Palliative care in gynaecological malignancy Flashcards
What are the physical symptoms of gynaecological malignancy?
- pain
- nausea and vomiting
- constipation
- bleeding
- treatment related
What are the social complicatons of gynaecological malignancy?
- altered body image
- fertility issues
What are the emotional complicatons of gynaecological malignancy?
Fear
Worry about the future
What are the spiritual complicatons of gynaecological malignancy?
Why me
Why now
family and carers
Describe the history for N&V?
- triggers, volume, pattern
- exacerbating and relieving factors, including individual and combinations of drugs tried and routes used
- bowel habit
- medication – consider drugs that may:
- contribute to the nausea and vomiting
- cause harm
- not take effect due to the nausea and vomiting
- exclude regurgitation as this will require a different approach. If suspected consider seeking advice
- check for other concurrent symptoms.
Describe examination for N&V
- general review for signs of dehydration, sepsis and drug toxicity
- central nervous system
- abdomen (for example organomegaly, bowel sounds, succussion splash)
- check temperature, pulse and respiration
What is succussion splash?
- sloshing sound heard through the stethoscope during sudden movement of the patient on abdominal auscultation
- It reflects the presence of gas and fluid in an obstructed organ, as in gastric outlet obstruction.
What are the cerebral cortex causes of nausea and vomiting?
Emotions, sight, smell, raised ICP, anxiety
What are the chemoreceptor trigger zone causes of nausea and vomiting?
Metabolic (uraemia, ca) drugs
What are the vestibular centre causes of N&V?
Motion
What are the GI tract causes of N&V?
GI distension, stasis, tumour, mass, constipation, XRT
What receptors are targeted in cerebral cortex to prevent stimulation of the vomiting centre?
What drugs do this?
GABA, NK1, 5HT
Dexamethasone, aprepitant, benzodiazepines
What receptors are targeted in the vestibular centre to prevent stimulation of the vomiting centre?
What drugs do this?
H1, ACh
Cyclizine, levomepromazine, Hyoscine
What receptors are targeted in the CTZ to prevent stimulation of the vomiting centre?
What drugs do this?
D2, 5HT, ACh
Haloperidol, levomepromazine, ondansetron
What receptors are targeted in the GI tract to prevent stimulation of the vomiting centre?
What drugs do this?
5HT, D2, ACh
Metoclopramide, levomepromazine, odensetron, dexamethasone
caution in obstruction
What are the causes of cerebral disease induced N&V?
Compression / irritation by tumour, raised ICP, anxiety
What is the clinical picture of cerebral disease causing N&V?
Worse in morning
Associated headache
What are the causes of impaired gastric emptying induced N&V?
Locally advanced cancer, drugs, radiotherapy damage to gut, autonomic neuropathy
What is the clinical picture of impaired gastric emptying causing N&V?
- not usually nauseated
- then very nauseated
- large volume vomits
- feels better after being sick
What are the causes of oncological treatment induced N&V?
Chemotherapy
Radiotherapy
What is the clinical picture of oncological treatment causing N&V?
Predictable from history
Often nausea is main complaint
What are the causes of chemical/metabolic induced N&V?
Medication, advanced cancer, sepsis, kidney or liver impairment, biochemical
What is the clinical picture of chemical/metabolic disturbance causing N&V?
Think: calcium, sodium, magnesium, urea
Persistent nausea
Little relief from vomiting
What is the non-pharmacological treatment for N&V?
- Regular mouth care
- Keep bowels moving to avoid constipation contributing
- Encouraging small meals, rather than large meals
- Avoid cooking or preparing food
- A calm and reassuring environment
- Acupressure bands (for example Seaband®)
- Acupuncture
- Psychological approaches
What is malignant bowel obstruction?
Clinical evidence of bowel obstruction in the setting of a diagnosis of intra-abdominal cancer OR non-intra abdominal cancer with clear intraperitoneal disease
What causes malignant bowel obstruction
Cancer
Adhesion- Post-radiotherapy
Constipation
What ar ethe mechanical and adynamic causes of MBO?
- Mechanical
- intraluminal
- intramural
- extramural extrinsic compression
- adynamic ileus (functional)
- tumour infiltration of mesentery, muscle or nerves
What is the different classifications of MBO?
Complete or partial (subacute)
Describe 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 intra-luminal pressure – hypoxia, gangrene and perforation
What are the symptoms of obstruction?
- Nausea
- Vomiting
- Pain
- Continuous or Colicy
- Anorexia/thirst
- Systemic symptoms from underlying cancer
- Reduced then absent bowel motions/flatus
- Paradoxical diarrhoea
Gradual onset over weeks- time can be taken to consider best management.
What are the management options for MBO?
Surgery
Self-expanding metallic stents
Venting procedures
What are the surgical options for management of MBO?
Resection
Palliative colostomy or ileostomy
Self-expanding metallic stent
What are the medical managment aims for MBO?
- if partial obstruction promote resolution
- relieve pain and colic
- reduce vomiting to acceptable level for patient
- relieve nausea
- relieve thirst
- achieve hospital discharge
What analgesic options are available for MBO?
Opioids
Hyoscine butylbromide for colicky pain (will slow down the bowel)
What antiemetics are available for use in MBO?
Metoclopramide 30mg/24hrs if not contra-indicated and partial/subacute obstruction
What steroids can be used for MBO and why?
Dexamethasone- 8-16mg/24 hrs
May promote resolution
May reduce symptoms
Low side effect incidence
