Palliative Care in Gynaecological Malignancy

Question 1

What are some of the symptoms of gynaecological malignancy?

Answer 1

Physical = pain, nausea/vomiting, constipation, bleeding
Social = altered body image, fertility issues
Emotional = fear, worry about future

Question 2

How common is nausea and vomiting in cancer patients?

Answer 2

Affects up to 70% of patients with advanced cancer

Question 3

What do you want to cover in the history of a patient with nausea and vomiting?

Answer 3

Triggers, volume, pattern, exacerbating/relieving factors (including drugs tried), bowel habit, concurrent symptoms

Question 4

What must you exclude in a patient with nausea and vomiting?

Answer 4

Regurgitation

Question 5

Why must you ask a patient with nausea and vomiting about any medication they are taking?

Answer 5

Must consider any medications that may be causing the symptoms and any that may not work due to the vomiting

Question 6

What are some features of the examination of a patient with nausea/vomiting?

Answer 6

Look for signs of dehydration, sepsis or drug toxicity
Do full CNS and abdominal examination
Check temperature, pulse and respiration

Question 7

What are the different parts of the body that send inputs to the vomiting centre in the brain?

Answer 7

Cerebral cortex, vestibular centre, GI tract and chemoreceptor trigger zone

Question 8

What are some features of the cerebral cortex in relation to vomiting?

Answer 8

Triggers = emotions, sight, smell, raised ICP, anxiety
Mediated by NKI and 5-HT
Treatment = dexamethasone, benzodiazepines + aprepilant

Question 9

What are some features of the vestibular centre as it relates to vomiting?

Answer 9

Trigger = motion
Mediated by H1 and ACh
Treatment = cyclizine, levomepromazine, hyoscine

Question 10

What are some features of the GI tract as it relates to vomiting?

Answer 10

Triggers = distension, stress, mass/tumour, constipation
Mediated by 5-HT, D2 and ACh
Treatment = metoclopramide, levomepromazine, ondansetron, dexamethasone

Question 11

What are some features of the chemoreceptor trigger zone as it relates to vomiting?

Answer 11

Triggers = metabolic causes, drugs
Mediated by D2, 5-HT and ACh
Treatment = haloperidol, levomepromazine, ondansetron

Question 12

What are some features of nausea/vomiting caused by cerebral disease?

Answer 12

Cause = compression/irritation by tumour, raised ICP, anxiety
Worse in morning with associated headache

Question 13

What are some features of nausea/vomiting caused by oncological treatments?

Answer 13

Chemo/radiotherapy induced
Predictable from history
Often nausea is main complaint

Question 14

What are the features of nausea/vomiting caused by impaired gastric emptying?

Answer 14

Cause = locally advanced cancer, drugs, radiotherapy damage to gut, autonomic neuropathy
Large volume of vomit
Feels better after being sick

Question 15

What are some features of nausea/vomiting caused by chemical or metabolic reasons?

Answer 15

Cause = medication, advanced cancer, sepsis, kidney/liver impairment
Persistent nausea with little relief after vomiting

Question 16

What are some non-pharmacological management options for nausea/vomiting?

Answer 16

Regular mouth care, keep bowels moving to avoid constipation contributing, encourage small meals, avoid preparing food, acupressure bands, acupuncture

Question 17

What is malignant bowel obstruction defined as?

Answer 17

Clinical evidence of bowel obstruction in setting of intra-abdominal cancer OR non-intra-abdominal cancer with clear intra-peritoneal disease

Question 18

What are some causes of malignant bowel obstruction?

Answer 18

Adhesions, post-radiotherapy, intraluminal, intramural, extramural extrinsic compression, adynamic ileus

Question 19

How common is malignant bowel obstruction?

Answer 19

3-15% of all cancer patients

20-50% of ovarian cancer patients

Question 20

What causes an adynamic ileus?

Answer 20

Tumour infiltration of mesentery, muscle or nerves

Question 21

How does malignant bowel obstruction occur?

Answer 21

Proximal accumulation of secretions and gut distension = further secretion, reduced water and sodium absorption, gut wall oedema, increased motor activity, increased intra-luminal pressure

Question 22

What are the symptoms of malignant bowel obstruction?

Answer 22

Nausea/vomiting, pain (may be colicky), anorexia, reduced or absent bowel motions/flatus, paradoxical diarrhoea

Question 23

What is the traditional management of malignant bowel obstruction?

Answer 23

Drip and suck pre-surgery, bowel rest, nil by mouth

Surgery = resection, palliative colostomy/ileostomy, self-expanding metallic stent

Question 24

What are the issues with using the traditional management of malignant bowel disease?

Answer 24

Needs prolonged recovery and hospital stay

Question 25

What are the aims of medical management of malignant bowel obstruction?

Answer 25

Promote resolution if there is partial obstruction Relieve pain, colic, nausea and thirst Reduce vomiting to acceptable level for patient without use of NG tube

Question 26

What are some analgesic and anti-emetic options used for malignant bowel obstruction?

Answer 26

Opioids, hysocine butlybromide for colicky pain | Metoclopramide 30 mg/24hrs for partial obstruction

Question 27

What are some other medications used to treat malignant bowel obstruction?

Answer 27

Dexamethasone 8-16 mg/24hrs Antisecretories= buscopan, octreotide 300-900 mcg/24hrs Docusate or movicol laxatives to soften stool in partial obstruction

Question 28

When are oral medications contraindicated?

Answer 28

If there is nausea/vomiting