Palliative Care in Gynaecology Flashcards
history of nausea and vomiting?
TEACH ED - triggers - exacerbating/alleviating factors - associated symptoms - colour, volume, pattern etc - how are the bowels? - exclude regurgitation - drugs currently in use (always follow with examination)
what can cause nausea and vomiting in cancer?
raised ICP (seen in brain mets) medications (including chemo) migraine motion sickness pregnancy gastroenteritis/infection mental health disorders
what receptors are involved in nausea?
serotonin
histamine
dopamine
acetylcholine
where is the vomiting centre located?
medulla
- therefore all the receptors act on this region to induce nausea and vomiting
what 4 systems interact with the vomiting centre to cause nausea and vomiting?
cerebral cortex (emotions, sight, smell, raised ICP, anxiety) vestibular centre (motion sickness) chemoreceptor trigger zone (metabolic (e.g uraemia and calcium) and drugs) GI tract (GI distension, stasis, tumour/mass, constipation, XRT)
what drugs are targeted at cerebral cortex causes of vomiting?
dexamethasone
aprepitant
benzodiazepines
what drugs are targetted at vestibular centre causes of vomiting?
cyclizine
levomepromazine
hyoscine
what drugs are targeted at chemoreceptor zone causes of vomiting?
haloperidol
levomepromazine
ondansetron
what drugs are targeted at GI tract causes of vomiting?
metoclopramide levomepromazine ondansetron dexamethasone (use with caution in obstruction)
classic history of vomiting due to cerebral disease?
caused by compression/irritation induced by a tumour causing raised ICP and anxiety
typically worse in the morning and associated with a headache
classic history of vomiting due to impaired gastric emptying?
can occur due to locally advanced cancer, drugs, radiotherapy damage or autonomic neuropathy
patient is typically not nauseous until they eat, they then vomit large amount soon after eating then feel fine again
classic history of vomiting due to chemical or metabolic causes?
can be due to medication, advanced cancer, sepsis, renal/liver impairment or biochemical causes
patient is typically constantly nauseated with little relief from vomiting
what biochemical markers can cause nausea and vomiting?
calcium
sodium
magnesium
urea
non-medical management of nausea and vomiting?
small meals keep bowels moving as constipation makes it worse acupressure bands acupuncture psychology
what is malignant bowel obstruction?
bowel obstruction in the setting of a primary intra-abdominal cancer or from compression due to abdominal spread from distant cancer (e.g ovarian)
is MBO always a direct result of the tumour?
no
they could co-exist but he obstruciton be from a hernia eg
what is adynamic ileus?
tumour infiltration of the mesentery, muscles or nerves
types of MBO?
complete (blocking the bowel and nothing gets through)
partial/subacute (up to 50% blockage)
pathophysiology of MBO symptoms?
colicky pain from peristalsis pushing against obstruction
secretions build up proximally to obstruction until vomiting occurs
distension due to blockage and build-up
reduced absorption of sodium and water
inflammatory response causes gut oedema
increased motor activity
increased intra-luminal pressure causes hypoxia, gangrene and perforation
main symptoms of MBO?
nausea and vomiting pain (continuous or colicky) impaired appetite thirst absent bowel motions, sounds and flatulence paradoxical diarrhoea gradual onset over weeks
how can MBO be managed surgically?
not ideal treatment
single blockage can be cut out and a stoma created
resection followed by palliative colostomy or ileostomy and self expanding metallic stent
medical treatment of MBO?
antiemetics/prokinetics to push bowel to work (dont use if colicky pain as bowel is working fine)
painkillers
NG tube if tolerated can reduce vomiting
treat symptoms
pharmacological management of MBO?
analgesics
anti-emetics (metoclopromide 30mg/24 hrs for partial)
steroids to reduce inflammation (dexamethasone 8-16mg/24 hrs)
anti-secretory agents (buscopan, octreotide)
laxatives (docusate or movicol)
when are oral medications never used?
if patient is nauseated and vomiting
