Palliative Management of Gastrointestinal Symptoms

IGCE SessionBy Cora Pontee, MD

Baylor GeriatricsFebruary 6th, 2013

Common Gastrointestinal Symptoms in Palliative Patients

• Oral discomfort• Dysphagia• Nausea and vomiting• Hiccups

Objectives

• To acquire knowledge of current evidence in managing GI symptoms

• To recognize oral discomfort and hiccups as treatable symptoms

• To apply principles of management of GI symptoms to clinical practice

Causes of Oral discomfort:Definitions

• Xerostomia: Dryness of the mouth resulting from diminished or arrested salivary secretion

• Dysgeusia: An impairment or dysfunction of the sensation of taste

• Stomatitis: The inflammation of the mucous lining of any structures of the mouth, which may involve the cheeks, tongue, gums, lips, and roof or floor of the mouth

• Mucositis: inflammation of a mucous membrane

The Free Dictionary By Farlex

Causes of Oral discomfort

• Oral pain: angular stomatitis, dental caries, poorly fitting dentures, XRT or chemo induced stomatitis or mucositis, candidiasis, burning mouth syndrome

• Xerostomia: related to cancer (head and neck), dehydration, radiation, drug therapy (anticholinergic, psychotropic, opioid, cardiovascular)

• Dysgeusia: sinusitis or other infection, xerostomia, medications (antidepressants, HIV meds, chemotherapy), vitamin or mineral deficiency (zinc)

Denture stomatitis• Definition: oral candidiasis that

can occur in healthy adults wearing dentures

• May present as bleeding, swelling, burning sensation, xerostomia, or cacogeusia

• 35-50% of people wearing complete dentures

Altarawneh et al, “Clinical and Histoligic Findings of Denture Stomatitis as Related to Intraoral Colonization Patterns of Candida albicans, Salivary Flow, and Dry Mouth,”J Prosthodont, 2012

Management of Oral Discomfort

Xerostomia treatment options

• Salivary substitute or oral gel every 1-2 hours or sugarfree gum

• Malic acid 1% spray• Oral care: encourage family members to keep

patient’s mouth moist (oral swabs to bedside)• Increase liquid PO intake; try frozen juices,

popsicles, ice chips, Resveratrol• Pilocarpine 5 to 10 mg three times daily (watch for

respiratory secretions or diarrhea)Gomez-Moreno G. et all, “Effectiveness of Malic Acid 1% in Patients with Xerostomia Induced by Antihypertensive Drugs,” Med Oral Patol Oral Cir Bucal 2012Furness S et al, “Interventions for Management of Dry Mouth: Topical Therapies,” Cochrane Database Syst Rev 2011

ALTENS• Acupuncture-like Transcutaneous Electric Nerve

Stimulation• 47 patients with cancer of the head and neck who were

3 to24 months from completing radiotherapy (mean age 60 years) with xerostomia

• Patients received twice weekly ALTENS sessions over 12 weeks

• Six month Xerostomia-Related Quality of Life Scale (XeQOLS) scores showed 86% of patients received a positive treatment response

• Now entering Phase 3 studiesWong RK et al, “Phase 2 Results from Radiation Therapy Oncology Group Study 0537: a Phase 2/3 Study Comparing Acupuncture-like Transcutaneous Electric Nerve Stimulation Verses PilocarpineIn Treating Early Radiation-Induced Xerostomia,” Cancer 2012, Sept 1

Mucositis: Physiology

The Biology of Blood and Marrow Transplantation, Volume 11 Issue 12, Dec 2005

Treatment of Mucositis• Chlorhexadine gluconate (Hibiclens, Betasept)

• Combination mouthwash preparations with:• Diphenhydramine• Lidocaine• Loperamide• Nystatin• Tetracycline• hydrocortisone

• Lidocaine 2% q4 to 8 hrs, 50/50 mixture with famotidine

• Sucralfate suspension swish and swallow q 3-4 times daily

• Doxepin oral rinse up to every 4 hours

• Opioids (topical, parenteral)Clarkson JE et al, “Interventions for Treating Oral Mucositis for Patients with Cancer Receiving Treatment,” Cochrane Database of Syst Rev, October, 2010

