Palliative Care in Gynaecological Malignancies

Question 1

what physical symptoms do patients usually experience in gynaecological malignancies?

Answer 1

pain 
nausea and vomiting 
constipation 
bleeding 
treatment related (eg chemotherapy)

Question 2

what emotional and psycho-social symptoms may patients experience in relation to gynaecological malignancy?

Answer 2

fear
worry about future
why me?
what will happen to my family?

Question 3

what is the difference between nausea and vomiting?

Answer 3

nausea = unpleasant feeling of the need to be sick, often with autonomic features

vomiting = forceful expulsion of gastric contents through the mouth

Question 4

what do you need to ask in order to take an adequate nausea and vomiting history?

Answer 4

triggers 
volume 
pattern 
exacerbation and relieving factors 
drug tried + route 
bowel habit 
medication - contributing to the nausea and vomiting cause harm

Question 5

what must you be aware of if a patient is already on medication and is experiencing nausea and vomiting?

Answer 5

is the drug contributing to nausea and vomiting

is the drug being absorbed if patient is vomiting

Question 6

what are the 4 main reasons that a patient experiences nausea and vomiting?

Answer 6

cerebral cortex = emotions, sight, smell, raised ICP, anxiety

vestibular centre = motion sickness

GI tract = distension, stasis, tumour mass, constipation

chemoreceptor trigger zone = metabolic (uraemia, Ca), drugs

Question 7

what drugs work to combat nausea and vomiting from the cerebral cortex and what receptors do these act on?

Answer 7

dexamethasone
benzodiazepines

NK1, 5HT, ?GABA

Question 8

what drugs work to combat nausea and vomiting from the vestibular centre and what receptors do these act on?

Answer 8

cyclizine, hyoscine

H1, ACh

Question 9

what drugs work to combat nausea and vomiting from the GI tract and what receptors do these act on?

Answer 9

metoclopramide
levomepromazine
ondansetron

5HT, D2, ACh

*use with caution in obstruction

Question 10

what drugs work to combat nausea and vomiting from the chemoreceptor trigger zone and what receptors do these act on?

Answer 10

haloperidol, ondansetron

D2, 5HT, ACh

Question 11

how would you identify from a nausea and vomiting history that the patients symptoms are due to cerebral cortex cause?

Answer 11

vomiting worse in morning then gets better throughout day

assoc headache

Question 12

what would cause impaired gastric emptying?

Answer 12

locally advanced cancer
drugs
radiotherapy damage to gut
autonomic neuropathy

Question 13

how would impaired gastric emptying present?

Answer 13

not usually nauseated until patient eats and then very nauseated
large volume vomits
feels better after being sick

Question 14

what clinical picture would indicate a chemical or metabolic cause of nausea and vomiting?

Answer 14

persistent nausea

little relief from vomiting

Question 15

what would cause a chemical or metabolic abnormality that stimulates nausea or vomiting?

Answer 15

medication
advanced cancer
sepsis
kidney or liver impairment

think: Ca, Na, Mg, Urea

Question 16

what non-pharmacological palliative care is provided to counteract nausea and vomiting in patients with gynaecological malignancies?

Answer 16

mouth care
keep bowels moving 
small meals 
avoid cooking or preparing food (due to smell)
acupressure bands (eg seaband)
acupuncture

Question 17

what is meant by malignant bowel obstruction?

Answer 17

clinical evidence of bowel obstruction in the setting of a diagnosis of intra-abdominal cancer OR non intra-abdominal cancer with clear intraperitoneal disease

Question 18

bowel obstruction in advanced cancer may not always be directly due to malignancy - what other causes are possible?

Answer 18

benign causes eg adhesions post-radiotherapy

Question 19

why do patients with malignant bowel obstruction vomit?

Answer 19

proximal accumulation of secretions - these need to be removed

Question 20

how do patients with malignant bowel obstruction usually present?

Answer 20

nausea and vomiting 
pain (continuous or cockily)
anorexia 
systemic symptoms from cancer
reduced then absent bowel motions

Question 21

how is malignant bowel obstruction managed?

Answer 21

“drip and suck” before surgery
bowel rest
nil by mouth

surgical resection

• palliative colostomy or ileostomy
• or self expending metallic stent

Question 22

what are the main aims of medical management of malignant bowel obstruction?

Answer 22

if partial - promote resolution with prokinetics 
relieve pain and colic 
reduce vomiting without use of NG tube 
relieve nausea 
relieve thirst

Question 23

what pharmacological options can be given for malignant bowel obstruction?

Answer 23

analgesics = opioids / hyoscine butylbromide (buscopan)

anti-emetics = metoclopramide if not contraindicated and partial / subtle obstruction

steroids = dexamethasone to reduce inflammation

anti-secretory agents = buscopan, octreotide (CSCI)

laxatives = docusate or movicol to soften stool

fluids

Question 24

why is it important to remember to not give nauseated / vomiting patients oral medication?

Answer 24

must be absorbed

- IV subcutaneous, transdermal or IM