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Learning objectives

� Identify common GI problems in Palliative Care

Management of GI Symptoms

Dr. Ruchika MakkarSenior Resident

Palliative Medicine

� Identify common GI problems in Palliative Care

� Management of oral thrush, stomatitis, dry mouth, nausea, vomiting, constipation and diarrhoea

� Management of Intestinal obstruction

Gastro symptoms

� Sizable proportion of Palliative Care Patients have GI symptoms

� Receives less attention than pain� We need to pay more attention as it causes patient

morbidity� We must anticipate problems� Ongoing assessment of treatment required.� Background medications as well as for breakthrough

symptoms

Oral problemsNormal Situation :

� Mouth is kept moist with normal secretion � About 1.5 litres of saliva per day� Helps keep mouth, teeth and gums healthy� Saliva has antibacterial activity

General decrease in salivary secretion seen in most patients in the palliative care setting

Oral problems – Risk is high in PC

� 90 % of palliative care patients� Reduced Fluid intake� Poor Nutritional state� Drug induced dryness� Chemotherapy related� Radiotherapy in facial area� Unable to take care of one’s self

Assessment of oral problems� Regular examination� Assess patients ability to carry out own mouth care� Altered taste� Oral pain� Dry mouth� Halitosis� Ulcers� Thrush� Dental problems

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� Low importance given to oral hygiene � Dental problems

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General mouth care Oral Candidiasis and Management

�Routinely, every 2-4 hours, in all patients

� Particular attention in comatose / mouth breathing

� Use of toothpaste, soft brush after meals

� Regular mouth rinsing

� Keeping mouth moist

� Look for evidence of oral problems

•Nystatin Suspension 1-2 ml, 4 hourly

• Tab. Fluconazole 150 mg daily, 7 -14

days

•Clotrimazole mouth paint

Stomatitis- Painful, Inflammatory, Ulcerative Condition

Causes : � Infection � Ulceration

Mucositis – post RT / Chemo

� Dry Mouth

� Pain – Infiltration / dental problems

Iron / Vitamin deficiency

Soreness± erythema

Erythema,ulcers; patient canswallowsolid food

Mucositisto the extentthat alimentationis not possible

Ulcers with extensive erythema; patient cannot swallow food

Grade 2 Grade 3

Severe Mucositis

Grade 1 Grade 4

Stomatitis ManagementNon Drug Management :

� Treat underlying cause

� Good Oral hygiene

� Avoid foods that trigger

pain

� Avoid tobacco / alcohol

� ENT / Oncology review

Drugs used :

� Local Anaesthetics :

eg., 2% lignocaine / 4%

viscous

� Salicyclate gel

� Soluble aspirin

Xerostomia (Dry Mouth)

� Subjective feeling of dry

mouth

� Associated speech difficulties

� Loss of taste� Need for frequent drinking� Common in palliative care

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� General mouth care

measures

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Xerostomia (Dry Mouth)

Causes : Management :

HalitosisCauses : Drugs eg: AntimuscarinicsThrush Mouth breathingDehydration RadiotherapyAnxietyOxygen therapy (non-

humidified)

Management :Treat Cause ReviewMedicationsBasic oral care regimenWater sippingSucking ice chipsPetroleum jelly / vegetable oil to lipsSaliva substitutes (expensive)

� Diagnose and treat cause

� Metronidazole gargle / systemic

� Frequent mouth wash

� Basic oral / dental care

Home made mouth washTo one litre of warm water, add the following:

One piece of Clove

5ml of Providine iodine solution

3ml of hydrogen peroxide

one spoon of table salt

metronidazole

mint tablets two

Courtesy : SudharshanaPalliative Care Clinic, Trichy

before after

Before and after using home made mouth wash

Courtesy : SudharshanaPalliative Care Clinic, Trichy

Soft tooth brush- innovated

remove the bristles

Soft tooth brush

Soft tooth brush

roll a cotton gauze around it

tie the lower portion

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wrap cotton roll around the tip

tie the lower portion

Courtesy : SudharshanaPalliative Care Clinic, Trichy

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Nausea, Retching & Vomiting• Biological defense mechanisms

Nausea and vomiting

• Biological defense mechanisms• To remove toxic or harmful substances from the

body after ingestion

the process of ‘emesis’ can be explained in threephases:

• Nausea• Retching and• Vomiting

Nausea & Vomiting� Nausea: The unpleasant sensation of the imminent

need to vomit.� Vomiting: Forceful oral expulsion of gastric contents

associated with contraction of the abdominal and chest wall musculature.

