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Gastrointestinal Symptoms in Palliative Care

Gastrointestinal Symptoms in Palliative Care. Dr Peter Nightingale Macmillan GP. 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

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Gastrointestinal Symptoms in Palliative Care

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  1. Gastrointestinal Symptoms in Palliative Care Dr Peter Nightingale Macmillan GP

  2. Introduction • Nausea and vomiting reported by 40-70% • Constipation reported by 50% of hospice inpatients • Dry mouth reported by over 75%

  3. Overview • Nausea and vomiting • Pathways and receptors • Evaluation • Causes • Receptor-specific anti-emetics • Malignant intestinal obstruction • Causes • Clinical features • management

  4. Overview • Constipation • Causes • Associated symptoms • Management/laxative guidance • Mouth care • Dry mouth • Oral candidiasis

  5. Nausea and Vomiting

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Chemical Drugs e.g. opioids Metabolic disturbance Calcium 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 Causes of Nausea and Vomiting

  12. 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

  13. 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

  14. 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

  15. Summary Points • Establish a cause • Reverse anything reversible • Choose the most appropriate receptor antagonist • Choose the most appropriate route of administration • Review regularly

  16. Malignant Intestinal Obstruction

  17. Incidence and Prognosis • Rates of up to 42% reported in ovarian cancer • Survival for several months without surgical intervention is possible

  18. Causes of Obstruction • Organic (mechanical) • Intraluminal • Intramural • Extramural • May be multiple sites of obstruction • Functional (pseudo-obstruction) • Mesenteric or bowel muscle infiltration • Coeliac plexus infiltration

  19. Clinical Features • Depends on level of obstruction • Usually insidious onset • Complete or partial (sub-acute) • Difficult to distinguish in practice • Abdominal pain • Constant background • Colic

  20. Clinical Features • Vomiting +/- nausea • Abdominal distension • Absolute constipation • Diarrhoea • Borborygmi, normal or absent bowel sounds

  21. 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

  22. 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

  23. Pain • Background pain • Opioids • Colic • May be relieved by opioids • Most need antispasmodic • Hyoscine butylbromide 20mg stat and PRN • Hyoscine butylbromide 60-120mg/24hr • Also has an antisecretory action

  24. Nausea and Vomiting • If no colic and passing flatus try prokinetic • Metoclopramide 40-100mg/24hr • Stop if develop colic • If patient has colic prokinetics are contraindicated • Cyclizine +/- haloperidol

  25. 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

  26. 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

  27. Corticosteroids • Cochrane review 1999 (Feuer and Broadley) • May relieve peri-tumour oedema • Resultant improvement in symptom control • Trial of dexamethasone • 8mg daily SC • Review after 5-7 days • Stop or reduce dose according to response

  28. Gastroduodenal Obstruction • Duodenum • Often caused by pancreatic tumour • Usually functional • Try metoclopramide first • Pylorus • Antisecretory drugs mainstay of treatment • Steroids • Consider NGT or venting gastrostomy

  29. Constipation

  30. 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

  31. 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

  32. 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

  33. 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 Causes of Constipation

  34. Effects of Opioids • Increased sphincter tone • Suppress forward peristalsis • Increase water and electrolyte absorption in the small and large bowel • Impaired defaecation reflex

  35. Flatulence Bloating Abdominal pain Feeling of incomplete evacuation Anorexia Overflow diarrhoea Confusion Nausea and vomiting Urinary dysfunction Restlessness Can mimic bowel obstruction by tumour Associated Symptoms

  36. Pattern of bowel movements Access to toilet, etc Halitosis Faecal leak Confusion Abdominal distension Visible peristalsis Palpable colon PR / stomal examination Assessment and Examination

  37. 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

  38. General Measures • Diet • Increase fluid intake • Privacy • Commode rather than bed-pan • Mobilise if possible • Stop or reduce constipating drugs where possible

  39. Oral Laxatives • Softeners • Surfactants/wetting agents e.g. docusate, poloxamer • 1-3 days latency • Osmotic laxatives e.g. lactulose, Movicol • 3 day latency • Lactulose: bloating, colic and flatulence • Need to increase fluid intake • Movicol better tolerated and more effective

  40. Oral Laxatives • Softeners • Bulk-forming agents e.g. Fybogel, Normacol • Stool normalisers • Large fluid intake required • Can exacerbate constipation in the terminally ill and those on opioids

  41. Oral Laxatives • Stimulants • e.g. senna, bisacodyl, danthron, sodium picosulphate • Induce peristalsis • 6-12 hr latency • Can cause colic and severe purgation • Especially useful in opioid induced constipation

  42. Oral Laxatives • Combinations • More effective and better tolerated than either alone for opioid induced constipation • Codanthramer = poloxamer + danthron • Codanthrusate = docusate + danthron • Discolouration of urine with danthron and may cause a rash

  43. 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

  44. Rectal Measures • Ensure adequate oral laxatives • Undignified and inconvenient • Suppositories • Glycerol softens and lubricates • Bisacodyl stimulates • Usually given in combination • 30mins to work

  45. Rectal Measures • Enemas • Micro-enemas • Phosphate enemas • Evacuates stools from the lower bowel • Arachis oil enema • Softens hard and impacted stools • May need high enema if stools higher than the rectum

  46. 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

  47. 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

  48. 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

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