EPECEPECEPECEPEC GI Symptoms Module 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

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

Pathophysiology … Nausea subjective sensation (easily learned) stimulation from gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex (ICH, anticipatory, psychogenic), vagal reflex Vomiting neuromuscular reflex

… Pathophysiology Cortex Vestibular apparatus GI tract Chemoreceptor Trigger Zone (CTZ) Neurotransmitters Serotonin Dopamine Acetylcholine Histamine Vomiting center

Assessment Timing Acute versus chronic Intermittent or constant Associated with sights or smells Eating patterns Bowel patterns Medications

Management Dopamine antagonists Antihistamines Anticholinergics Serotonin antagonists Neurokinin antagonists Prokinetic agents Antacids Cytoprotective agents Other medications

Medications … Dopamine antagonists Haloperidol Metoclopramide Prochlorperazine Promethazine Histamine antagonists Diphenhydramine Meclizine Hydroxyzine

… Medications … Acetylcholine antagonists Scopolamine Serotonin antagonists Granisetron Ondansetron

… Medications Prokinetic agents Metoclopramide Antacids H2 receptor antagonists Proton pump inhibitors Dexamethasone 6-20 mg PO daily Tetrahydrocannabinol mg PO tid Lorazepam mg PO q 4-6 h

Constipation... Straining Hard stool Sensation of incomplete evacuation anorectal obstruction

Pathophysiology Medications opioids calcium-channel blockers anticholinergics ondansetron

Pathophysiology Decreased motility Ileus Mechanical obstruction Metabolic abnormalities Malignancy Dehydration Spinal cord compression Autonomic dysfunction

Management General measures regular toiletinggastrocolic reflex activity Specific measures softenersosmotics stimulantslubricants enemas

Stimulant laxatives Prune juice Senna Bisacodyl

Osmotic agents Lactulose or sorbitol Milk of magnesia (other Mg salts) Magnesium citrate Polyethylene glycol

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

... Opioid constipation Combination stimulant / softeners are useful first-line medications senna + docusate sodium Bisacodyl Opioid antagonists

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

Epidemiology Prevalence range from 6% (ovarian cancer) to 48% (colorectal cancer) Prognosis – poor if inoperable... Bowel obstruction

Pathophysiology Intraluminal mass Carcinomatosis/infiltration External compression Adhesions

Assessment Symptoms distension pain 92% intestinal colic 72-76% nausea/vomiting % Abdominal radiograph dilated loops, air-fluid levels CT scan staging, treatment planning

Surgical management Surgical evaluation Standard intravenous fluids nasogastric tube - intermittent suction Inoperable stent placement

Analgesics opioids Antiemetics haloperidol Steroids dexamethasone Pharmacological management

Antisecretory agents DrugDoseNotes Octreotide10 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 Glycopyrrolate0.2 to 0.4 mg SQ q 2 to 4 h; titrate Anticholinergic effects possible

Anticholinergics Antispasmodic and antisecretory Scopolamine 10 to100 mcg/h SC/IV 0.1 mg sc q 6 h and titrate Glycopyrrolate 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/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

Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve end-of-life care