Managing GI symptoms in palliative care

Question 1

What are the features of N&V caused by gastric stasis?

Answer 1

• Large-volume of vomitus
• Infrequent vomiting
• Relief of symptoms after vomiting
• Oesophageal reflux
• Epigastric fullness
• Early satiation
• Hiccups.
• Succussion splash (sloshing sound heard on auscultation) in some people.

Question 2

What are the features of N&V caused by gastric outflow obstruction?

Answer 2

Symptoms similar to gastric stasis, but also forceful vomiting and rapid dehydration.

Question 3

What are the features of N&V caused by “squashed stomach syndrome” (reduction in size of gastric cavity due to external compression)?

Answer 3

Symptoms similar to gastric stasis, but low-volume vomiting.

Question 4

What are the features of N&V caused by oesophageal blockage?

Answer 4

• Vomiting soon after eating or drinking
• Vomitus consisting of what has just been swallowed
• Sensation of food sticking

Question 5

What are the features of N&V caused by bowel obstruction?

Answer 5

• Intermittent nausea (often relieved by vomiting)
• Worsening nausea and/or faeculent vomiting as obstruction progresses
• Abdominal pain (may be colicky)
• Abdominal distention (may be absent if high obstruction).

Question 6

What are the features of N&V caused by raised ICP?

Answer 6

• Effortless vomiting, often in the morning, which may be associated with headache (diurnal) and papilloedema
• Nausea (may be diurnal)
• Neurological signs and photophobia may be absent.

Question 7

What are the features of N&V caused by motion?

Answer 7

Nausea and/or sudden vomiting on movement (for example turning in bed).

Question 8

What are the features of N&V caused by anxiety?

Answer 8

Nausea present in waves — may be triggered by a previously experienced stimulus and may be relieved by distraction.

Question 9

What are the features of N&V induced by chemical stimuli?

Answer 9

Constant nausea, variable vomiting.

Question 10

What are the non-pharmacological approaches to managing nausea & vomiting?

Answer 10

• Relaxation
• Calm, reassuring environment
• Small snacks, bland foods
• Avoid odours and control malodours
• Attention to food preparation
• Mouth care
• Acupuncture and acupressure
• NG/PEG tubes
• Surgery/stenting

Question 11

How should nausea & vomiting be treated if cause is unknown or multiple causes?

Answer 11

1. Haloperidol 1st line
2. If ineffective, add cyclizine
3. If still ineffective, change to levomepromazine (generally 1st line if multiple causes are suspected)
4. If still ineffective, change to dexamethsone

Question 12

How should nausea & vomiting caused by chemical stimuli be treated?

Answer 12

1. Haloperiodol or metoclopromide 1st line
2. Ondansetron 2nd line

Question 13

How should nausea & vomiting caused by bowel obstruction be treated?

Answer 13

No colic (obstruction due to peristaltic failure or gastric stasis):

1. Metoclopromide 1st line
2. If Parkinson’s disease, use domperidone

Colic (obstruction is mechanical):

1. Cyclizine 1st line
2. Anti-muscarinics (e.g. hyoscine butylbromide) is often used to reduce intestinal secretions to reduce volume of vomitus
3. Haloperidol or levomepromazine 2nd line

Question 14

How should nausea & vomiting caused by intracranial disease be treated?

Answer 14

1. Cyclizine 1st line
2. If evidence of raised ICP, add dexamethasone

Question 15

How should nausea & vomiting caused by motion be treated?

Answer 15

H₁ antagonists (cyclizine 1st line)

Question 17

What are the specific points for anti-emetic prescribing?

Answer 17

• Anti-emetics should be prescribed subcutaneously if patient actively vomiting. Only give anti-emetics orally if for prophylaxis
• Cyclizine and metoclopromide should never be used together as they have antagonistic actions

Question 18

What laxatives are used for opioid-induced constipation?

Answer 18

Stimulant laxative (senna, bisacodyl) + osmotic laxative (macrogol, lactulose or phosphate enema) +/- stool softener (glycerol, docusate, arachis oil)