Palliative Care in Gynaecological Malignancy Flashcards
What is the difference between nausea and vomiting?
Nausea; unpleasant feeling of need to be sick, often with autonomic features
Vomiting; forceful expulsion of gastric contents through the mouth
How many patients with advanced malignancy will be affected by N+V?
70%
What history is important to take when concerned with N+V?
Triggers Volume Pattern Exacerbating and relieving factors Bowel habit Medication Exclude regurg
What are the different pathways for vomiting?
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
What receptors are involved in vomiting via cerebral cortex?
GABA
NK1
5HT
What receptors are involved in vomiting via vestibular centre?
H1
ACh
M1
What receptors are involved in vomiting via GI tract?
5HT
D2
ACh
What receptors are involved in vomiting via CTZ?
D2 5HT NK1 ACh H1 M1 Opioid
Which drugs are best to treat vomiting via cerebral cortex?
Dexamethasone
Aprepitant
BZD
Which drugs are best to treat vomiting via vestibular centre?
Cyclizine
Levomepromazine
Hyoscine
Which drugs are best to treat vomiting via GI tract?
Metoclopramide
Levomepromazine
Ondansetron
Dexamethasone
Which drugs are best to treat vomiting via CTZ?
Haloperidol
Levomepromazine
Ondansetron
What is the clinical picture of cerebral disease related vomiting?
Worse in morning
Assoc headache
What is the clinical picture of oncological treatment related vomiting?
Predictable from history
Nausea main complaint
What is the clinical picture of vomiting related to chemical/ metabolic dysregulation?
THINK; calcium, sodium, magnesium, urea
Persistent resistant nausea with little to no relief from vomiting
What is the clinical picture of vomiting related to impaired gastric emptying?
Not usually nauseated
Then will become suddenly nauseated
Large volume vomitus after eating
Feel much better after vomit
What is the recommended non-pharmacological management of N+V?
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
What will be seen on small bowel obstruction?
Valvulae convientes
What will be seen on large bowel obstruction?
Haustra
What is a malignant bowel obstruction?
Clinical evidence of bowel obstruction in setting of a diagnosis of intra-abdominal cancer or non-intra abdominal cancer with clear intraperitoneal disease
What can cause malignant bowel obstruction?
Adhesions, post-radiotherapy
Constipation
Intraluminal, intramural or extramural extrinsic compression
Adynamic ileus
What is the pathophysiology of obstruction?
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)
What is the clinical presentation of a malignant bowel obstruction?
N+V Pain Anorexia/ thirst Systemic sy from underlying ca Absent bowel motions/ flatus Paradoxical diarrhoea if high up Gradual onset over weeks
What are the management options for MBO?
Surgical
Venting
Medical
Stents
What is the traditional management of bowel obstruction?
Drip and suck
Bowel rest
NBM
This is unpleasant and so in people in end of life, not recommended
What is the traditional surgical management of bowel obstruction?
Resection
Palliative colostomy or ileostomy
Self expanding metallic stent
What are the aims of medical management of MBO?
If partial; promote resolution Relieve pain and colic Reduce vomiting Relieve nausea Relieve thirst Achieve hospital discharge
What analgesics are recommended in MBO?
Opioids
Hyoscine butylbromide for colicky pain
What anti-emetic is recommended for MBO?
Metoclopramide; antiemetic and prokinetic
NOT INDICATED IN COLICKY PAIN
What steroid is indicated for MBO and why?
Dexamethasone
Reduce inflammation of bowel lining
What laxatives are recommended for MBO?
Docusate
Movicol
Soften stool in partial obstruction
What anti-secretory agents are recommended for MBO?
Buscopan
Octreotide (somatostatin analogue)
What receptors are present on the vomiting centre of the medulla?
M1/M3
5 HT3
Histamine
What autonomic symptoms tend to precede vomiting?
Profuse salivation
Sweating
Increased HR
Sensation of nause
What are the metabolic consequences of severe vomiting?
Dehydration
Loss of gastric protons and chloride; hypochloremic metabolic alkalosis, increased blood pH
Hypokalaemia (reflex potassium excretion by kidneys)
Mallory weiss tear
Why will chemo result in nausea and vomiting?
Release of 5HT and substance P from enterochromaffin cells in gut
What is the mechanism of aprepitant?
NK1 receptor antagonist
Antagonism of substance P
What is the presentation of an upper small bowel obstruction?
Acute
Hours of onset
Large volumes of gastric, pancreatic and biliary secretions
What is the presentation of a large bowel obstruction?
Colicky abdomen and distention
Vomiting; possible feculent
What does the type of vomiting tell you about the location of obstruction?
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
In terms of bowel movements, what is pathognomonic of bowel obstruction?
Absolute constipation
What is the most useful initial investigation for suspected bowel obstruction?
Supine AXR
What are the different forms of abdominal hernias?
Inguinal Femoral Umbilical Paraumbilical Ventral Incisional