� Retching: Spasmodic respiratory movements against a closed glottis with contractions of the abdominal musculature without expulsion of any gastric contents.

� Regurgitation: The act by which food is brought back into the mouth without the abdominal and diaphragmatic muscular activity that characterizes vomiting. 21

Nausea

• Described as an unpleasant sensation ( in the back of

the throat and stomach)

• that usually proceeds vomiting,

• but may not result in vomiting always

� Other terminologies:� “sick to my stomach”� “queasy”� “butterflies

Retching

• Follows nausea

• Comprises laboured spasmodic respiratory movements against

a closed glottis

• With contractions of the abdominal muscles and chest wall

contents

� Retching can occur without vomiting but normally it generates

the pressure gradient that leads to vomiting.

Types Description Acute Occurring from few minutes to hours and

resolving within 24 hoursDelayed Occurring usually after 24 hours of chemo

and will be worst from 48 to 72 hours following chemo and can last 6 to 7 days.

Breakthrough Occurring despite antiemetic treatment

Refractory Unmanageable with current antiemetic regime

Nausea and Vomiting especially Chemotherapy induced can be….

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the pressure gradient that leads to vomiting.regime

Anticipatory Conditioned response prior to chemotherapy

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Management of Nausea and vomiting� Occurs in 40 – 70% patients with cancer

After effects of Nausea and vomiting

� Affects patients’ daily functioning� Occurs in 40 – 70% patients with cancer

� Management involves accurate assessment

� Good knowledge of anti-emetic drugs

� Consider route of administration

� Control of symptom possible in 60% patients

� Affects patients’ daily functioning

� Quality of Life

� Non compliance to cancer treatment

� Refusal of effective pain medications

� Family distress

Rationale of Treatment

� To stop or reduce symptom frequency

� To establish compliance to treatment

� To enable analgesic medications

� To improve quality of life

Vomiting Centre

Higher Cortical Centres Memory, fear,

anticipationSensory input

(Pain,Smell

Sight)

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Chemotherapy

AnaestheticsOpioids

Chemotherapy

VomitingReflex

Pathophysiologyof Nausea and Vomiting

Stomach Small Intestine

ChemotherapySurgeryRadiotherapy Labyrinth

sSurgery

Anti emetics and mechanism of their actions

.

Mechanism of vomiting

? 5HT3

Gut mucosa Area postremaCTZ

D25HT3 Cerebral cortexGABA 5HT

Vestibular nucleiAchm H1

Emetic pattern generator(Vomiting centre)

D2 AChm H1 U-opioid 5HT2

Gastricirritants

Abdominalradiotherapy

Intestinaldistension

Cytotoxicchemotherapy

Morphine /digoxin

Hypercalcaemia/uraemia

Fear/anxiety

Hyponatraemia

Raised intra-Cranical pressure

Movement / Vertigo

Vagal / splanchnicafferents

Gastric atony, Retroperistalsis,T horacic and abdominal muscle contractions

Blood- brain barrier

Anti Nausea & Vomiting drugs ….

• As per patient’s condition and preference

• Oral route is usually the best and easiest way

• If vomiting is severe, IV route / IM route/ CSCI

• Suppositories

• Sublingual

• Transdermal patches

Managing vomiting

Treatment

should be

Mechanism-based,

Not generalized!

Management of nausea and vomiting:• After clinical evaluation, Document the most likely cause(s) of

N&V. Examples:• Gastric stasis• Intestinal obstruction,• Biochemical• Drugs• Raised intracranial pressure.

• Ask the patient to record the symptoms and response to treatment, preferably using a diary

• Correct the correctable causes/ exacerbating factors ..