Laser Therapy in Mucositis

• 16 children (mean age 9.4 years) with chemotherapy-induced mucositis

• All children treated with GaAIAs diode laser with 830 nm wavelength, repeated every 48 hours until healing of lesion occurred

• On average 2.5 treatments in a period of 1 week were sufficient to heal the lesion; pain relief noted immediately after each treatment

Cauwels RG and Martens LC, “Low level laser therapy in oral mucositis: a pilot study,”Eur Arch Paediatr Dent, 2011

Dysphagia

• Definition: Difficulty in swallowing or inability to swallow

The Free Dictionary by Farlex

Dysphagia

• Oropharyngeal dysphagia• Obstructing esophageal lesions• Esophageal dysmotility (neuromuscular,

autoimmune)• Cognitive impairment

Oropharyngeal Dysphagia

• Upright positioning in bed, sitting at a table for meals

• Changing consistency of food (soft, pureed, thickened liquids)

• Careful hand feeding by caregivers• Videofluoroscopy and Speech therapy

consultationDeane K et al, “Dysphagia occurs frequently in Parkinson's disease although patientsthemselves may be unaware of swallowing difficulties. Speech and language therapistsin conjunction with nurses and dietitians use techniques that aim to improve swallowing,”Cochrane Database of Syst Rev, Jan 2001.

Esophageal obstruction

• Surgical resection or laser ablation• Placement of esophageal stent (SEMS)• Placement of gastrostomy tube• Help family cope with anxiety about

patient’s poor PO intake• Clarify goals of care• Consider artificial nutrition and hydration

Larssen L et al, “Long-term outcome of palliative treatment with self-expanding metal stents for malignant obstructions of the GI tract,” Scand J Gastroenterol, Oct 2012

Artificial Nutrition and Hydration (ANH)

• Feeding tubes: nasogastric or percutaneous endoscopic gastrostomy tube • First PEG in 1980• Research studies indicate no mortality benefit in dementia

patients• No reduction in aspiration events with PEG

• Total parenteral nutrition• Rarely beneficial for cancer patients due to metabolic

derangements, cachexia syndrome • Benefit for post-surgical oncology patients expected to recover

bowel function• Adverse effects: infections, liver failure, thrombosis

• IV hydration or subcutaneous hypodermoclysisFinucane TE et al. Tube Feeding in Patients With Advanced Dementia: A Review of the Evidence. JAMA. 1999; 282(14) 1365-1370Gillick MR. Rethinking the Role of Tube Feeding in Patients with Advanced Dementia. NEJM. 2000; 34 (3) 206-210

Nausea and Vomiting Definitions

• Nausea: A feeling of sickness in the stomach characterized by an urge to vomit

• Vomit (v): To eject part or all of the contents through the mouth, usually in a series of involuntary, spasmic movements

The Free Dictionary by Farlex

Nausea and Vomiting

Diagnostic Work up• Blood chemistries: calcium, sodium, BUN,

creatinine, bilirubin• Drug levels (theophylline, digoxin, anti-epileptic

drugs)• Neuroradiologic imaging to evaluate for sources

of increased intracranial pressure or brainstem causes or vertigo and nausea

• Abdominal imaging• HIDA scan

Nausea from GI tract• Bowel inflammation or

compression………………………………………………….

• Drugs (iron, NSAIDS, alcohol, antibiotics)

• Constipation

• Tube feedings (abdominal distention, diarrhea)

• Thick respiratory secretions, cough-induced vomiting

• Haldol (D, H1, M1), metoclopramide (D2), olanzapine (H1, M1)

• Stop drug, add PPI, H2 blocker

• Laxative, enema

• Reduce volume or change from bolus to continuous

• Nebulized saline, expectorant if cough reflex intact, anticholinergic if no cough reflex

Nausea from Chemoreceptor Trigger Zone

• Metabolic (renal, liver failure, or tumor products)

• Hyponatremia

• Drugs (opiates, chemotherapy, digoxin, carbemazepine, antibiotics, theophylline)

• Haldol (start at 0.5-1 mg q6 or q12), olanzapine

• Treat underlying etiology

• Decrease drug dosage or discontinue drug if possible

Nausea due to Vestibular etiology

• Middle ear infections

• Motion sickness ………………….

