Palliative Management of
Gastrointestinal Symptoms
IGCE Session
By Cora Pontee, MD
Baylor Geriatrics
February 6th, 2013
Common Gastrointestinal
Symptoms in Palliative Patients
• Oral discomfort
• Dysphagia
• Nausea and vomiting
• Hiccups
Objectives
• To acquire knowledge of current evidence in
managing GI symptoms
• To recognize oral discomfort and hiccups as
treatable symptoms
• To apply principles of management of GI symptoms
to clinical practice
Causes of Oral discomfort:
Definitions
• Xerostomia: Dryness of the mouth resulting from
diminished or arrested salivary secretion
• Dysgeusia: An impairment or dysfunction of the
sensation of taste
• Stomatitis: The inflammation of the mucous lining
of any structures of the mouth, which may involve
the cheeks, tongue, gums, lips, and roof or floor of
the mouth
• Mucositis: inflammation of a mucous membrane
The Free Dictionary By Farlex
Causes of Oral discomfort
• Oral pain: angular stomatitis, dental caries, poorly
fitting dentures, XRT or chemo induced stomatitis or
mucositis, candidiasis, burning mouth syndrome
• Xerostomia: related to cancer (head and neck),
dehydration, radiation, drug therapy
(anticholinergic, psychotropic, opioid,
cardiovascular)
• Dysgeusia: sinusitis or other infection, xerostomia,
medications (antidepressants, HIV meds,
chemotherapy), vitamin or mineral deficiency (zinc)
Denture stomatitis
• Definition: oral candidiasis that can occur
in healthy adults wearing dentures
• May present as bleeding, swelling,
burning sensation, xerostomia, or
cacogeusia
• 35-50% of people wearing complete
dentures
Altarawneh et al, “Clinical and Histoligic Findings of Denture Stomatitis as Related
to Intraoral Colonization Patterns of Candida albicans, Salivary Flow, and Dry
Mouth,”J Prosthodont, 2012
Management of Oral
Discomfort
Xerostomia treatment options
• Salivary substitute or oral gel every 1-2 hours or sugarfree
gum
• Malic acid 1% spray
• Oral care: encourage family members to keep patient’s
mouth moist (oral swabs to bedside)
• Increase liquid PO intake; try frozen juices, popsicles, ice
chips, Resveratrol
• Pilocarpine 5 to 10 mg three times daily (watch for
respiratory secretions or diarrhea)
Gomez-Moreno G. et all, “Effectiveness of Malic Acid 1% in Patients with Xerostomia
Induced by Antihypertensive Drugs,” Med Oral Patol Oral Cir Bucal 2012
Furness S et al, “Interventions for Management of Dry Mouth: Topical Therapies,”
Cochrane Database Syst Rev 2011
ALTENS
• Acupuncture-like Transcutaneous Electric Nerve Stimulation
• 47 patients with cancer of the head and neck who were 3 to24
months from completing radiotherapy (mean age 60 years)
with xerostomia
• Patients received twice weekly ALTENS sessions over 12 weeks
• Six month Xerostomia-Related Quality of Life Scale
(XeQOLS) scores showed 86% of patients received a positive
treatment response
• Now entering Phase 3 studies
Wong RK et al, “Phase 2 Results from Radiation Therapy Oncology Group Study 0537: a Phase 2/3
Study Comparing Acupuncture-like Transcutaneous Electric Nerve Stimulation Verses Pilocarpine
In Treating Early Radiation-Induced Xerostomia,” Cancer 2012, Sept 1
Mucositis: Physiology
The Biology of Blood and Marrow Transplantation, Volume 11 Issue 12, Dec 2005
Treatment of Mucositis
•
Chlorhexadine gluconate (Hibiclens, Betasept)
•
Combination mouthwash preparations with:
•
•
•
•
•
•
Diphenhydramine
Lidocaine
Loperamide
Nystatin
Tetracycline
hydrocortisone
•
Lidocaine 2% q4 to 8 hrs, 50/50 mixture with famotidine
•
Sucralfate suspension swish and swallow q 3-4 times daily
•
Doxepin oral rinse up to every 4 hours
•
Opioids (topical, parenteral)
Clarkson JE et al, “Interventions for Treating Oral Mucositis for Patients with Cancer
Receiving Treatment,” Cochrane Database of Syst Rev, October, 2010
Laser Therapy in Mucositis
• 16 children (mean age 9.4 years) with
