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Learning objectives
� Identify common GI problems in Palliative Care
Management of GI Symptoms
Dr. Ruchika MakkarSenior Resident
Palliative Medicine
� Identify common GI problems in Palliative Care
� Management of oral thrush, stomatitis, dry mouth, nausea, vomiting, constipation and diarrhoea
� Management of Intestinal obstruction
Gastro symptoms
� Sizable proportion of Palliative Care Patients have GI symptoms
� Receives less attention than pain� We need to pay more attention as it causes patient
morbidity� We must anticipate problems� Ongoing assessment of treatment required.� Background medications as well as for breakthrough
symptoms
Oral problemsNormal Situation :
� Mouth is kept moist with normal secretion � About 1.5 litres of saliva per day� Helps keep mouth, teeth and gums healthy� Saliva has antibacterial activity
General decrease in salivary secretion seen in most patients in the palliative care setting
Oral problems – Risk is high in PC
� 90 % of palliative care patients� Reduced Fluid intake� Poor Nutritional state� Drug induced dryness� Chemotherapy related� Radiotherapy in facial area� Unable to take care of one’s self
Assessment of oral problems� Regular examination� Assess patients ability to carry out own mouth care� Altered taste� Oral pain� Dry mouth� Halitosis� Ulcers� Thrush� Dental problems
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� Low importance given to oral hygiene � Dental problems
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General mouth care Oral Candidiasis and Management
�Routinely, every 2-4 hours, in all patients
� Particular attention in comatose / mouth breathing
� Use of toothpaste, soft brush after meals
� Regular mouth rinsing
� Keeping mouth moist
� Look for evidence of oral problems
•Nystatin Suspension 1-2 ml, 4 hourly
• Tab. Fluconazole 150 mg daily, 7 -14
days
•Clotrimazole mouth paint
Stomatitis- Painful, Inflammatory, Ulcerative Condition
Causes : � Infection � Ulceration
Mucositis – post RT / Chemo
� Dry Mouth
� Pain – Infiltration / dental problems
Iron / Vitamin deficiency
Soreness± erythema
Erythema,ulcers; patient canswallowsolid food
Mucositisto the extentthat alimentationis not possible
Ulcers with extensive erythema; patient cannot swallow food
Grade 2 Grade 3
Severe Mucositis
Grade 1 Grade 4
Stomatitis ManagementNon Drug Management :
� Treat underlying cause
� Good Oral hygiene
� Avoid foods that trigger
pain
� Avoid tobacco / alcohol
� ENT / Oncology review
Drugs used :
� Local Anaesthetics :
eg., 2% lignocaine / 4%
viscous
� Salicyclate gel
� Soluble aspirin
Xerostomia (Dry Mouth)
� Subjective feeling of dry
mouth
� Associated speech difficulties
� Loss of taste� Need for frequent drinking� Common in palliative care
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� General mouth care
measures
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Xerostomia (Dry Mouth)
Causes : Management :
HalitosisCauses : Drugs eg: AntimuscarinicsThrush Mouth breathingDehydration RadiotherapyAnxietyOxygen therapy (non-
humidified)
Management :Treat Cause ReviewMedicationsBasic oral care regimenWater sippingSucking ice chipsPetroleum jelly / vegetable oil to lipsSaliva substitutes (expensive)
� Diagnose and treat cause
� Metronidazole gargle / systemic
� Frequent mouth wash
� Basic oral / dental care
Home made mouth washTo one litre of warm water, add the following:
One piece of Clove
5ml of Providine iodine solution
3ml of hydrogen peroxide
one spoon of table salt
metronidazole
mint tablets two
Courtesy : SudharshanaPalliative Care Clinic, Trichy
before after
Before and after using home made mouth wash
Courtesy : SudharshanaPalliative Care Clinic, Trichy
Soft tooth brush- innovated
remove the bristles
Soft tooth brush
Soft tooth brush
roll a cotton gauze around it
tie the lower portion
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wrap cotton roll around the tip
tie the lower portion
Courtesy : SudharshanaPalliative Care Clinic, Trichy
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Nausea, Retching & Vomiting• Biological defense mechanisms
Nausea and vomiting
• Biological defense mechanisms• To remove toxic or harmful substances from the
body after ingestion
the process of ‘emesis’ can be explained in threephases:
• Nausea• Retching and• Vomiting
Nausea & Vomiting� Nausea: The unpleasant sensation of the imminent
need to vomit.� Vomiting: Forceful oral expulsion of gastric contents
associated with contraction of the abdominal and chest wall musculature.
