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 Causes Receptor-specific anti-emetics

Malignant intestinal obstruction Causes Clinical features management

Overview

ConstipationCausesAssociated symptomsManagement/laxative guidance

Mouth care Dry mouthOral candidiasis

Nausea and Vomiting

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

Malignant Intestinal Obstruction

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

Constipation

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

Mouth Care

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

Summary Gastrointestinal symptoms are extremely common

in all cancer patients A thorough evaluation of the underlying cause of

any symptom is vital Treatment should be directed according to the

underlying cause Set achievable goals Review the response to treatment regularly