Gastrointestinal Symptoms in
Palliative Care
Dr Peter Nightingale
Macmillan GP
Introduction
 Nausea
and vomiting reported by 40-70%
 Constipation
 Dry
reported by 50% of hospice inpatients
mouth reported by over 75%
Overview

Nausea and vomiting
Pathways and receptors
 Evaluation
 Causes
 Receptor-specific anti-emetics


Malignant intestinal obstruction
Causes
 Clinical features
 management

Overview
 Constipation
 Causes
 Associated
symptoms
 Management/laxative guidance
 Mouth
 Dry
care
mouth
 Oral candidiasis
Nausea and Vomiting
Which of the following is true?
A
Cyclizine and metoclopramide is a logical
combination of drugs
 B Steroids are unhelpful in malignant bowel
dysfunction
 C Cyclizine and Haloperidol is a powerful
combination of antiemetics
 D Metoclopramide can help colicy pain in
malignant bowel dysfunction
Definitions

Nausea
A feeling of the need to vomit
 May be accompanied by autonomic symptoms


Retching


Rhythmic, laboured, spasmodic movements of the diaphragm
and abdominal muscles
Vomiting

Forceful expulsion of gastric contents through the mouth
Table 2 Mechanism of action of drugs used in the treatment of nausea and vomiting 1 2
Class
Drug
Dopamine 2 receptor antagonist
Metoclopramide
Domperidone
Haloperidol
5-Hydroxytryptamine 3 antagonist
Ondansetron
Granisetron
Antihistaminic antimuscarinic
Cyclizine
Dopamine 2 antagonist, antihistaminic, antimuscarinic, 5-hydroxytryptamine 2 antagonist
Levomepromazine
Antimuscarinic
Hyoscine hydrobromide
Benzodiazepine
Lorazepam
Cannabinoid
Nabilone
Corticosteroid
Dexamethasone
Prokinetic
5-hydroxytryptamine 4, D2
Metoclopramide
Domperidone
Antisecretory
Antimuscarinic
Hyoscine butylbromide
Glycopyrronium
Somatostatin analogue
Octreotide
Evaluation

Establish a likely cause
Examination
 Thorough review of medication-do they need a PPI?(most do)
 Check bloods where appropriate

Treat anything reversible
 Non-drug measures
 Set realistic goals
 Identify the most likely pathway and receptors involved

Evaluation
 Choose
the most potent antagonist
 Choose the most appropriate route of
administration
 Opt for regular rather than PRN dosing
 Titrate the drug dose accordingly
 Review regularly:
 Have
you identified the cause correctly?
 Consider combined therapy
Causes of Nausea and Vomiting

Chemical

Drugs e.g. opioids
 Metabolic disturbance
Calcium and urea


Gastrointestinal
Gastric stasis
 Stretch/distortion of GI
tract ?correctable bowel
obstruction

Cranial
Elevated ICP
 Meningeal irritation
 Skull mets


Other
XRT
 Anticipatory and anxiety
 Movement
 Cough

Is a prokinetic (e.g.metoclopramide
10-20mg tds) indicated?
 Promote
gastric emptying
 Useful in gastric stasis (large volume vomits-late
in day-undigested food-little nausea-hiccoughs)
 If not settling in 2 or 3 days or happening 2-3 times
daily consider using a syringe driver
Is vomiting due to opioids or
chemical/metabolic factors?
 Haloperidol
1.5mg is drug of choice for opioid
induced vomiting (can usually be stopped after 1014 days)
 Some patients develop secondary gastric stasis so
metoclopramide helps.
 Alternative opioid indicated if nausea persists
 Haloperidol 1.5-3mg is indicated for uraemia or
hypercalcaemia
Is the patient still vomiting?
With vomiting more than 2-3 times daily then consider a
syringe driver.
 Cyclizine (25-50mg tds) is broad spectrum but can cause
drowsiness and a dry mouth.
 Haloperidol and cyclizine is a potent combination
 Avoid cyclizine and metoclopramide (they oppose each
others action)
 Levomepromazine 3-25mg acts at multiple sites and is
sedating at higher doses.
 Dexamethasone 8mg daily has an anti emetic activity

