Palliative GI/GU symptoms

Question 1

Broad categories of nausea pathophysiology

Answer 1

GI/Heart

Vestibular input

CNS input (emotional/memory)

Chemoreceptor trigger zone (area postrema)

Question 2

Anti-emetic for vestibular nausea

Answer 2

Cyclizine

25-50mg TDS PO

Question 3

Anti-emetics for gastritis/gastric stasis/functional bowel obstruction

Answer 3

Prokinetics e.g. metoclopramide, domperidone

Question 4

Anti-emetics for raised ICP

Answer 4

Cyclizine

25-50mg TDS

Question 5

Anti-emetics for post-operative nausea

Answer 5

Antipsychotics e.g. haloperidol

Question 6

Anti-emetic for mechanical bowel obstruction

Answer 6

Cyclizine

50-150mg CSCI/24h

Consider hyoscine/haloperidol as 2nd line

Avoid prokinetics (e.g. metoclopramide)

Question 7

Anti-emetics for chemical causes of nausea

Answer 7

Haloperidol as first line!

Ondansetron

Metoclopramide

Question 8

Dosing of metoclopramide

Answer 8

10mg TDS

Up to 20mg QDS

Question 9

Side effects of metoclopramide

Answer 9

Acute dystonia

EPSEs

Question 10

Cuases of nausea in cancer patients

Answer 10

Chemotherapy

Bowel obstruction/gastric stasis

hypercalcaemia!

Question 11

Anti-emetic dosing of haloperidol

Answer 11

1. 5mg BDS/PRN PO
2. 5-10mg syringe driver /24h

Question 12

Side effects of cyclizine

Answer 12

Drowsiness

Tachycardia > caution in heart failure

Question 13

Side effects of ondansetron

Answer 13

Constipation

Headache

Reduce efficacy of tramadol

Caution in hepatic impairment

Question 14

Dosing of cyclizine

Answer 14

50mg TDS

Question 15

Dose ondansetron

Answer 15

4mg IV, given at induction of anaesthesia (prophylaxis) or post-op to treat nausea

8mg PO for chemotherapy

Question 16

Pharmacological treatment of constipation

Answer 16

Stimulants: e.g. senna as first line

Add softeners/osmotics esp if colic a problem

Softeners: e.g. Docusate

Osmotic laxatives: e.g. laxido/movicol; lactulose

Question 17

Dosing of senna

Answer 17

7.5-15mg daily

Question 18

Dosing of lactulose

Answer 18

15ml BDS

Question 19

Dosing of laxido/movicol

Answer 19

1-3 full-strength sachets, 2-6 half-strength sachets

Question 20

Treatment of bowel obstruction in palliative care

Answer 20

Incomplete: Prokinetic + softener + stimulant + analgesia

Incomplete + can’t tolerate prokinetic: Softening laxative + ranitidine (antisecretory)

Complete: IV fluids, NG tube, hyoscine drying agent

Question 21

Indications for hyoscine

Answer 21

Excessive secretions

Bowel colic

Bladder spasm (butylbromide)

End-of-life bowel obstruction

Question 22

Management of dysphagia in palliative patients

Answer 22

Conservative: SALT review

Medical: Radiotherapy, hyoscine/other anti-spasmodic, prokinetic

Surgical: Stenting, PEG/RIG tubes

Question 23

Treatment of jaundice itch

Answer 23

Sertraline

Question 24

Pharmacological management of hiccups

Answer 24

Baclofen

Metoclopramide

Gabapentin

Question 25

Management of bladder spasm/incontinence

Answer 25

Pads

Catheter

Oxybutinin/hyoscine (antimuscarinics)

Question 26

Treatment of urinary obstruction

Answer 26

Catheters

Alpha blockers (e.g. tamsulosin, terazocin)

Question 27

Treatment of opioid-induced constipation

Answer 27

NOT bulking/fibre

Prophylactically prescribe senna 15mg when introducing opioid

Aim for non-straining bowel opening every 1-3d

Question 28

Contraindications for rectal interventions

Answer 28

Neutropaenia

Thrombocytopaenia

Rectal/anal disease

Question 29

Reversible factors contributing to constipation

Answer 29

Dehydration

Privacy/bedpan

Haemmorhoids/fissure

Anorectal disease

Question 30

Treatment of hypercalcaemia

Answer 30

IV fluids

Bisophosphonates