Palliative Care in Gynaecology

Question 1

history of nausea and vomiting?

Answer 1

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)

Question 2

what can cause nausea and vomiting in cancer?

Answer 2

raised ICP (seen in brain mets)
medications (including chemo)
migraine
motion sickness
pregnancy
gastroenteritis/infection
mental health disorders

Question 3

what receptors are involved in nausea?

Answer 3

serotonin
histamine
dopamine
acetylcholine

Question 4

where is the vomiting centre located?

Answer 4

medulla

- therefore all the receptors act on this region to induce nausea and vomiting

Question 5

what 4 systems interact with the vomiting centre to cause nausea and vomiting?

Answer 5

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)

Question 6

what drugs are targeted at cerebral cortex causes of vomiting?

Answer 6

dexamethasone
aprepitant
benzodiazepines

Question 7

what drugs are targetted at vestibular centre causes of vomiting?

Answer 7

cyclizine
levomepromazine
hyoscine

Question 8

what drugs are targeted at chemoreceptor zone causes of vomiting?

Answer 8

haloperidol
levomepromazine
ondansetron

Question 9

what drugs are targeted at GI tract causes of vomiting?

Answer 9

metoclopramide
levomepromazine
ondansetron
dexamethasone
(use with caution in obstruction)

Question 10

classic history of vomiting due to cerebral disease?

Answer 10

caused by compression/irritation induced by a tumour causing raised ICP and anxiety
typically worse in the morning and associated with a headache

Question 11

classic history of vomiting due to impaired gastric emptying?

Answer 11

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

Question 12

classic history of vomiting due to chemical or metabolic causes?

Answer 12

can be due to medication, advanced cancer, sepsis, renal/liver impairment or biochemical causes
patient is typically constantly nauseated with little relief from vomiting

Question 13

what biochemical markers can cause nausea and vomiting?

Answer 13

calcium
sodium
magnesium
urea

Question 14

non-medical management of nausea and vomiting?

Answer 14

small meals
keep bowels moving as constipation makes it worse
acupressure bands
acupuncture 
psychology

Question 15

what is malignant bowel obstruction?

Answer 15

bowel obstruction in the setting of a primary intra-abdominal cancer or from compression due to abdominal spread from distant cancer (e.g ovarian)

Question 16

is MBO always a direct result of the tumour?

Answer 16

no

they could co-exist but he obstruciton be from a hernia eg

Question 17

what is adynamic ileus?

Answer 17

tumour infiltration of the mesentery, muscles or nerves

Question 18

types of MBO?

Answer 18

complete (blocking the bowel and nothing gets through)

partial/subacute (up to 50% blockage)

Question 19

pathophysiology of MBO symptoms?

Answer 19

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

Question 20

main symptoms of MBO?

Answer 20

nausea and vomiting
pain (continuous or colicky)
impaired appetite
thirst
absent bowel motions, sounds and flatulence
paradoxical diarrhoea
gradual onset over weeks

Question 21

how can MBO be managed surgically?

Answer 21

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

Question 22

medical treatment of MBO?

Answer 22

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

Question 23

pharmacological management of MBO?

Answer 23

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)

Question 24

when are oral medications never used?

Answer 24

if patient is nauseated and vomiting