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