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eg: Drugs, Severe pain, Infection, Cough, Hypercalcemia and Anxiety

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Management Continued…• Prescribe the most appropriate anti-emetic stat,

General principles of Management

� Single anti-emetic may not be adequate• Prescribe the most appropriate anti-emetic stat, regularly, and p.r.n

• Choose parenteral route if continuous nausea and/ frequent vomiting

• Prokinetic Anti-emetics: for gastritis, gastric stasis, functional bowel obstructions -eg: Metaclopramide

• Anti-emetics acting principally on CTZ: for most chemical causes of vomiting - eg: Haloperidol

� Single anti-emetic may not be adequate

� Multiple causes may require combination

e.g., for Raised ICP & Uremia

Dexamethasone, Haloperidol – metoclopramide

� Persistent vomiting – subcutaneous preferable

� Keep in mind side-effects :

e.g. extra pyramidal, Constipation

Nausea & VomitingCauses Treatment� Drug induced

� Radiotherapy

� Chemotherapy

� Metabolic eg. Uremia

� Haloperidol 1.5 to 2.5 mg H.S / b.d.

� Ondansetron 8 mg stat then4 mg. tds / granisetron 1 mg.

stat then 1 mg. b.d.

� Ondansetron / Granisetron. Dexameth. 8 mg o.d for 3 days. Metoclopr. 10 to 20 mg. q.d.s. po/sc

� Haloperidol – start with 1.5 mg H.S.

Causes Treatment� Raised Intracranial

Pressure

� Bowel Obstruction

� Delayed Gastric Emptying

� Gastric Irritation

� Dexamethasone 8 to 36 mg I.V.

� If partial, no colic, Metoclopramide

� If colic, Hyoscine Butylbromide 40 to 100 mg/24 hrs.

Ondansteron 8 to 24 mg/24 hrs. p.o., i.v. or s.c.

� Metoclopramide 10 20 mg q.d.s.

� Domperidone 10 to 20 mg q.d.s.

� PPIs, Stop Irritants

Opioid induced Nausea & Vomiting

� Different mechanisms may be at play :CTZ, increased vestibular sensitivitygastric stasis, Constipation

� Drug of Choice : Haloperidol, Metoclopramide� Prevent with initial antiemetics� Treat N / V aggressively before reducing opioid.

Role of Dexamethazone in vomiting� By reducing the permeability of CTZ and of the Blood-

brain barrier for emetogenic substances

� By reducing the neuronal content of Gamma Amino

butyric acid (GABA) in the Brain stem

� By reducing the inflammation at the site of

obstruction and thereby increasing the lumen

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� By reducing the pressure on the intestinal nerves and

correcting neural dysfunction

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Management- Pharmacological Management- PharmacologicalAbdominal Tumors Gastric Stasis

Irritation of Meninges� Inj dexa 8-16 mg/day.� Inj. Mannitol 100 ml bd� Possible role of palliative

radiation.� Levomepromazine 12.5 mg

orally or cyclizine 25 mg tdsorally.

� Anxiety induced vomiting

� Lorazepam- 0.5-1 mg� Levomepromazine� start with low dose (6.25mg

tds)

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Abdominal Tumors� Anticholinergics.� Steroids to reduce the mass.� Haloperidol 1.5 mg BD, to

reduce D2 activity.

Gastric Stasis� Metoclopramide or

domperidone as first line.� Dexamethasone for

oedema.� Octreotide for non

responsive vomitings.

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Recent Trials� Olanzepine Dose 2.5-10 mg OD

� NK1 antagonist- Aprepitant-prevents binding of substance P to NK1 receptors. decrease emesis after cisplatin and radiation therapy 125 mg before,80 mg/day after.

� Cannabinnoids- nebilone,blocks CB1 receptors in area postrema, nucleus solitarus, also at gut.1-2 mg before

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Management Continued…

• Review the anti emetic dose every 24 hrs. taking note of p.r.n. use and the patient’s diary

• If inadequate response despite optimising the dose of anti emetic , review the diagnosis

• If diagnosis is found to be the same, change to an alternative anti-emetic and optimize the dose.

