The Project to Educate Physicians on End-of
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Transcript The Project to Educate Physicians on End-of
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Module 6a
GI Symptoms
Education in Palliative and End-of-life Care for Veterans is a collaborative effort
between the Department of Veterans Affairs and EPEC®
Objectives
Discuss pathophysiology of common
GI symptoms in palliative care
Discuss assessment strategies
Describe management strategies
Nausea/vomiting ...
Definition
nausea is an unpleasant subjective
sensation of being about to vomit
vomiting is the reflex expulsion of gastric
contents through the mouth
... Nausea/vomiting
Impact very distressing:
awareness of nausea
inability to keep food or fluids down
acid and bitter tastes
unpleasant smells of vomitus
Pathophysiology …
Nausea
subjective sensation (easily learned)
stimulation
gastrointestinal lining, CTZ, vestibular
apparatus, cerebral cortex
Vomiting
neuromuscular reflex
… Pathophysiology
Chemoreceptor
Trigger Zone (CTZ)
Vomiting center
Neurotransmitters
l Neurokinin
l Serotonin
l Dopamine
l Acetylcholine
l Histamine
Cortex
Vestibular
apparatus
GI tract
Assessment
When
Acute versus chronic
Intermittent or constant
Associated with sights or smells
Eating patterns
Bowel patterns
Medications
Chemotherapyassociated
nausea/vomiting
Acute
< 24 hours
chemoreceptor trigger zone
serotonin release in the gut
Delayed
24 hours (may be days)
unclear mechanism
Chemotherapy
emetogenicity
Emetogenic
Class
Examples of Medications
Incidence of acute
vomiting
I
Capecitabine, Rituximab
Minimal (<10%)
II
Gemcitabine, Paclitaxel
Low (10-30%)
III
Mild (30-60%)
Doxorubicin, Carboplatin
IV
V
Moderate (80-90%)
Cisplatin, high dose
cyclophophamide
High (>90%)
Management
Dopamine
antagonists
Prokinetic
agents
Antihistamines
Antacids
Anticholinergics
Serotonin
antagonists
Cytoprotective
agents
Other
medications
Neurokinin
antagonists
Medications …
Dopamine antagonists
Haloperidol
Metoclopramide
Prochlorperazine
Histamine antagonists
Diphenhydramine
Meclizine
Hydroxyzine
… Medications …
Acetylcholine antagonists
Scopolamine
Serotonin antagonists
Granisetron
Ondansetron
Neurokinin-1 antagonists
Aprepitant
… Medications
Prokinetic agents
Metoclopramide
Antacids
H2 receptor antagonists
Proton pump inhibitors
Dexamethasone 6-20 mg PO daily
Tetrahydrocannabinol 2.5-5 mg PO tid
Anti-anxiety agents
Summary
Constipation
Definition
straining
hard stool
sensation of incomplete evacuation
fewer than 3 BM / week
12 weeks duration > 2 symptoms
Pathophysiology
Medications
opioids
calcium-channel
blockers
anticholinergic
Decreased motility
Ileus
Mechanical
obstruction
Metabolic
abnormalities
Spinal cord
compression
Dehydration
Autonomic
dysfunction
Malignancy
Assessment
Specifically ask about bowel function
Establish what is normal for patient
Management
General measures
regular toileting
gastrocolic reflex
activity
Specific therapies
softeners
osmotics
stimulants
lubricants
large volume enemas
Stool softeners
Sodium docusate
Calcium docusate
Stimulant laxatives
Prune juice
Senna
Bisacodyl
Osmotic agents
Lactulose or sorbitol
Milk of magnesia (other Mg salts)
Magnesium citrate
Polyethylene glycol
Lubricants/enemas
Glycerin suppositories
Phosphate enema
Oil retention enema
Tap water, 500–1,000 ml
Opioid-induced
constipation ...
