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Repro and Sexual Health > Palliative Care in Gynaecological Malignancy > Flashcards

Palliative Care in Gynaecological Malignancy Flashcards

1
Q

What is the difference between nausea and vomiting?

A

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

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2
Q

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

A

70%

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3
Q

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

A 
Triggers 
Volume 
Pattern 
Exacerbating and relieving factors 
Bowel habit 
Medication
Exclude regurg
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4
Q

What are the different pathways for vomiting?

A

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

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5
Q

What receptors are involved in vomiting via cerebral cortex?

A

GABA
NK1
5HT

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6
Q

What receptors are involved in vomiting via vestibular centre?

A

H1
ACh
M1

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7
Q

What receptors are involved in vomiting via GI tract?

A

5HT
D2
ACh

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8
Q

What receptors are involved in vomiting via CTZ?

A 
D2
5HT
NK1
ACh
H1 
M1 
Opioid
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9
Q

Which drugs are best to treat vomiting via cerebral cortex?

A

Dexamethasone
Aprepitant
BZD

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10
Q

Which drugs are best to treat vomiting via vestibular centre?

A

Cyclizine
Levomepromazine
Hyoscine

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11
Q

Which drugs are best to treat vomiting via GI tract?

A

Metoclopramide
Levomepromazine
Ondansetron
Dexamethasone

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12
Q

Which drugs are best to treat vomiting via CTZ?

A

Haloperidol
Levomepromazine
Ondansetron

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13
Q

What is the clinical picture of cerebral disease related vomiting?

A

Worse in morning

Assoc headache

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14
Q

What is the clinical picture of oncological treatment related vomiting?

A

Predictable from history

Nausea main complaint

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15
Q

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

A

THINK; calcium, sodium, magnesium, urea

Persistent resistant nausea with little to no relief from vomiting

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16
Q

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

A

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

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17
Q

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

A 
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
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18
Q

What will be seen on small bowel obstruction?

A

Valvulae convientes

19
Q

What will be seen on large bowel obstruction?

A

Haustra

20
Q

What is a malignant bowel obstruction?

A

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

21
Q

What can cause malignant bowel obstruction?

A

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

22
Q

What is the pathophysiology of obstruction?

A

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)

23
Q

What is the clinical presentation of a malignant bowel obstruction?

A 
N+V 
Pain 
Anorexia/ thirst 
Systemic sy from underlying ca 
Absent bowel motions/ flatus
Paradoxical diarrhoea if high up 
Gradual onset over weeks
24
Q

What are the management options for MBO?

A

Surgical
Venting
Medical
Stents

25
Q

What is the traditional management of bowel obstruction?

A

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

26
Q

What is the traditional surgical management of bowel obstruction?

A

Resection
Palliative colostomy or ileostomy
Self expanding metallic stent

27
Q

What are the aims of medical management of MBO?

A 
If partial; promote resolution 
Relieve pain and colic
Reduce vomiting 
Relieve nausea
Relieve thirst
Achieve hospital discharge
28
Q

What analgesics are recommended in MBO?

A

Opioids

Hyoscine butylbromide for colicky pain

29
Q

What anti-emetic is recommended for MBO?

A

Metoclopramide; antiemetic and prokinetic

NOT INDICATED IN COLICKY PAIN

30
Q

What steroid is indicated for MBO and why?

A

Dexamethasone

Reduce inflammation of bowel lining

31
Q

What laxatives are recommended for MBO?

A

Docusate
Movicol
Soften stool in partial obstruction

32
Q

What anti-secretory agents are recommended for MBO?

A

Buscopan

Octreotide (somatostatin analogue)

33
Q

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

A

M1/M3
5 HT3
Histamine

34
Q

What autonomic symptoms tend to precede vomiting?

A

Profuse salivation
Sweating
Increased HR
Sensation of nause

35
Q

What are the metabolic consequences of severe vomiting?

A

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

36
Q

Why will chemo result in nausea and vomiting?

A

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

37
Q

What is the mechanism of aprepitant?

A

NK1 receptor antagonist

Antagonism of substance P

38
Q

What is the presentation of an upper small bowel obstruction?

A

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

39
Q

What is the presentation of a large bowel obstruction?

A

Colicky abdomen and distention

Vomiting; possible feculent

40
Q

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

A

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

41
Q

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

A

Absolute constipation

42
Q

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

A

Supine AXR

43
Q

What are the different forms of abdominal hernias?

A 
Inguinal
Femoral
Umbilical
Paraumbilical
Ventral
Incisional

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