small bowel for 1-2hr
and in the colon for 2-3 days In constipated patients colonic transit can be
greatly prolonged (4-12 days) Most of the colon’s action is mixing Forward movement 6x/day The frequency and strength of peristaltic
contractions are influenced by meals and activity
Causes of Constipation Cancer
e.g. hypercalcaemia, intra-abdominal disease
Debility Weakness Immobility Poor nutrition
Treatment Drugs e.g. opioids,
anticholinergics
Concurrent disease e.g. anal fissure
Neurological disease Immobility Loss of rectal sensation and
anal tone
Effects of Opioids
Increased sphincter tone Suppress forward peristalsis Increase water and electrolyte absorption in the
small and large bowel Impaired defaecation reflex
Associated Symptoms Flatulence Bloating Abdominal pain Feeling of incomplete
evacuation Anorexia Overflow diarrhoea
Confusion Nausea and vomiting Urinary dysfunction Restlessness Can mimic bowel
obstruction by tumour
Assessment and Examination Pattern of bowel
movements Access to toilet, etc Halitosis Faecal leak Confusion
Abdominal distension Visible peristalsis Palpable colon PR / stomal examination
Management
Prevention is better than waiting until intervention is needed
The aim is to achieve comfortable defaecation rather than any particular frequency and without the need for enemas or suppositories
General Measures
Diet Increase fluid intake Privacy Commode rather than bed-pan Mobilise if possible Stop or reduce constipating drugs where possible
Oral Laxatives
SoftenersSurfactants/wetting agents e.g. docusate, poloxamer
1-3 days latency
Osmotic laxatives e.g. lactulose, Movicol3 day latencyLactulose: bloating, colic and flatulenceNeed to increase fluid intakeMovicol better tolerated and more effective
Oral Laxatives
Softeners Bulk-forming agents e.g. Fybogel, Normacol
Stool normalisersLarge fluid intake requiredCan exacerbate constipation in the terminally ill and those on
opioids
Oral Laxatives
Stimulants e.g. senna, bisacodyl, danthron, sodium picosulphate
Induce peristalsis6-12 hr latencyCan cause colic and severe purgationEspecially useful in opioid induced constipation
Oral Laxatives
CombinationsMore effective and better tolerated than either alone for
opioid induced constipationCodanthramer = poloxamer + danthronCodanthrusate = docusate + danthronDiscolouration of urine with danthron and may cause a
rash
Equivalent Doses (Regnard, 1995)
3 codanthrusate capsules 15ml codanthrusate suspension 6 codanthramer capsules 4 codanthramer strong capsules 30ml codanthramer suspension 10ml codanthramer strong suspension 2 senna tabs + 200mg docusate 10ml senna liquid + 10ml lactulose
Rectal Measures
Ensure adequate oral laxatives Undignified and inconvenient Suppositories
Glycerol softens and lubricatesBisacodyl stimulatesUsually given in combination30mins to work
Rectal Measures
Enemas Micro-enemasPhosphate enemas
Evacuates stools from the lower bowel
Arachis oil enemaSoftens hard and impacted stools
May need high enema if stools higher than the rectum
Faecal Impaction Empty rectum/loaded colon
Oral stimulant and softener +/- high enema Movicol
Soft faeces Bisacodyl suppositories
Hard faeces Oral laxatives Suppositories and osmotic enemas first Arachis oil retention enema Manual evacuation may be necessary
Laxative Guidance Prescribe daily stimulant AND softener, especially
if on opioids Escalate dose until bowels opened If maximum dose ineffective reduce by half and
add an osmotic agent If bowels not opened for three days use rectal
measures Continue daily oral laxatives
Summary Points Constipation should be considered in all palliative
care patients Prophylactic laxatives for patients on opioids are
essential Consider PR examination in all constipated
patients Remember non-drug measures Titrate oral laxative dose according to response
Dry Mouth Reported in over 75% of patients Causes:
Reduction in amount of saliva producedPoor quality of salivaDrug therapyXRTDehydrationAnd lots of others
Associated Problems Chewing and swallowing
impaired Taste impaired Difficulty speaking Poor oral hygiene Dental caries
Dentures problematic Embarrassment Oral candida Other oral infection General deterioration in
health
Management of Dry Mouth Review medication Frequent sips of water Mouth care
Debride tongueMouthwashesPineapple chunksSponge sticksLip salve
Management of Dry Mouth
Stimulate salivary flowChewing gum, boiled sweets, citric acidPilocarpine (Davies et al 1998)
Artificial salivaGlandosane, Saliva Orthana, OralbalanceUse PRNUsually better than water
Oral Candidiasis
30% of terminally ill patients Causes
Dry mouthDentures Topical steroids (oral corticosteroids, antibiotics)
Oral Candidiasis
Features:May be asymptomaticSymptoms may relate to underlying cause e.g. dry
mouthWhite plaques +/- smooth, red, painful tongue +/-
angular stomatitis
Oral Candidiasis
TreatmentGood mouth care, including denturesTreat underlying problemTopical antifungal agents e.g. nystatin for 10 days
(sometimes continuous)Systemic antifungals e.g. fluconazole, ketoconazoleSignificant resistance to systemic antifungals