� Retching: Spasmodic respiratory movements against a closed glottis with contractions of the abdominal musculature without expulsion of any gastric contents.
� Regurgitation: The act by which food is brought back into the mouth without the abdominal and diaphragmatic muscular activity that characterizes vomiting. 21
Nausea
• Described as an unpleasant sensation ( in the back of
the throat and stomach)
• that usually proceeds vomiting,
• but may not result in vomiting always
� Other terminologies:� “sick to my stomach”� “queasy”� “butterflies
Retching
• Follows nausea
• Comprises laboured spasmodic respiratory movements against
a closed glottis
• With contractions of the abdominal muscles and chest wall
contents
� Retching can occur without vomiting but normally it generates
the pressure gradient that leads to vomiting.
Types Description Acute Occurring from few minutes to hours and
resolving within 24 hoursDelayed Occurring usually after 24 hours of chemo
and will be worst from 48 to 72 hours following chemo and can last 6 to 7 days.
Breakthrough Occurring despite antiemetic treatment
Refractory Unmanageable with current antiemetic regime
Nausea and Vomiting especially Chemotherapy induced can be….
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the pressure gradient that leads to vomiting.regime
Anticipatory Conditioned response prior to chemotherapy
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Management of Nausea and vomiting� Occurs in 40 – 70% patients with cancer
After effects of Nausea and vomiting
� Affects patients’ daily functioning� Occurs in 40 – 70% patients with cancer
� Management involves accurate assessment
� Good knowledge of anti-emetic drugs
� Consider route of administration
� Control of symptom possible in 60% patients
� Affects patients’ daily functioning
� Quality of Life
� Non compliance to cancer treatment
� Refusal of effective pain medications
� Family distress
Rationale of Treatment
� To stop or reduce symptom frequency
� To establish compliance to treatment
� To enable analgesic medications
� To improve quality of life
Vomiting Centre
Higher Cortical Centres Memory, fear,
anticipationSensory input
(Pain,Smell
Sight)
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Chemotherapy
AnaestheticsOpioids
Chemotherapy
VomitingReflex
Pathophysiologyof Nausea and Vomiting
Stomach Small Intestine
ChemotherapySurgeryRadiotherapy Labyrinth
sSurgery
Anti emetics and mechanism of their actions
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Mechanism of vomiting
? 5HT3
Gut mucosa Area postremaCTZ
D25HT3 Cerebral cortexGABA 5HT
Vestibular nucleiAchm H1
Emetic pattern generator(Vomiting centre)
D2 AChm H1 U-opioid 5HT2
Gastricirritants
Abdominalradiotherapy
Intestinaldistension
Cytotoxicchemotherapy
Morphine /digoxin
Hypercalcaemia/uraemia
Fear/anxiety
Hyponatraemia
Raised intra-Cranical pressure
Movement / Vertigo
Vagal / splanchnicafferents
Gastric atony, Retroperistalsis,T horacic and abdominal muscle contractions
Blood- brain barrier
Anti Nausea & Vomiting drugs ….
• As per patient’s condition and preference
• Oral route is usually the best and easiest way
• If vomiting is severe, IV route / IM route/ CSCI
• Suppositories
• Sublingual
• Transdermal patches
Managing vomiting
Treatment
should be
Mechanism-based,
Not generalized!