• Add a second anti-emetic if needed

� Establish a likely cause. � Identify the most likely pathway. � See which receptors are involved.� Choose the most potent antagonist.� Choose the most appropriate route of administration.� Review after 24 hrs, add other drug.� Opt for regular rather than PRN dosing.� Titrate the drug dose accordingly.� Reassure patient/ family.

Steps in the Management of Nausea / Vomiting

Common Palliative Care Situations leading to vomiting

� Gastric Stasis

� Intestinal Obstruction

� Drugs

� Raised ICP

� Biochemical Disturbances

� Others

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� Reassure patient/ family.

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Non-pharmacological management

� Fresh air

Distractions� Self hypnosis

Progressive muscle relaxation� Fresh air

� Bed rest to avoid vestibular stimulation

� Good oropharyngeal hygiene

� Nurse in the upright position

� Avoid situations which induce N&V

� Suitable distractions

� Progressive muscle relaxation� Biofeedback� Systematic desensitization � More useful in anticipatory vomiting� Can be used alone or together with anti-vomiting drugs• Promote relaxation, which may decrease nausea and vomiting• Serve to distract the individual’s attention• Enhance feelings of control• Reduce feelings of helplessness• They have no side effects and can be used by anyone

Nutritional advice during nausea and vomiting:

• Try to eat small frequent meals rather than three large meals

• Try consuming most foods during the time of the day when able to eat better

• Many people find that breakfast time is best• Eat foods and drink that are “easy on the stomach”• Do NOT force yourself to eat when nauseated• Cold food or at room temperature are better tolerated� Try to avoid fatty / sweet / spicy food � Avoid fibre� Avoid carbonated drinks

Diet advice continued…

• Make someone else to make food, if you are

nauseated

• If a person is having difficulty in eating his special

diabetic or heart disease diet, their diet

requirements can be relaxed

• A dietitian can be consulted to provide more tips to

help eating

What else to be done?

� Keep your mouth clean and do oral care after each episode of vomiting

� Wear loose fitting clothes� Have fresh air with a fan or open window� Limit sounds, sights, and smell that cause nausea and

vomiting� Call your doctor or nurse if your nausea or vomiting is

not controlled`.

Management of nausea and vomitingin palliative care -Guidelines � Document most likely causes.� Treat potentially reversible causes and exacerbating

factors(e.g. Drugs, constipation, severe pain, infection, cough)

� Review dose after 24 hours� If N & V persist after 24 – 48 hours, review cause.� Remember 1/3 of patients will need > 1 anti emetic.� If on parenteral, consider converting to oral after 72

hours of good control, to oral regimen

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not controlled`. hours of good control, to oral regimen

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ConstipationSubjective feeling:

Constipation

Subjective feeling:

“What the patient says”

Normal habit may be- Twice a day or- Once in 2 days

Constipation� Difficult or painful defaecation and is associated with

infrequent bowel evacuations and hard faeces

� A subjective feeling: “how it is different from their

normal”

� 45% of Palliative Care patients are constipated on

admission

Constipation can lead to…� Feeling of incomplete evacuation

� Bloated feeling

� Nausea and Vomiting

� Abdominal cramps / pain

� Bowel obstruction,

� Overflow diarrhoea

� Urinary retention

Causes� Pharmacological

Opioids(90%), Anti depressants, Anti cholinergic, Anti epileptics, Anti emetics, Antacids, Somatostat in analogues

� Metabolic Dehydration, hypercalcemia, hypokalemia, uremia

� Diet Poor appetite, low fluid and fibre intake

� Environment Hospitalization, Inability to attend to the call

� NeurologicalMalignant spinal cord compression, Sacral Nerve infiltration

� Structural

Assessment� What is normal for the patient?

Frequency, amount, consistency, blood stained or not

� When was the last bowel movement?

� Is the patient experiencing any abdominal discomfort,

cramping, nausea and vomiting, excessive gas or

rectal fullness?

� Does the patient regularly use laxatives?

� What medications are the patient on?

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� StructuralPelvic tumors, RT induced fibrosis, painful anorectalcondition, intraluminal obstruction

Others : Depression, weakness, immobility, inactivity, sedation, age

� What medications are the patient on?

� Is constipation a recent change?

