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E P E C for V E T E R A N S 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