Management of nausea and vomiting:• After clinical evaluation, Document the most likely cause(s) of
N&V. Examples:• Gastric stasis• Intestinal obstruction,• Biochemical• Drugs• Raised intracranial pressure.
• Ask the patient to record the symptoms and response to treatment, preferably using a diary
• Correct the correctable causes/ exacerbating factors ..
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eg: Drugs, Severe pain, Infection, Cough, Hypercalcemia and Anxiety
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Management Continued…• Prescribe the most appropriate anti-emetic stat,
General principles of Management
� Single anti-emetic may not be adequate• Prescribe the most appropriate anti-emetic stat, regularly, and p.r.n
• Choose parenteral route if continuous nausea and/ frequent vomiting
• Prokinetic Anti-emetics: for gastritis, gastric stasis, functional bowel obstructions -eg: Metaclopramide
• Anti-emetics acting principally on CTZ: for most chemical causes of vomiting - eg: Haloperidol
� Single anti-emetic may not be adequate
� Multiple causes may require combination
e.g., for Raised ICP & Uremia
Dexamethasone, Haloperidol – metoclopramide
� Persistent vomiting – subcutaneous preferable
� Keep in mind side-effects :
e.g. extra pyramidal, Constipation
Nausea & VomitingCauses Treatment� Drug induced
� Radiotherapy
� Chemotherapy
� Metabolic eg. Uremia
� Haloperidol 1.5 to 2.5 mg H.S / b.d.
� Ondansetron 8 mg stat then4 mg. tds / granisetron 1 mg.
stat then 1 mg. b.d.
� Ondansetron / Granisetron. Dexameth. 8 mg o.d for 3 days. Metoclopr. 10 to 20 mg. q.d.s. po/sc
� Haloperidol – start with 1.5 mg H.S.
Causes Treatment� Raised Intracranial
Pressure
� Bowel Obstruction
� Delayed Gastric Emptying
� Gastric Irritation
� Dexamethasone 8 to 36 mg I.V.
� If partial, no colic, Metoclopramide
� If colic, Hyoscine Butylbromide 40 to 100 mg/24 hrs.
Ondansteron 8 to 24 mg/24 hrs. p.o., i.v. or s.c.
� Metoclopramide 10 20 mg q.d.s.
� Domperidone 10 to 20 mg q.d.s.
� PPIs, Stop Irritants
Opioid induced Nausea & Vomiting
� Different mechanisms may be at play :CTZ, increased vestibular sensitivitygastric stasis, Constipation
� Drug of Choice : Haloperidol, Metoclopramide� Prevent with initial antiemetics� Treat N / V aggressively before reducing opioid.
Role of Dexamethazone in vomiting� By reducing the permeability of CTZ and of the Blood-
brain barrier for emetogenic substances
� By reducing the neuronal content of Gamma Amino
butyric acid (GABA) in the Brain stem
� By reducing the inflammation at the site of
obstruction and thereby increasing the lumen
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� By reducing the pressure on the intestinal nerves and
correcting neural dysfunction
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Management- Pharmacological Management- PharmacologicalAbdominal Tumors Gastric Stasis
Irritation of Meninges� Inj dexa 8-16 mg/day.� Inj. Mannitol 100 ml bd� Possible role of palliative
radiation.� Levomepromazine 12.5 mg
orally or cyclizine 25 mg tdsorally.
� Anxiety induced vomiting
� Lorazepam- 0.5-1 mg� Levomepromazine� start with low dose (6.25mg
tds)
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Abdominal Tumors� Anticholinergics.� Steroids to reduce the mass.� Haloperidol 1.5 mg BD, to
reduce D2 activity.
Gastric Stasis� Metoclopramide or
domperidone as first line.� Dexamethasone for
oedema.� Octreotide for non
responsive vomitings.
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Recent Trials� Olanzepine Dose 2.5-10 mg OD
� NK1 antagonist- Aprepitant-prevents binding of substance P to NK1 receptors. decrease emesis after cisplatin and radiation therapy 125 mg before,80 mg/day after.