� What type of diet is the patient on?

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Management of constipation Non Pharmacological Measures� Access and ability to go to toilet.

�Correct the correctable� Judicious use of laxatives� Improve general condition� Symptom control� Encourage activity� Fibre – diet

� Access and ability to go to toilet.

� Timing and privacy.

� Squatting position

� In bed, feet under knees and gentle blowing, arms resting on thighs.

� Encourage normal balanced diet and plenty of water.

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Create Favourable EnvironmentEducate Patient and Family

� Common to Hear :

� “Not eaten enough at all. How will she /he pass motion?

� “I have diarrhoea” (overflow))

A patient with less/no intake

� Large bowel transit take 3-4 days even in normal people.

� stool contains shed epithelium and a major bulk is the byeproduct of bacterial action.

� Even if patient has not taken any food for a few days, he may need bowel care.

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Treatment of Constipation

� Rectal Examination� Proper use of the right laxatives� Suppositories� Enema – Proctoclysis (Glycerine)

Warm Saline / Plain Water� Do not give soap water enema� Digital evacuation for faecal impaction

Pharmacological Management - Laxatives

1. Softeners: Docusate, Liquid Paraffin3 tsp (15ml) upto 3 times a day

2. Stimulant LaxativesSenna , Bisacodyl – 2 tabs upto 4 a day

3. Bulk-Forming: Isapgul – not used

Osmotic agents: Lactulose

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� Digital evacuation for faecal impaction 4. Osmotic agents: Lactulose

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Considerations Using Laxatives Considerations Using Laxatives

� Paraplegic patients need regular stimulants and stool softeners.

� May need initial manual evacuation.

� Patients with colostomies are treated in the same manner.

� After obstruction is excluded, Bisacodyl suppository can be used but it is less well absorbed and oral tablets need to be added.

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� Soft stools- bisacodyl suppository

� Hard stools- glycerine suppository

� Empty rectum- oral stimulants, high oil enema

Impaction of faeces and overflow diarrhoea

• Longer the stools stay in the gut• more is the absorption of water • leading to severe constipation

“Over flow diarrhoea” – Spurious diarrhoea

Treatment of faecal impaction:

� If soft faeces palpable P/R……Biscodyl suppositories� If hard faeces palpable P/R ….. Biscodyl and Glycerol

suppositoriesPlain warm water/Saline enemaSodium phosphate enemaand Oral LaxativesManual evacuation with lubrication

Manual evacuation:

• Proper explanation about the procedure and informed consent

• Sufficient lubrication preferably with local anaesthetic jelly

• Allowing enough time for the local anaesthetics to act

• Gently and slowly doing the procedure with careful watching of the patient’s reaction and acceptance, at

Intestinal obstruction

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watching of the patient’s reaction and acceptance, at the same time keep talking with the patient

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Intestinal Obstruction Intestinal Obstruction - managementPartial Obstruction may resolve – Aim to :

�Most common in Bowel / Ovarian cancer

� Often multiple sites

� Plain X-ray Abdomen may help

� Surgical vs. medical treatment

� Consider Quality of life while planning treatment

Partial Obstruction may resolve – Aim to :

1. Reduce Bowel wall odema - Steroids2. Stimulate Gut Motility

- Metoclopramide

If not resolved (? Complete obstruction)� Reduce intestinal secretions� Treat nausea and vomiting

Factors Indicating Poor Surgical Prognosis

� Advanced age� Ascites� Palpable abdominal mass� Previous radiotherapy to abdomen/pelvis� History of combination chemotherapy� Multiple sites of obstruction� Poor performance status

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Antiemetics

� Metoclopramide- dopamine antagonist, in higher doses 30- 120mg/ 24 hours via s/c infusion. Start with 10mg Q8H s/c. Gradually increase dose day by day basis

� 5 HT3 antagonist, and prokinetic, only in partial obstruction, dose 40-120 mg/day s/c

� Haloperidol-for nausea and vomiting 2.5 to 5 mg /24 hours via s/c infusion

Anticholinergics

� Hyoscine butyl bromide(Buscopan)-120 mg/day/SC, acts at peripheral ACh receptors