chemotherapy-induced mucositis
• All children treated with GaAIAs diode laser with
830 nm wavelength, repeated every 48 hours until
healing of lesion occurred
• On average 2.5 treatments in a period of 1 week
were sufficient to heal the lesion; pain relief noted
immediately after each treatment
Cauwels RG and Martens LC, “Low level laser therapy in oral mucositis: a pilot study,”
Eur Arch Paediatr Dent, 2011
Dysphagia
• Definition: Difficulty in swallowing or inability to
swallow
The Free Dictionary by Farlex
Dysphagia
• Oropharyngeal dysphagia
• Obstructing esophageal lesions
• Esophageal dysmotility (neuromuscular,
autoimmune)
• Cognitive impairment
Oropharyngeal Dysphagia
• Upright positioning in bed, sitting at a table for
meals
• Changing consistency of food (soft, pureed,
thickened liquids)
• Careful hand feeding by caregivers
• Videofluoroscopy and Speech therapy consultation
Deane K et al, “Dysphagia occurs frequently in Parkinson's disease although patients
themselves may be unaware of swallowing difficulties. Speech and language therapists
in conjunction with nurses and dietitians use techniques that aim to improve swallowing,”
Cochrane Database of Syst Rev, Jan 2001.
Esophageal obstruction
• Surgical resection or laser ablation
• Placement of esophageal stent (SEMS)
• Placement of gastrostomy tube
• Help family cope with anxiety about patient’s poor
PO intake
• Clarify goals of care
• Consider artificial nutrition and hydration
Larssen L et al, “Long-term outcome of palliative treatment with self-expanding metal
stents for malignant obstructions of the GI tract,” Scand J Gastroenterol, Oct 2012
Artificial Nutrition and
Hydration (ANH)
•
Feeding tubes: nasogastric or percutaneous endoscopic
gastrostomy tube
• First PEG in 1980
• Research studies indicate
events with PEG
•
Total parenteral nutrition
• Rarely beneficial for cancer patients due to metabolic derangements,
cachexia syndrome
• Benefit for post-surgical oncology patients expected to recover bowel
function
• Adverse effects: infections, liver failure, thrombosis
•
IV hydration or subcutaneous hypodermoclysis
Finucane TE et al. Tube Feeding in Patients With Advanced Dementia:
A Review of the Evidence. JAMA. 1999; 282(14) 1365-1370
Gillick MR. Rethinking the Role of Tube Feeding in Patients with Advanced Dementia.
NEJM. 2000; 34 (3) 206-210
Nausea and Vomiting
Definitions
• Nausea: A feeling of sickness in the stomach
characterized by an urge to vomit
• Vomit (v): To eject part or all of the contents
through the mouth, usually in a series of
involuntary, spasmic movements
The Free Dictionary by Farlex
Nausea and Vomiting
Diagnostic Work up
• Blood chemistries: calcium, sodium, BUN, creatinine,
bilirubin
• Drug levels (theophylline, digoxin, anti-epileptic drugs)
• Neuroradiologic imaging to evaluate for sources of
increased intracranial pressure or brainstem causes or
vertigo and nausea
• Abdominal imaging
• HIDA scan
Nausea from GI tract
•
Bowel inflammation or
compression…………………
……………………………….
•
Haldol (D, H1, M1),
metoclopramide (D2),
olanzapine (H1, M1)
•
Drugs (iron, NSAIDS,
alcohol, antibiotics)
•
Stop drug, add PPI, H2
blocker
•
Constipation
•
Laxative, enema
•
Tube feedings (abdominal
distention, diarrhea)
•
Reduce volume or change
from bolus to continuous
•
Thick respiratory secretions,
cough-induced vomiting
•
Nebulized saline, expectorant
if cough reflex intact,
anticholinergic if no cough
reflex
Nausea from Chemoreceptor
Trigger Zone
• Metabolic (renal, liver
failure, or tumor products)
• Haldol (start at 0.5-1 mg q6 or
q12), olanzapine
• Hyponatremia
• Treat underlying etiology
• Drugs (opiates,
chemotherapy, digoxin,
carbemazepine, antibiotics,
theophylline)
• Decrease drug dosage or
discontinue drug if possible
Nausea due to Vestibular
etiology
• Middle ear infections
• Antibiotics, decongestants
• Motion sickness
………………….