� Cannabinnoids- nebilone,blocks CB1 receptors in area postrema, nucleus solitarus, also at gut.1-2 mg before
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Management Continued…
• Review the anti emetic dose every 24 hrs. taking note of p.r.n. use and the patient’s diary
• If inadequate response despite optimising the dose of anti emetic , review the diagnosis
• If diagnosis is found to be the same, change to an alternative anti-emetic and optimize the dose.
• Add a second anti-emetic if needed
� Establish a likely cause. � Identify the most likely pathway. � See which receptors are involved.� Choose the most potent antagonist.� Choose the most appropriate route of administration.� Review after 24 hrs, add other drug.� Opt for regular rather than PRN dosing.� Titrate the drug dose accordingly.� Reassure patient/ family.
Steps in the Management of Nausea / Vomiting
Common Palliative Care Situations leading to vomiting
� Gastric Stasis
� Intestinal Obstruction
� Drugs
� Raised ICP
� Biochemical Disturbances
� Others
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� Reassure patient/ family.
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Non-pharmacological management
� Fresh air
Distractions� Self hypnosis
Progressive muscle relaxation� Fresh air
� Bed rest to avoid vestibular stimulation
� Good oropharyngeal hygiene
� Nurse in the upright position
� Avoid situations which induce N&V
� Suitable distractions
� Progressive muscle relaxation� Biofeedback� Systematic desensitization � More useful in anticipatory vomiting� Can be used alone or together with anti-vomiting drugs• Promote relaxation, which may decrease nausea and vomiting• Serve to distract the individual’s attention• Enhance feelings of control• Reduce feelings of helplessness• They have no side effects and can be used by anyone
Nutritional advice during nausea and vomiting:
• Try to eat small frequent meals rather than three large meals
• Try consuming most foods during the time of the day when able to eat better
• Many people find that breakfast time is best• Eat foods and drink that are “easy on the stomach”• Do NOT force yourself to eat when nauseated• Cold food or at room temperature are better tolerated� Try to avoid fatty / sweet / spicy food � Avoid fibre� Avoid carbonated drinks
Diet advice continued…
• Make someone else to make food, if you are
nauseated
• If a person is having difficulty in eating his special
diabetic or heart disease diet, their diet
requirements can be relaxed
• A dietitian can be consulted to provide more tips to
help eating
What else to be done?
� Keep your mouth clean and do oral care after each episode of vomiting
� Wear loose fitting clothes� Have fresh air with a fan or open window� Limit sounds, sights, and smell that cause nausea and
vomiting� Call your doctor or nurse if your nausea or vomiting is
not controlled`.
Management of nausea and vomitingin palliative care -Guidelines � Document most likely causes.� Treat potentially reversible causes and exacerbating
factors(e.g. Drugs, constipation, severe pain, infection, cough)
� Review dose after 24 hours� If N & V persist after 24 – 48 hours, review cause.� Remember 1/3 of patients will need > 1 anti emetic.� If on parenteral, consider converting to oral after 72
hours of good control, to oral regimen
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not controlled`. hours of good control, to oral regimen
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ConstipationSubjective feeling:
Constipation
Subjective feeling:
“What the patient says”
Normal habit may be- Twice a day or- Once in 2 days
Constipation� Difficult or painful defaecation and is associated with
infrequent bowel evacuations and hard faeces
� A subjective feeling: “how it is different from their
normal”
� 45% of Palliative Care patients are constipated on
admission
Constipation can lead to…� Feeling of incomplete evacuation
� Bloated feeling
� Nausea and Vomiting
� Abdominal cramps / pain
� Bowel obstruction,
� Overflow diarrhoea
� Urinary retention
Causes� Pharmacological
Opioids(90%), Anti depressants, Anti cholinergic, Anti epileptics, Anti emetics, Antacids, Somatostat in analogues
� Metabolic Dehydration, hypercalcemia, hypokalemia, uremia
� Diet Poor appetite, low fluid and fibre intake
� Environment Hospitalization, Inability to attend to the call
� NeurologicalMalignant spinal cord compression, Sacral Nerve infiltration
� Structural
Assessment� What is normal for the patient?