� Hyoscine hydro bromide(Scopolamine)-900-1200 micrograms/day/SC, acts at central and peripheral Ach receptors

� Not to be given with pro kinetics

Corticosteroids

� Dexamethasone 16 mg/day/IV� To be given before 3 PM, as late administration interferes

with sleep� Given for 3 days trial� If vomiting subsides, continue oral steroids� Steroids act by reducing peritumoral oedema

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� Not to be given with pro kinetics

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Somatostatin analogues Medical Management in a nutshellDrugs used -

� Octreotide 300 micrograms/day� Will reduce the secretions, slow down the motility,

reduces splanchnic flow, increases the absorption of water and electrolytes, potent anti vasoactive intestinal peptide effect.

� Also tried as preventive step� Depot preparation 20 mg/ 4week� Along with steroids in carcinomatosis

Drugs used -

� Dexamethasone : 8 –16mg S.C / I.V – 3 days trial

� Metoclopramide : 30 to 120mg / 24h S.C. Infusion

OR

� Hyoscine butylbromide : 40-100mg / 24h S.C.

infusion

� Haloperidol : 3-5mg / 24 h SC infusion

Other measures :

Nasogastric Tube : ?

Venting Gastrostomy : almost never! Diarrhoea

Causes� Imbalance of laxative therapy� Drugs� Faecal impaction – overflow diarrhoea� Radiotherapy – 2-3 rd week of therapy� Malabsorption of fat and water

- Ca Pancreas- Gastrectomy- Vagotomy- Ileal resection- Colectomy

� Fistulae� Colonic or rectal tumour

Patterns of diarrhoea

� Anal incontinence� Colonic diarrhoea� Faecal impaction� Alternate diarrhoea/ constipation� Pale white- malabsorption

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� Colonic or rectal tumour� Endocrine tumour

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Treatment of Diarrhoea Managing intermittent diarrhoea

� Is the patient dehydrated?� Oral rehydration solution orally or through nasogastric feed.� IV fluids- Ringer Lactate should be administered in severe

dehydration. � Loperamide – 10 mg tab, choice no crossing BBB.� Glycopyrrolate / atropine – 0.4/0.6 mg� Octreotide 300 – 600 mcg sc

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� Exclude spurious diarrhoea due to neglected constipation or partial bowel obstruction, irritable colon, anxiety and fear

� Check nasogastric feeding – exclude high osmotic load in the feed, increase the feeding time and dilute the feeds

� Exclude infection

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Pharmacological management

� Stool mixed with blood/ discharge, add anti biotics� Fungating rectal or colonic tumors:

metronidazole 400mg 8-12 hourly or sucralfate paste PR for bleeding

� Consider palliative radiotherapy for bleeding rectal tumors

� Exclude infections and inflammation (NSAIDS, radiotherapy)

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Diarrhoea management

�Specific Drug treatment

Pancreatin, Ondansetron, Metronidazole,

Somatostatin (if affordable) / Buscopan

�Nonspecific Drug TreatmentOpioids – Codeine / loperamide

� Radiation induced diarrhoeaondansetron

Hiccups� Close to 100 different causes� GI causes – Most common� Extremely distressing� Pharmacological and non-pharmacological management

� A good clinical assessment is important

Causes� Medications- Corticosteroids� Metabolic- Renal failure/Uraemia- Hyponatraemia� Intracranial disease- tumours- brain stem� Infection� Idiopathic

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Idiopathic

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Management� Remove causes

Drug Management- Baclofen – 5-10mg tid� Remove causes

� Decrease distension by smaller frequent meals� Prokinetic – Metoclopramide /Domperidone 10mg Qid� Gas absorbing – Simethicone/ Dimethicone 5mls Qid� Gastritis – Omeprazole 10mg Qid

� Sugar/crushed ice� Long slow sips of water� Breath holding� NG tube� Massage external auditory canal

- Baclofen – 5-10mg tid- Chlopromazine- Nifedipine- Haloperidol- Phenytoin- Gabapentin

� Drugs used for management can cause hiccups !!

"I saw few die of hunger; of eating, a hundred thousand"- Benjamin Franklin

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