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M. El Ansary Prof. of Pain MedicineAl Azhar University, Cairo, Egypt
Al Azhar Univ.
ESMP
55 yrs. Female. Cancer sigmoid colonFollowed by sup. mesenteric art. ThrombosisExtensive colectomy & small intestine Short bowel syndrome
Nausea & vomiting Hyper‐motility and diarrhea Dehydration, Hypo kalaemia (K+) & Natremia (Na+) Negative nitrogen, lipid and CHO balances , Loss of weight , anemia , infections …………..
Chemotherapy started
What to do first ?
Stop diarrhea and vomiting.
Or
Replacement therapy
Or
Other suggestions
Stop diarrhea by: MetclopremideOnadosteronePromethazineSteroids + B6
Stop diarrhea by:Opium derivatives not effective Spastic constipation
Not Effective and Expensive
STOp
What to do more ?
Causes are:
Short bowel small capacity of the bowel
Hyper motility diarrhea & vomiting
Chemotherapy diarrhea & vomiting
How to manage ? Normal bowel
capacityShort bowl
Atropine or hyoscine
Stop hyper‐motility .
Stop vomiting
Relax the intestinal contractions
Contraction of anal sphincters.
Increase the capacity of the bowel
Accommodate more food.
Very cheap
Increase bowel
capacity
Short bowel
Dehydration fluid balance (in & out) Hypo kalaemia (K+) glucose + Insulin Hpo Natremia (Na+) 10 % saline solution Negative nitrogen amino acidsNegative lipid intralipidAnemia blood transfusion or tonics ?I infections Bacterial antibioticsFungal antimycotics
Lines of treatment
WHO analgesic ladder ?
I. V opioids (tramal &morphine)
What else ?
Adjuvant Agents1. Antidepressants2. Anticonvulsants 3. Oral local
anesthetics,4. Corticosteroid5. Neuroleptics,6. Anxiolytics,7. Psychostimulant8. Laxatives,9. Antiemetics
WHO ladder vomiting & diarrhea
Oral / rectal drugs re‐vomited & rejected
No time for absorption
Fentanyl patch central vomiting
I.V opioids (tramal & morphine) tolerance
What to do next
Treatment of side effects
Treatment of other Cancer problems
Strong opioid + non opioid
Weak opioid+ non opioid
Non Opioids
+ Adjuvant
+ Adjuvant
+ Adjuvant
Lumbar neuroaxial blockade (L.A + opioid) Spinal Epidural
Caudal neuroaxial blockade (L.A + opioid) Neurolytics
Celiac plexus Superior &and inferior hypogastric plexuses.Ganglion impar
Radio frequency
Palliative care But this is another story