Summary Points
 Establish
a cause
 Reverse anything reversible
 Choose the most appropriate receptor antagonist
 Choose the most appropriate route of
administration
 Review regularly
Malignant Intestinal Obstruction
Incidence and Prognosis
 Rates
of up to 42% reported in ovarian cancer
 Survival
for several months without surgical
intervention is possible
Causes of Obstruction
 Organic
(mechanical)
 Intraluminal
 Intramural
 Extramural
 May
be multiple sites of obstruction
 Functional
(pseudo-obstruction)
 Mesenteric
or bowel muscle infiltration
 Coeliac plexus infiltration
Clinical Features
 Depends
on level of obstruction
 Usually insidious onset
 Complete or partial (sub-acute)
 Difficult
to distinguish in practice
 Abdominal
 Constant
 Colic
pain
background
Clinical Features
 Vomiting
+/- nausea
 Abdominal distension
 Absolute constipation
 Diarrhoea
 Borborygmi, normal or absent bowel sounds
Management
 Try
to anticipate and plan treatment in advance
 Surgical intervention should be considered in all
patients
 Radiological investigations
 To
distinguish between severe constipation and
obstruction
 In patients considered for surgery
Medical Management
 Appropriate
drug regimen can provide excellent
symptom relief
 CSCI is route of choice for most drugs
 IV fluids, NG tubes rarely needed
 Allow to eat and drink little and often
 Good mouth care vital
 Realistic goals
Pain
 Background
pain
 Opioids
 Colic
 May
be relieved by opioids
 Most need antispasmodic
 Hyoscine
butylbromide 20mg stat and PRN
 Hyoscine butylbromide 60-120mg/24hr
 Also has an antisecretory action
Nausea and Vomiting
 If
no colic and passing flatus try prokinetic
 Metoclopramide
40-100mg/24hr
 Stop if develop colic
 If
patient has colic prokinetics are contraindicated
 Cyclizine
+/- haloperidol
Somatostatin Analogues
 Octreotide
inhibits secretion of numerous
hormones
 Resultant reduction in volume of GI secretions
 More rapidly effective than hyoscine
 Duration of action 8 hours
 Administer via CSCI or SC bolus
 Side effects: dry mouth and flatulence
Laxatives
 Stop
stimulant, osmotic or bulk-forming laxatives
 If likely to be constipated try phosphate enema and
a softener e.g. docusate sodium 100-200mg bd
Corticosteroids
 Cochrane
review 1999 (Feuer and Broadley)
 May relieve peri-tumour oedema
 Resultant improvement in symptom control
 Trial of dexamethasone
 8mg
daily SC
 Review after 5-7 days
 Stop or reduce dose according to response
Gastroduodenal Obstruction
 Duodenum
 Often
caused by pancreatic tumour
 Usually functional
 Try metoclopramide first
 Pylorus
 Antisecretory
drugs mainstay of treatment
 Steroids
 Consider
NGT or venting gastrostomy
Constipation
Definitions
 The
passage of small, hard faeces infrequently and
with difficulty
 The
passage of hard stools less frequently than the
patient’s own normal pattern
Prevalence in Palliative Care
 A frequent
cause of distress in terminally ill
patients
 50% of patients admitted to Palliative Care Units
report constipation
 80% require laxatives
 90% of terminally ill patients on opioid analgesics
are constipated
Physiology
 Food
residue usually in the small bowel for 1-2hr
and in the colon for 2-3 days
 In constipated patients colonic transit can be
greatly prolonged (4-12 days)
 Most of the colon’s action is mixing
 Forward movement 6x/day
 The frequency and strength of peristaltic
contractions are influenced by meals and activity
Causes of Constipation

Cancer


e.g. hypercalcaemia, intraabdominal disease
Debility
Weakness
 Immobility
 Poor nutrition


Treatment


Concurrent disease


Drugs e.g. opioids,
anticholinergics
e.g. anal fissure
Neurological disease
Immobility
 Loss of rectal sensation and
anal tone

Effects of Opioids
 Increased
sphincter tone
 Suppress forward peristalsis
 Increase water and electrolyte absorption in the
small and large bowel
 Impaired defaecation reflex
Associated Symptoms
Flatulence
 Bloating
 Abdominal pain
 Feeling of incomplete
evacuation
 Anorexia
 Overflow diarrhoea

Confusion
 Nausea and vomiting
 Urinary dysfunction
 Restlessness
 Can mimic bowel
obstruction by tumour

Assessment and Examination
Pattern of bowel
movements
 Access to toilet, etc
 Halitosis
 Faecal leak
 Confusion

Abdominal distension
 Visible peristalsis
 Palpable colon
 PR / stomal examination