Occurs with all opioids
Pharmacological tolerance develops
slowly, or not at all
Dietary interventions alone usually not
sufficient
Avoid bulk-forming agents in
debilitated patients
... Opioid-induced
constipation
Combination stimulant / softeners
are useful first-line medications
casanthranol + docusate sodium
senna + docusate sodium
Prokinetic agents
Opioid antagonists
Summary
Diarrhea
Definition: stool that is looser than
‘normal’ and /or increased in
frequency
Pathophysiology
Secretory
Osmotic
Inflammatory
Infectious
Assessment
Medical history
laxative use
previous antibiotics
last BM
Physical examination
Tests: C. diff. if recent
hospitalizations or
antibiotics
Specific types of
diarrhea
Medication-related diarrhea
C. Difficile
Diarrhea associated with
enteral feeding
dietary supplements
Pancreatic insufficiency-associated
diarrhea
Management
Avoid gas-forming foods
e.g. milk (lactose)
Increase bulk
Transient, mild diarrhea
attapulgite
bismuth salts
Management
of persistent diarrhea
Codeine
Diphenoxylate/atropine
Loperamide
Cholestyramine
Tincture of opium
Summary
Bowel obstruction
Definition: mechanical or functional
obstruction of the progress of food
and fluids through the GI tract
Prevalence
range from 6% (ovarian cancer) to 48%
(colorectal cancer)
Prognosis – poor if inoperable
Pathophysiology
Intraluminal mass
Direct infiltration
External compression
Carcinomatosis
Adhesions
Assessment
Symptoms
continuous distension pain 92%
intestinal colic 72-76%
nausea/vomiting 68-100%
Abdominal radiograph
dilated loops, air-fluid levels
CT scan
staging, treatment planning
Management
Surgical evaluation
Standard
intravenous fluids
nasogastric tube - intermittent suction
Inoperable
stent placement
Pharmacological
management
Analgesics
opioids
Antiemetics
haloperidol
Steroids
dexamethasone
Antisecretory agents
Drug
Dose
Notes
Octreotide
10 mcg/hr SQ/IV
cont. infusion or
100 mcg SQ q 8 h
Minimal adverse
effects; titrate
daily
Scopolamine
50-200 mcg/hr cont. Anticholinergic
infusion or 0.1 mg
effects may be
SQ q 6 h
dose-limiting;
titrate daily
Glycopyrrolate
0.2 to 0.4 mg SQ q 2 Anticholinergic
to 4 h; titrate
effects possible
Anticholinergics
Antispasmodic and antisecretory
Scopolamine
50-200 mcg/hr
0.1 mg sc q 6 h and titrate
Glycopyrrolate
0.2-0.4 mg sc q 2 to 4 h and titrate
Octreotide ...
Polypeptide analog of somatostatin
serum half-life = 2 h
Relieves symptoms of obstruction
... Octreotide
Octreotide 10 mcg/hr continuous
infusion
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
Ascites …
Definition: accumulation of fluid in the
abdomen
10% caused by malignancy
Other etiologies:
heart failure
cirrhosis
renal failure
... Ascites
Prognosis:
mean survival with malignant ascites < 4
months
if chemo-responsive cancer (e.g. new dx
ovarian ca) 6 months – 1 year
Pathophysiology ...
Normal physiology:
intravascular pressure = extravascular
pressure
no extravascular fluid accumulation
Ascites:
fluid influx increases
fluid outflow decreases
fluid accumulates
... Pathophysiology
Elevated hydrostatic pressure (e.g.,
congestive heart failure, cirrhosis)
Decreased osmotic pressure (e.g.,
nephrotic syndrome, malnutrition)
Fluid production > fluid resorption
(infections, malignancy)
Assessment
History & symptoms
ankle swelling
weight gain
nausea
discomfort
Physical exam
bulging flanks
flank dullness
shifting dullness
fluid wave
Diagnostic imaging
If physical exam is equivocal
Detects small amounts of fluid,
loculation
‘Ground Glass’ X-ray
CT scan
Management
Goal: to relieve the symptoms
With little or no discomfort: don’t
treat
Before intervening, discuss
prognosis, benefits, risks
Sodium and fluid balance
Sodium and severe fluid restriction
difficult for patients
discuss benefits, burdens & other
treatment options first
Diuretics
Effective
Well-tolerated
Treatment goals:
remove only enough fluid to manage the
symptoms
slow & gradual diuresis
Selecting a diuretic
Spironolactone 100-400 mg/day
Amiloride 10-40 mg/day
Furosemide 100-300 mg/day
Therapeutic paracentesis
Indications:
respiratory distress
diuretic failure
rapid symptomatic relief
Safe
In clinic or home
Summary
Mucositis
Definition: mucosal barrier injury
may affect the entire GI tract
Impact
oral erythema, ulceration, pain, infection
diarrhea (if it affects entire GI tract)
decreased oral intake
Prevalence
40% of patients on chemotherapy
100% with stem cell transplants
Pathophysiology
Direct injury
Secondary infection
Graft versus host disease (GVHD)
Assessment
History
pain and its effect on the patient
eating and drinking
Physical examination
orthostatic blood pressure and pulse
weight
evaluate affected oral mucosa
Management ...
l
Diminish mucosal delivery, e.g., oral
cryotherapy
l
Modify epithelial proliferation, e.g.,
growth factors
l
Reduce infections, inflammatory
complications
l
Reduce, inhibit pro-inflammatory
cytokines
... Management
Oral hygiene
Diet (minimize contact with food)
Local anesthetics
Systemic analgesics
Summary