Download The Project to Educate Physicians on End-of

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