Palliative Care in Gynaecological Malignancy

Question 1

What is the difference between nausea and vomiting?

Answer 1

Nausea; unpleasant feeling of need to be sick, often with autonomic features
Vomiting; forceful expulsion of gastric contents through the mouth

Question 2

How many patients with advanced malignancy will be affected by N+V?

Answer 2

70%

Question 3

What history is important to take when concerned with N+V?

Answer 3

Triggers 
Volume 
Pattern 
Exacerbating and relieving factors 
Bowel habit 
Medication
Exclude regurg

Question 4

What are the different pathways for vomiting?

Answer 4

Cerebral cortex; emotions, sight, smell, raised ICP, anxiety
Vestibular centre; motion
CTZ; metabolic (uraemic, Ca), drugs
GI tract; GI distension, stasis, tumour mass, constipation, XRT

Question 5

What receptors are involved in vomiting via cerebral cortex?

Answer 5

GABA
NK1
5HT

Question 6

What receptors are involved in vomiting via vestibular centre?

Answer 6

H1
ACh
M1

Question 7

What receptors are involved in vomiting via GI tract?

Answer 7

5HT
D2
ACh

Question 8

What receptors are involved in vomiting via CTZ?

Answer 8

D2
5HT
NK1
ACh
H1 
M1 
Opioid

Question 9

Which drugs are best to treat vomiting via cerebral cortex?

Answer 9

Dexamethasone
Aprepitant
BZD

Question 10

Which drugs are best to treat vomiting via vestibular centre?

Answer 10

Cyclizine
Levomepromazine
Hyoscine

Question 11

Which drugs are best to treat vomiting via GI tract?

Answer 11

Metoclopramide
Levomepromazine
Ondansetron
Dexamethasone

Question 12

Which drugs are best to treat vomiting via CTZ?

Answer 12

Haloperidol
Levomepromazine
Ondansetron

Question 13

What is the clinical picture of cerebral disease related vomiting?

Answer 13

Worse in morning

Assoc headache

Question 14

What is the clinical picture of oncological treatment related vomiting?

Answer 14

Predictable from history

Nausea main complaint

Question 15

What is the clinical picture of vomiting related to chemical/ metabolic dysregulation?

Answer 15

THINK; calcium, sodium, magnesium, urea

Persistent resistant nausea with little to no relief from vomiting

Question 16

What is the clinical picture of vomiting related to impaired gastric emptying?

Answer 16

Not usually nauseated
Then will become suddenly nauseated
Large volume vomitus after eating
Feel much better after vomit

Question 17

What is the recommended non-pharmacological management of N+V?

Answer 17

KEEP bowels moving to avoid constipation 
Regular mouth care
Encourage small meals often 
Avoid cooking or preparing foods
Calm and reassuring environment 
Acupressure bands
Acupuncture
Psychological approaches

Question 18

What will be seen on small bowel obstruction?

Answer 18

Valvulae convientes

Question 19

What will be seen on large bowel obstruction?

Answer 19

Haustra

Question 20

What is a malignant bowel obstruction?

Answer 20

Clinical evidence of bowel obstruction in setting of a diagnosis of intra-abdominal cancer or non-intra abdominal cancer with clear intraperitoneal disease

Question 21

What can cause malignant bowel obstruction?

Answer 21

Adhesions, post-radiotherapy
Constipation
Intraluminal, intramural or extramural extrinsic compression
Adynamic ileus

Question 22

What is the pathophysiology of obstruction?

Answer 22

Proximal accumulation of secretions
Distension of gut; further secretions, reduced absorption of water and sodium, inflammatory response (gut wall oedema), increased motor activity, increased intraluminal pressure (hypoxia, gangrene, perforation)

Question 23

What is the clinical presentation of a malignant bowel obstruction?

Answer 23

N+V 
Pain 
Anorexia/ thirst 
Systemic sy from underlying ca 
Absent bowel motions/ flatus
Paradoxical diarrhoea if high up 
Gradual onset over weeks

Question 24

What are the management options for MBO?

Answer 24

Surgical
Venting
Medical
Stents

Question 25

What is the traditional management of bowel obstruction?

Answer 25

Drip and suck Bowel rest NBM This is unpleasant and so in people in end of life, not recommended

Question 26

What is the traditional surgical management of bowel obstruction?

Answer 26

Resection Palliative colostomy or ileostomy Self expanding metallic stent

Question 27

What are the aims of medical management of MBO?

Answer 27

``` If partial; promote resolution Relieve pain and colic Reduce vomiting Relieve nausea Relieve thirst Achieve hospital discharge ```

Question 28

What analgesics are recommended in MBO?

Answer 28

Opioids | Hyoscine butylbromide for colicky pain

Question 29

What anti-emetic is recommended for MBO?

Answer 29

Metoclopramide; antiemetic and prokinetic | NOT INDICATED IN COLICKY PAIN

Question 30

What steroid is indicated for MBO and why?

Answer 30

Dexamethasone | Reduce inflammation of bowel lining

Question 31

What laxatives are recommended for MBO?

Answer 31

Docusate Movicol Soften stool in partial obstruction

Question 32

What anti-secretory agents are recommended for MBO?

Answer 32

Buscopan | Octreotide (somatostatin analogue)

Question 33

What receptors are present on the vomiting centre of the medulla?

Answer 33

M1/M3 5 HT3 Histamine

Question 34

What autonomic symptoms tend to precede vomiting?

Answer 34

Profuse salivation Sweating Increased HR Sensation of nause

Question 35

What are the metabolic consequences of severe vomiting?

Answer 35

Dehydration Loss of gastric protons and chloride; hypochloremic metabolic alkalosis, increased blood pH Hypokalaemia (reflex potassium excretion by kidneys) Mallory weiss tear

Question 36

Why will chemo result in nausea and vomiting?

Answer 36

Release of 5HT and substance P from enterochromaffin cells in gut

Question 37

What is the mechanism of aprepitant?

Answer 37

NK1 receptor antagonist | Antagonism of substance P

Question 38

What is the presentation of an upper small bowel obstruction?

Answer 38

Acute Hours of onset Large volumes of gastric, pancreatic and biliary secretions

Question 39

What is the presentation of a large bowel obstruction?

Answer 39

Colicky abdomen and distention | Vomiting; possible feculent

Question 40

What does the type of vomiting tell you about the location of obstruction?

Answer 40

Gastric outlet; semi-digested food eaten a day or 2 previously Distal to ampulla of vater; copious bile-stained fluid Distal obstruction; thick, brown, faeculent vomitus

Question 41

In terms of bowel movements, what is pathognomonic of bowel obstruction?

Answer 41

Absolute constipation

Question 42

What is the most useful initial investigation for suspected bowel obstruction?

Answer 42

Supine AXR

Question 43

What are the different forms of abdominal hernias?

Answer 43

``` Inguinal Femoral Umbilical Paraumbilical Ventral Incisional ```