Gastrointestinal problems Flashcards
causes of dry mouth in palliative care
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.
- complications of a dry mouth
A dry mouth can result in loss of taste, anorexia, halitosis, dysphagia and oral infection.
oral thrush presentation and treatment
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).
summary list of gastrointestinal problems you can get in palliative care
Anorexia treatment in palliative care
- 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.
Nausea and vomiting is caused by stimulation of the vomiting centre by one of four main mechanisms:
- Gastric stasis/irritation
- Toxic’ causes
- Cerebral causes
- Vestibular causes
N+V: Gastric stasis/irritation features, causes and treatment
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.
N+V “toxic” causes, features and treatment
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.
N+V cerebral causes: 3 different causes and its features and treatment
N+V vestibular causes: features and treatment
Features
May be associated with movement, hearing loss, vertigo or tinnitus
Treatment
Consider cyclizine, hyoscine or cinnarizine
Constipation is very common in palliative care patients due to…
it can lead to…
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.
Laxatives can be classified as predominantly :
- bulk forming
- stool softeners
- stimulants
examples of bulk forming agent laxatives
Bulk forming agents e.g. fybogel are rarely appropriate in palliative care patients.
examples of stool softener laxatives and side effects
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.
Stimulant laxatives examples and when to avoid
Stimulants include senna and dantron. Avoid stimulants if the patient has colic.
Some laxatives contain both a softener and a stimulant such as:
(e.g. co-danthrusate = dantron + docusate)
drug choice for opioid induced constipation
Most patients require a softener and a stimulant. For opioid induced constipation co-danthrusate, co-danthramer or movicol are the drugs of choice
how often to review laxatives prescribed?
Review laxatives every 2 days. If bowels haven’t moved in 3 days, consider rectal examination and the use of suppositories and enemas.
Symptoms of intestinal obstruction in palliative care
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
which cancers cause the highest incidence of bowel obstruction?
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.
management of intestinal obstruction in palliative care
- 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.
Management of hiccups
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
Two main tyoes of syringe dirver in the uk
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
