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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
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Nausea / vomiting ...
Definitionnausea is an unpleasant subjective sensation of being about to vomit
vomiting is the reflex expulsion of gastric contents through the mouth
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Pathophysiology …
Nausea subjective sensation (easily learned)stimulation from
gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex (ICH, anticipatory, psychogenic), vagal reflex
Vomitingneuromuscular reflex
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… Pathophysiology
Cortex
Vestibular apparatus
GI tract
ChemoreceptorTrigger Zone (CTZ)
Neurotransmitters Serotonin Dopamine Acetylcholine Histamine
Vomiting center
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Assessment
Timing Acute versus chronic Intermittent or constant Associated with sights or smells Eating patterns Bowel patterns Medications
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Management Dopamine
antagonists Antihistamines Anticholinergics Serotonin
antagonists Neurokinin
antagonists
Prokinetic agents
Antacids Cytoprotective
agents Other
medications
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Medications …
Dopamine antagonistsHaloperidolMetoclopramideProchlorperazinePromethazine
Histamine antagonistsDiphenhydramineMeclizineHydroxyzine
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… Medications …
Acetylcholine antagonistsScopolamine
Serotonin antagonistsGranisetronOndansetron
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… 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
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Constipation ...
Straining Hard stool Sensation of
incomplete evacuationanorectal obstruction
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Pathophysiology Medications
opioidscalcium-channel
blockersanticholinergicsondansetron
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Pathophysiology Decreased
motility Ileus Mechanical
obstruction Metabolic
abnormalities
Malignancy Dehydration Spinal cord
compression Autonomic
dysfunction
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Management
General measuresregular toileting gastrocolic
reflexactivity
Specific measuressofteners osmoticsstimulants lubricantsenemas
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Stimulant laxatives
Prune juice Senna Bisacodyl
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Osmotic agents
Lactulose or sorbitol Milk of magnesia (other Mg salts) Magnesium citrate Polyethylene glycol
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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
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... Opioid constipation
Combination stimulant / softeners are useful first-line medications
senna + docusate sodium Bisacodyl Opioid antagonists
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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
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Epidemiology Prevalence
range from 6% (ovarian cancer) to 48% (colorectal cancer)
Prognosis – poor if inoperable
... Bowel obstruction
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Pathophysiology Intraluminal mass Carcinomatosis/infiltration External compression Adhesions
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Assessment Symptoms
distension pain 92%intestinal colic 72-76%nausea/vomiting 68-100%
Abdominal radiographdilated loops, air-fluid levels
CT scanstaging, treatment planning
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Surgical management
Surgical evaluation Standard
intravenous fluidsnasogastric tube - intermittent suction
Inoperablestent placement
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Analgesicsopioids
Antiemeticshaloperidol
Steroidsdexamethasone
Pharmacological management
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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
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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
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Octreotide ...
Polypeptide analog of somatostatinserum half-life = 2 h
Relieves symptoms of obstruction
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... 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
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Summary
Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve end-of-life care