• Vestibular

• Antibiotics, decongestants

• Scopolamine (M1) or meclizine

• Meclizine, consider ENT consult

Pullens B and van Bentham PP, “Intratympanic gentamycin for Meniere’s disease or syndrome,” Cochrane Database of Syst Rev 2011

Nausea due to bowel obstruction

• Therapeutic goal to manage symptoms in terminal patients (pain, cramps, nausea, emesis)

• Dexamethasone (may relieve malignant bowel obstruction)• Transdermal scopolamine (slows gut, causes dry mouth,

urinary retention, confusion)• Glycopyrrolate (slows gut, causes dry mouth, urinary

retention, confusion)• Hyoscyamine (slows gut, causes dry mouth, urinary

retention, confusion)• Octreotide (expensive, reduces gut secretions)

Hiccups

• Definition: involuntary, intermittent, spasmodic contraction of the diaphragm and intercostal muscles. Muscle contraction results in a sudden inspiration and ends with abrupt closure of the glottis, thereby generating the characteristic ‘hic’ sound. Hiccups often occur with a frequency of 4 to 60 per minute, remaining relatively constant in a given individual.

Lembo A, “Overview of hiccups”, Up to Date 2011

Hiccups

• Hiccup bout: lasts up to 48 hours• Persistent hiccups: continues after 48 hours

up to 1 month• Intractable hiccups: continue longer than 1

month

Pathophysiology of hiccups

• Neural pathways of the hiccup reflex arc:• Afferent limb of phrenic and

vagus nerves and sympathetic chain

• Central mediator• Efferent limb of phrenic nerve,

nerve connections to glottis and inspiratory intercostal muscles

• Thought to involve the medulla oblongata, reticular formation of the brainstem, nuclei of phrenic nerve, and hypothalamus

Image from Journal of Pain and Symptom Management, Vol 38, Sept 2009

Etiology

• Psychogenic• gastric distension, aerophagia, sudden

change in GI temperature• Alcoholism, acute alcohol ingestion• Arrhythmia-induced syncope (both cause

and effect)• Weight loss, insomnia

Etiology

• Foreign body adjacent to tympanic membrane

• Infections: pneumonia, pharyngitis• Asthma• CV: arrhythmia, MI, pericarditis, thoracic

aortic aneurysm, PE• Cerebral lesions, MS

Treatment options• Non-pharmacological• Pharmacological• Surgical

Calsina-Berna A et al, “Treatment of Chronic Hiccups in Cancer Patients: A Systematic Review,” Journal of Palliative Medicine, 2012

Non pharmacological treatment of hiccups

• Accupuncture• Nebulized saline• Folk remedies:• Traction on the tongue• Pressure over the eyebrow area• Valsalva maneuver• Drinking a glass of water through a straw• Breath holding• Sudden fright• Irritation of the vagus nerve by supraorbital pressure or

carotid sinus massage

Pharmacological treatment of hiccups

• Baclofen• Gabapentin when CNS lesions are present• Chlorpromazine 24-50 mg IV/IM• Haldol 2-5 mg• Metoclopramide 10 mg q8 hrs• Anticonvulsants (phenytoin, valproic acid, carbemazepine)• Muscle relaxants, sedatives, analgesics• Dexamethasone, amantadine, nifedipine, methylphenidate• Avoid benzos

Menon M, “Gabapentin in the treatment of persistent hiccups in advanced malignancy,”Indian J Palliat Care, May 2012Calsina-Berna A et al, “Treatment of Chronic Hiccups in Cancer Patients: A Systematic Review,” Journal of Palliative Medicine, 2012

In Summary…

• Discussed current evidence in managing GI symptoms including oral discomfort, dysphagia, nausea and vomiting, and hiccups

• Discussed treatment options for oral discomfort and hiccups

• Discussed principles of management of GI symptoms that can be applied clinically

Questions?