Management
 Prevention
is better than waiting until intervention
is needed
 The aim is to achieve comfortable defaecation
rather than any particular frequency and without
the need for enemas or suppositories
General Measures
 Diet
 Increase
fluid intake
 Privacy
 Commode
rather than bed-pan
 Mobilise if possible
 Stop or reduce constipating drugs where possible
Oral Laxatives
 Softeners
 Surfactants/wetting
 1-3
days latency
 Osmotic
3
agents e.g. docusate, poloxamer
laxatives e.g. lactulose, Movicol
day latency
 Lactulose: bloating, colic and flatulence
 Need to increase fluid intake
 Movicol better tolerated and more effective
Oral Laxatives
 Softeners
 Bulk-forming
 Stool
agents e.g. Fybogel, Normacol
normalisers
 Large fluid intake required
 Can exacerbate constipation in the terminally ill and those on
opioids
Oral Laxatives
 Stimulants
 e.g.
senna, bisacodyl, danthron, sodium picosulphate
 Induce
peristalsis
 6-12 hr latency
 Can cause colic and severe purgation
 Especially useful in opioid induced constipation
Oral Laxatives
 Combinations
 More
effective and better tolerated than either alone for
opioid induced constipation
 Codanthramer = poloxamer + danthron
 Codanthrusate = docusate + danthron
 Discolouration of urine with danthron and may cause a
rash
Equivalent Doses (Regnard, 1995)
3 codanthrusate capsules
 15ml codanthrusate suspension
 6 codanthramer capsules
 4 codanthramer strong capsules
 30ml codanthramer suspension
 10ml codanthramer strong suspension
 2 senna tabs + 200mg docusate
 10ml senna liquid + 10ml lactulose

Rectal Measures
 Ensure
adequate oral laxatives
 Undignified and inconvenient
 Suppositories
 Glycerol
softens and lubricates
 Bisacodyl stimulates
 Usually given in combination
 30mins to work
Rectal Measures
 Enemas
 Micro-enemas
 Phosphate
enemas
 Evacuates
 Arachis
oil enema
 Softens
 May
stools from the lower bowel
hard and impacted stools
need high enema if stools higher than the rectum
Faecal Impaction

Empty rectum/loaded colon
Oral stimulant and softener +/- high enema
 Movicol


Soft faeces


Bisacodyl suppositories
Hard faeces
Oral laxatives
 Suppositories and osmotic enemas first
 Arachis oil retention enema
 Manual evacuation may be necessary

Laxative Guidance
 Prescribe
daily stimulant AND softener, especially
if on opioids
 Escalate dose until bowels opened
 If maximum dose ineffective reduce by half and
add an osmotic agent
 If bowels not opened for three days use rectal
measures
 Continue daily oral laxatives
Summary Points
 Constipation
should be considered in all palliative
care patients
 Prophylactic laxatives for patients on opioids are
essential
 Consider PR examination in all constipated
patients
 Remember non-drug measures
 Titrate oral laxative dose according to response
Mouth Care
Dry Mouth
 Reported
in over 75% of patients
 Causes:
 Reduction
in amount of saliva produced
 Poor quality of saliva
 Drug therapy
 XRT
 Dehydration
 And lots of others
Associated Problems
Chewing and swallowing
impaired
 Taste impaired
 Difficulty speaking
 Poor oral hygiene
 Dental caries

Dentures problematic
 Embarrassment
 Oral candida
 Other oral infection
 General deterioration in
health

Management of Dry Mouth
 Review
medication
 Frequent sips of water
 Mouth care
 Debride
tongue
 Mouthwashes
 Pineapple chunks
 Sponge sticks
 Lip salve
Management of Dry Mouth
 Stimulate
salivary flow
 Chewing
gum, boiled sweets, citric acid
 Pilocarpine (Davies et al 1998)
 Artificial
saliva
 Glandosane,
 Use
Saliva Orthana, Oralbalance
PRN
 Usually better than water
Oral Candidiasis
 30%
of terminally ill patients
 Causes
 Dry
mouth
 Dentures
 Topical steroids
 (oral corticosteroids, antibiotics)
Oral Candidiasis
 Features:
 May
be asymptomatic
 Symptoms may relate to underlying cause e.g. dry
mouth
 White plaques +/- smooth, red, painful tongue +/angular stomatitis
Oral Candidiasis
 Treatment
 Good
mouth care, including dentures
 Treat underlying problem
 Topical antifungal agents e.g. nystatin for 10 days
(sometimes continuous)
 Systemic antifungals e.g. fluconazole, ketoconazole
 Significant resistance to systemic antifungals
Summary
 Gastrointestinal
symptoms are extremely common
in all cancer patients
 A thorough evaluation of the underlying cause of
any symptom is vital
 Treatment should be directed according to the
underlying cause
 Set achievable goals
 Review the response to treatment regularly