Palliative Care

Question 1

physical symptom burden ovarian cancer

Answer 1

abdominal swelling/distension 
constipation 
ascities/pleural effusion 
pressure symptoms 
nausea/ vomiting 
bleeding 
endocrine symptoms 
pain

Question 2

what do you ask in a nausea history (TEACH ED)

Answer 2

T- triggers
E- exacerbating/alleviating factors 
A- associated symptoms 
C- colour, volume, pattern etc
H- how are your bowels 
E- exclude regurgitation 
D- drugs 

(always follow with examination)

Question 3

what are some causes of nausea and vomiting

Answer 3

gynaecological malignancy 
raised ICP 
medications (chemo)
migraines 
motion sickness 
pregnancy 
gastroenteritis/infection 
mental health disorders (eg.bulimia)

Question 4

what neurological-receptors are involved in nausea

Answer 4

serotonin
histamine
dopamine
acetylcholine

Question 5

where is the vomiting centre located

Answer 5

the medulla

Question 6

what areas act on the vomiting centre to induce nausea and vomiting

Answer 6

cerebral cortex (emotions, sights, raised ICP, anxiety, smell etc) 
Vestibular centre (motion) 
Chemoreceptor trigger zone (metabolic/drugs)
Gastrointestinal tract (distension, stasis, tumour, constipation)

Question 7

what drugs can be used to treat nausea and vomiting from the cerebral cortex

Answer 7

Dexamethasone
Aprepitant
Benzodiazapines

(act on GABA, NK1, 5HT)

Question 8

what drugs can be used to treat nausea and vomiting coming from the vestibular centre

Answer 8

Cyclizine
Levomepromazine
Hyocine
(act on H1, and ACh)

Question 9

what drugs can be used to treat nausea and vomiting coming from chemoreceptor trigger zones

Answer 9

Haloperidol
Levomepromazine
Ondansetron

Question 10

what drugs can be used to treat nausea and vomiting coming from the GI tract

Answer 10

Metoclopramide
Levomepromazine
Ondansterone
Dexamethasone

Question 11

classic history of cerebral disease (raised ICP and anxiety) nausea and vomiting

Answer 11

worse in the morning

associated with headache

Question 12

classic history of N&V caused by oncological treatment (chemo/radio)

Answer 12

predictable from history

nausea main complaint

Question 13

classic history of impaired gastric emptying N&V

Answer 13

not usually nauseated - feel it as soon as they have something to eat

continues to worsen until committing and large volume and then feeling fine again

Question 14

classic history of chemical and metabolic N&V

Answer 14

persistent nausea

little relief from vomiting

Question 15

causes of chemical and metabolic N&V

Answer 15

medication 
advanced cancer 
sepsis 
kidney or liver impairment 
biochemical 

think - calcium, sodium, magnesium, urea

Question 16

causes of impaired gastric emptying

Answer 16

locally advanced cancer
drugs
radio damage to gut
autonomic neuropathy

Question 17

what are some non-pharmacological managements for N&V

Answer 17

avoid cooking 
have small meals 
keep bowels moving to prevent constapation 
acupressure bands 
acupuncture 
psychological approaches 
calm, reassuring environments

Question 18

what is anticipatory nausea

Answer 18

worrying so much about being sick that it make you nauseous

Question 19

what is malignant bowel obstruction (MBO)

Answer 19

bowel obstruction in the setting of intraabdominal cancer (primary or mets)

MBO does not have to be caused directly by the cancer

Question 20

causes of MBO

Answer 20

mechanical (intraluminal, intramural, extramural compression)

dynamic ileus (tumour infiltration of mesentery, muscles or nerves)

Question 21

two main types of MBO

Answer 21

complete - blocking the bowel and nothing is going to get through

partial/subacute - incomplete blockage up to 50%

Question 22

what is the pathophysiology behind MBO

Answer 22

colicky pain comes from gut pushing against obstruction

secretions build up

reduced absorption

inflammatory response

increased intraluminal pressure leads to hypoxia, gangrene and perforation

Question 23

symptoms of MBO

Answer 23

nausea 
vommiting 
pain 
impaired appetite 
thirst 
absent bowel motions and flatulence 
paradoxical diarrhoea 
gradual onset over weeks

Question 24

management of MBO

Answer 24

surgery - if single blockage

medical treatment

Question 25

what is the medical treatment for MBO

Answer 25

Analgesics (opioids, hyoscine butylbrommide for colicky pain)

anti-emetics (metoclopramine (not in colicky as gut already pushing against blockage)

steroids (dexamethasone to reduce inflammation)

anti-secretory agents (buscopan, octreotide)

Laxatives (decussate or movicol to soften stock in partial obstruction