Palliative Care

Question 1

how many patients with any type of cancer get nausea and/or vomiting

Answer 1

70%

Question 2

what is nausea

Answer 2

unpleasant feeling of the need to be sick, often with autonomic features (hot, skin stands on ends, sweaty, salivation)

Question 3

what extra questions should you ask in a history of nausea and vomiting

Answer 3

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.

Question 4

what should you look for on exam in a patient with nausea and vomiting

Answer 4

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

Question 5

what causes of N&V affect the cerebral cortex

Answer 5

emotions, sight, smell, raised ICP, anxiety

Question 6

what part of brain controls vomiting

Answer 6

vomiting center

Question 7

what receptors for N&V are in the cerebral cortex and what anti emetic drugs target them

Answer 7

GABA, NK1, 5HT

Dexamethasone, Aprepitant, Benzodiazepines

Question 8

what receptors for N&V are in the vestibular centre and what anti emetic drugs target them

Answer 8

H1, ACh

Cyclizine, Levomepromazine, Hyoscine

Question 9

what stimulus affects the vestibular centre causing N&V

Answer 9

motion

Question 10

what receptors for N&V are in the chemoreceptor trigger zone and what anti emetic drugs target them

Answer 10

D2, 5HT, Ach

Haloperidol, Levomepromazine, Ondansetron

Question 11

what things can trigger the chemoreceptor trigger zone causing N&V

Answer 11

metabolic (uraemia, Ca), drugs

Question 12

what receptors for N&V are in the GI tract and what anti emetic drugs target them

Answer 12

5HT, D2, Ach

Metoclopramide, Levomepromazine, Ondansetron, Dexamethasone
(Caution in obstruction- prokinetic drugs can cause perforation)

Question 13

what can trigger the receptors in the GI tract causing N&V

Answer 13

GI distension, stasis, tumour mass, constipation, XRT

Question 14

how does cerebral disease cause N&V and how does it present

Answer 14

Compression / irritation by tumour, raised ICP, anxiety

Clinical picture:
Worse in morning
Associated headache

Question 15

how does N&V caused by oncological (chemo/radio) treatments present

Answer 15

Predictable from history

Often nausea is the main complaint

Question 16

what can cause impaired gastric emptying

Answer 16

Locally advanced cancer, drugs, radiotherapy damage to gut, autonomic neuropathy

Question 17

what is the clinical picture of N&V caused by impaired gastric emptying

Answer 17

Not usually nauseated
very nauseated after eating
Large volume vomits
Feels better after being sick

Question 18

what can cause chemical/ metabolic N&V

Answer 18

Medication, advanced cancer, sepsis, kidney or liver impairment, biochemical

Think: Calcium, Sodium, Magnesium, Urea

Question 19

what is the chemical picture of N&V caused by chemical/ metabolic

Answer 19

persistent nausea

little relief from vomiting

Question 20

what is the non pharmacological management of N&V

Answer 20

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

Question 21

what is anticipatory nausea

Answer 21

when being anxious about being sick makes you feel/ be sick

Question 22

what is seen on X ray in small bowel obstruction

Answer 22

vulvulae coniventes

Question 23

what is malignant bowel obstruction

Answer 23

bowel obstruction in the context of intra-abdominal cancer/ non intra-abdo cancer with clear intraperitoneal disease

Obstruction may still be due to benign causes in advanced cancer
Eg; Adhesions, post-radiotherapy (up to 50% in colorectal ca)
Also constipation may contributory factor

Question 24

what are the causes of malignant bowel obstruction

Answer 24

mechanical:
-intraluminal
-intramural
-extra mural extrinsic compression
(Omental deposits, peritoneal deposits, nodal deposits)

adynamic ileus:
-tumour infiltration of mesentery, muscle or nerves

Question 25

what is the difference between complete and partial (subacute) bowel obstruction

Answer 25

Complete- nothing can get past, completely occluded | Partial- some passage through bowel but bowel not working properly so have majority of symptoms of complete

Question 26

what cycle occurs in bowel obstruction

Answer 26

secretion- distention- secretion: ``` 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 ```

Question 27

what causes colic pain in obstruction

Answer 27

increased peristalsis of bowel

Question 28

what is the clinical presentation of bowel obstruction

Answer 28

``` 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 ```

Question 29

what is the surgical management for bowel obstruction

Answer 29

‘Drip and suck’ before surgery (NG tube brings up all of fluid and given IV fluids) Bowel rest NBM (nil by mouth) Not comfortable, tube is very large Surgical treatment Resection Palliative colostomy or ileostomy Self expanding metallic stent when palliative consider QOL

Question 30

what is the medical management for bowel obstruction

Answer 30

If partial obstruction promote resolution: antiemetic and prokinetic agents= metoclopramide Laxatives - Docusate or movicol to soften stool in partial obstruction Relieve pain and colic: Opioids (will cause constipation) Hyoscine butylbromide for colicky pain (will slow down the bowel) Reduce vomiting to acceptable level for patient without use of NG tube: Metoclopramide 30mg / 24 hours if not contra-indicated and partial/subacute obstruction Relieve nausea Relieve thirst Fluids (will loose lots of GI fluids, not drinking as much) Steroids (to reduce inflammation, especially If you have nodal disease) Dexamethasone – 8-16mg / 24hours Anti-secretory agents Buscopan (Hyoscine butylbromide) – slows bowel down Octreotide - 300-900 mcg/24 hours in CSCI (somatostatin analogue, potent secretion reducer)

Question 31

is metoclopromide an antiemetic or an prokinetic

Answer 31

both

Question 32

should you give metoclopramide if a patient already has colic pain

Answer 32

no- risk perforation

Question 33

should patient who are vomiting be given oral medications

Answer 33

no | will not be absorbed

Question 34

what is a common reversible cause of bowel obstruction

Answer 34

constipation

Question 35

how do you pick which antiemetic to use

Answer 35

use history and exam to find cause of nausea and vomiting- pick drug that will target to right receptor