Palliative care gynaecological malignancies Flashcards
What should be included when taking a history of vomiting and nausea?
Triggers, volume, patterns
Exacerbating and relieving factors including drugs taken and administration route
Bowel habit
Other concurrent symptoms
Examination of nausea and vomiting?
General review for signs of dehydration, sepsis and drug toxicity
Central nervous system
Abdomen (check for signs of dehydration, sepsis and drug toxicity).
Different causes of nausea and vomiting?
Cerebral disease
Oncological treatments
Impaired gastric emptying
Chemical/metabolic
Cerebral disease n+v features?
Compression/irritation from tumour, raised ICP, anxiety
Clinical picture:
- Worse in morning
- Associated headache
Impaired gastric emptying n+v features?
Locally advanced cancer, drugs, radiotherapy damage to gut and autonomic neuropathy.
Clinical picture:
- Not usually nauseated
- Then very nauseated
- Large volume vomits
- Feels better after release of vomit
Oncological treatments n+v?
Chemotherapy/radiotherapy induced
Clinical picture:
- Predictable from history
- Nausea is often main complaint
Chemical and metabolic n+v?
Medication, advanced cancer, sepsis, kidney or liver impairment, biochemical
Think: calcium, sodium, magnesium, urea
Clinical picture:
- Persistent nausea
- Little relief from vomiting
What is malignant bowel obstruction?
Bowel obstruction caused by cancer is referred to as malignant bowel obstruction
Causes of malignant bowel obstruction?
Mechanical
- Intraluminal (inner space of tubular structure)
- Intramural (situated within hollow wall of organ)
- Extramural extrinsic compression (occurring outside wall and pressing down)
Adynamic ileus (functional) - tumour infiltration of mesentery, muscle or nerves.
Pathophysiology of obstruction?
Proximal accumulation of secretions
Distension of gut
- Further secretions
- Reduced absoprtion of water and sodium
- Inflammatory response - gut wall oedema
- Increased motor activity
- Increased intra-luminal pressure - hypoxia, gangrene and perforation.
Symptoms of malignant bowel obstruction?
Nausea
Vomiting
Pain - continuous or colicky
Anorexia/thirst
Systemic symptoms from underlying cancer
Reduced then absent bowel motions
Gradual onset usually over weeks
Pharmacological managements for MBO?
Analgesics
Opioids
Hyoscine butylbromide for colicky pain (although this will slow down the bowel!)
Anti-Emetics
* Metoclopramide 30mg / 24 hours if not contra-indicated and partial/subacute obstruction
Steroids
Dexamethasone -8-16mg / 24hours
Anti-secretory agents
Buscopan (Hyoscine butylbromide)
- Octreatide - 300-900 mcg/24 hours in OSCI
Laxatives
• Docusate or Laxido to soften stool in partial obstruction
Fluids
Can oral medication be used in n+v?
No
Preferred routes include: IV, subcutaneous, transdermal and intramuscular
