Gastrointestinal problems

Question 1

causes of dry mouth in palliative care

Answer 1

Dry mouth (xerostomia) can result from reduced intake of oral fluids and is an adverse effect of many drugs used in palliative care (e.g. antiemetics, antidepressants).
Radiotherapy to the head and neck may cause a severe dry mouth.

Question 2

• complications of a dry mouth

Answer 2

A dry mouth can result in loss of taste, anorexia, halitosis, dysphagia and oral infection.

Question 3

oral thrush presentation and treatment

Answer 3

Oral thrush (candidosis) may be asymptomatic or cause altered taste, soreness or pain. Treat with systemic antifungals (fluconazole 50mg o.d. 7 days) or topical agents (nystatin 1ml q.d.s 7 days).

Question 4

summary list of gastrointestinal problems you can get in palliative care

Question 5

Anorexia treatment in palliative care

Answer 5

• As with other symptoms, always try to elicit any reversible cause such as oral thrush, nausea, pain, constipation, depression.
• Ensure food is nicely presented and small portions are offered.
• The family may need educating not to pressurise the patient to eat and about food preparation.

Drug treatments may help but carry side effects.
* Dexamethasone (4mg o.d) may help but the effect often wears off after 2-3 weeks.
* Megestrol acetate (160mg o.d) is effective for longer but may cause fluid retention.

Question 6

Nausea and vomiting is caused by stimulation of the vomiting centre by one of four main mechanisms:

Answer 6

• Gastric stasis/irritation
• Toxic’ causes
• Cerebral causes
• Vestibular causes

Question 7

N+V: Gastric stasis/irritation features, causes and treatment

Answer 7

Features
Early satiety, epigastric fullness, hiccups, heartburn, often minimal nausea between vomits.

May be caused by tumour, hepatomegaly, ascites (‘squashed stomach’) and dysmotility (drugs, autonomic failure).

Treatment
Metoclopramide 10-20 mg po/sc 30 minutes before meals or 30-60 mg SC over 24 hours. Stop any causative drugs if possible. Consider proton pump inhibitor if gastric irritation.

Question 8

N+V “toxic” causes, features and treatment

Answer 8

Features
Persistent or intermittent nausea, small vomits, ‘possets’, and retching.

May be caused by drugs (opioids, digoxin, antiepileptics), hypercalcaemia, uraemia and infections (UTI, pneumonia).
Treatment
Haloperidol 1.5-5 mg po/sc nocte.

Question 9

N+V cerebral causes: 3 different causes and its features and treatment

Answer 9

Question 10

N+V vestibular causes: features and treatment

Answer 10

Features
May be associated with movement, hearing loss, vertigo or tinnitus
Treatment
Consider cyclizine, hyoscine or cinnarizine

Question 11

Constipation is very common in palliative care patients due to…
it can lead to…

Answer 11

Constipation is very common in palliative care patients due to a combination of factors including immobility, reduced food and fluid intake, drugs (e.g. opioids), bowel pathology and hypercalcaemia.

Severe constipation may cause overflow diarrhoea.

Assess the cause and reverse this if possible.
Ask the patient whether they prefer laxatives in liquid or tablet form.

Question 12

Laxatives can be classified as predominantly :

Answer 12

• bulk forming
• stool softeners
• stimulants

Question 13

examples of bulk forming agent laxatives

Answer 13

Bulk forming agents e.g. fybogel are rarely appropriate in palliative care patients.

Question 14

examples of stool softener laxatives and side effects

Answer 14

Stool softeners include lactulose and sodium docusate. Lactulose may cause significant bloating and flatulence. Movicol is predominantly a softener but may also stimulate bowel motions; each sachet requires 125mls of liquid to be swallowed.

Question 15

Stimulant laxatives examples and when to avoid

Answer 15

Stimulants include senna and dantron. Avoid stimulants if the patient has colic.

Question 16

Some laxatives contain both a softener and a stimulant such as:

Answer 16

(e.g. co-danthrusate = dantron + docusate)

Question 17

drug choice for opioid induced constipation

Answer 17

Most patients require a softener and a stimulant. For opioid induced constipation co-danthrusate, co-danthramer or movicol are the drugs of choice

Question 18

how often to review laxatives prescribed?

Answer 18

Review laxatives every 2 days. If bowels haven’t moved in 3 days, consider rectal examination and the use of suppositories and enemas.

Question 19

Symptoms of intestinal obstruction in palliative care

Answer 19

Symptoms vary depending on the level and degree of obstruction and may include any or all of the following:
* Nausea and vomiting
* Colicky pain
* Abdominal distension
* Dull aching pain
* Diarrhoea and/or constipation

Question 20

which cancers cause the highest incidence of bowel obstruction?

Answer 20

Intestinal obstruction in advanced cancer is frequently incomplete, intermittent, and at multiple sites.
There is a high incidence in patients with ovarian and bowel cancer.
With appropriate symptomatic treatment patients may survive several weeks or occasionally months.

Question 21

management of intestinal obstruction in palliative care

Answer 21

• Surgical intervention will depend on the patient’s disease status and co-morbidity, level of the obstruction, and co-existing symptoms.
• Intravenous fluids and nasogastric tubes may be appropriate as a short-term intervention but are rarely appropriate for long-term management.
• Oral intake of food and drink can continue for the patients’ enjoyment and is often surprisingly well tolerated. The patient will decide if the risk of vomiting outweighs the pleasure of eating.

Medication should generally be given by continuous subcutaneous infusion. A combination of antiemetics, analgesics, antispasmodics is usually required.

If colic is a feature, stimulant laxatives and prokinetic drugs (metoclopramide) should be stopped and antispasmodics prescribed (hyoscine butylbromide).
Dexamethasone and octreotide may also be used.

Question 22

Management of hiccups

Answer 22

Management of hiccups
* chlorpromazine is licensed for the treatment of intractable hiccups
* haloperidol, gabapentin are also used
* dexamethasone is also used, particularly if there are hepatic lesions

Question 23

Two main tyoes of syringe dirver in the uk

Answer 23

In the UK there are two main types of syringe driver:
Graseby MS16A (blue): the delivery rate is given in mm per hour
Graseby MS26 (green): the delivery rate is given in mm per 24 hours