• Scopolamine (M1) or
meclizine
• Vestibular
• Meclizine, consider ENT
consult
Pullens B and van Bentham PP, “Intratympanic gentamycin for Meniere’s disease or
syndrome,” Cochrane Database of Syst Rev 2011
Nausea due to bowel
obstruction
• Therapeutic goal to manage symptoms in terminal patients
(pain, cramps, nausea, emesis)
• Dexamethasone (may relieve malignant bowel obstruction)
• Transdermal scopolamine (slows gut, causes dry mouth,
urinary retention, confusion)
• Glycopyrrolate (slows gut, causes dry mouth, urinary
retention, confusion)
• Hyoscyamine (slows gut, causes dry mouth, urinary retention,
confusion)
• Octreotide (expensive, reduces gut secretions)
Hiccups
• Definition: involuntary, intermittent, spasmodic
contraction of the diaphragm and intercostal
muscles. Muscle contraction results in a sudden
inspiration and ends with abrupt closure of the
glottis, thereby generating the characteristic ‘hic’
sound. Hiccups often occur with a frequency of 4 to
60 per minute, remaining relatively constant in a
given individual.
Lembo A, “Overview of hiccups”, Up to Date 2011
Hiccups
• Hiccup bout: lasts up to 48 hours
• Persistent hiccups: continues after 48 hours up to 1
month
• Intractable hiccups: continue longer than 1 month
Pathophysiology of hiccups
•
Neural pathways of the
hiccup reflex arc:
• Afferent limb of phrenic and
vagus nerves and sympathetic
chain
• Central mediator
• Efferent limb of phrenic nerve,
nerve connections to glottis and
inspiratory intercostal muscles
•
Thought to involve the
medulla oblongata, reticular
formation of the brainstem,
nuclei of phrenic nerve, and
hypothalamus
Image from Journal of Pain and Symptom Management, Vol 38, Sept 2009
Etiology
• Psychogenic
• gastric distension, aerophagia, sudden change in GI
temperature
• Alcoholism, acute alcohol ingestion
• Arrhythmia-induced syncope (both cause and effect)
• Weight loss, insomnia
Etiology
• Foreign body adjacent to tympanic membrane
• Infections: pneumonia, pharyngitis
• Asthma
• CV: arrhythmia, MI, pericarditis, thoracic aortic
aneurysm, PE
• Cerebral lesions, MS
Treatment options
• Non-pharmacological
• Pharmacological
• Surgical
Calsina-Berna A et al, “Treatment of Chronic Hiccups in Cancer Patients: A Systematic
Review,” Journal of Palliative Medicine, 2012
Non pharmacological
treatment of hiccups
• Accupuncture
• Nebulized saline
• Folk remedies:
•
•
•
•
•
•
•
Traction on the tongue
Pressure over the eyebrow area
Valsalva maneuver
Drinking a glass of water through a straw
Breath holding
Sudden fright
Irritation of the vagus nerve by supraorbital pressure or
carotid sinus massage
Pharmacological treatment of
hiccups
•
Baclofen
•
Gabapentin when CNS lesions are present
•
Chlorpromazine 24-50 mg IV/IM
•
Haldol 2-5 mg
•
Metoclopramide 10 mg q8 hrs
•
Anticonvulsants (phenytoin, valproic acid, carbemazepine)
•
Muscle relaxants, sedatives, analgesics
•
Dexamethasone, amantadine, nifedipine, methylphenidate
Menon M, “Gabapentin in the treatment of persistent hiccups in advanced malignancy,”
Indian J Palliat Care, May 2012
Calsina-Berna A et al, “Treatment of Chronic Hiccups in Cancer Patients: A Systematic
Review,” Journal of Palliative Medicine, 2012
In Summary…
• Discussed current evidence in managing GI
symptoms including oral discomfort, dysphagia,
nausea and vomiting, and hiccups
• Discussed treatment options for oral discomfort and
hiccups
• Discussed principles of management of GI
symptoms that can be applied clinically
Questions?