Frequency, amount, consistency, blood stained or not
� When was the last bowel movement?
� Is the patient experiencing any abdominal discomfort,
cramping, nausea and vomiting, excessive gas or
rectal fullness?
� Does the patient regularly use laxatives?
� What medications are the patient on?
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� StructuralPelvic tumors, RT induced fibrosis, painful anorectalcondition, intraluminal obstruction
Others : Depression, weakness, immobility, inactivity, sedation, age
� What medications are the patient on?
� Is constipation a recent change?
� What type of diet is the patient on?
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Management of constipation Non Pharmacological Measures� Access and ability to go to toilet.
�Correct the correctable� Judicious use of laxatives� Improve general condition� Symptom control� Encourage activity� Fibre – diet
� Access and ability to go to toilet.
� Timing and privacy.
� Squatting position
� In bed, feet under knees and gentle blowing, arms resting on thighs.
� Encourage normal balanced diet and plenty of water.
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Create Favourable EnvironmentEducate Patient and Family
� Common to Hear :
� “Not eaten enough at all. How will she /he pass motion?
� “I have diarrhoea” (overflow))
A patient with less/no intake
� Large bowel transit take 3-4 days even in normal people.
� stool contains shed epithelium and a major bulk is the byeproduct of bacterial action.
� Even if patient has not taken any food for a few days, he may need bowel care.
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Treatment of Constipation
� Rectal Examination� Proper use of the right laxatives� Suppositories� Enema – Proctoclysis (Glycerine)
Warm Saline / Plain Water� Do not give soap water enema� Digital evacuation for faecal impaction
Pharmacological Management - Laxatives
1. Softeners: Docusate, Liquid Paraffin3 tsp (15ml) upto 3 times a day
2. Stimulant LaxativesSenna , Bisacodyl – 2 tabs upto 4 a day
3. Bulk-Forming: Isapgul – not used
Osmotic agents: Lactulose
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� Digital evacuation for faecal impaction 4. Osmotic agents: Lactulose
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Considerations Using Laxatives Considerations Using Laxatives
� Paraplegic patients need regular stimulants and stool softeners.
� May need initial manual evacuation.
� Patients with colostomies are treated in the same manner.
� After obstruction is excluded, Bisacodyl suppository can be used but it is less well absorbed and oral tablets need to be added.
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� Soft stools- bisacodyl suppository
� Hard stools- glycerine suppository
� Empty rectum- oral stimulants, high oil enema
Impaction of faeces and overflow diarrhoea
• Longer the stools stay in the gut• more is the absorption of water • leading to severe constipation
“Over flow diarrhoea” – Spurious diarrhoea
Treatment of faecal impaction:
� If soft faeces palpable P/R……Biscodyl suppositories� If hard faeces palpable P/R ….. Biscodyl and Glycerol
suppositoriesPlain warm water/Saline enemaSodium phosphate enemaand Oral LaxativesManual evacuation with lubrication
Manual evacuation:
• Proper explanation about the procedure and informed consent
• Sufficient lubrication preferably with local anaesthetic jelly
• Allowing enough time for the local anaesthetics to act
• Gently and slowly doing the procedure with careful watching of the patient’s reaction and acceptance, at
Intestinal obstruction
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watching of the patient’s reaction and acceptance, at the same time keep talking with the patient
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Intestinal Obstruction Intestinal Obstruction - managementPartial Obstruction may resolve – Aim to :
�Most common in Bowel / Ovarian cancer
� Often multiple sites
� Plain X-ray Abdomen may help
� Surgical vs. medical treatment
� Consider Quality of life while planning treatment
Partial Obstruction may resolve – Aim to :
1. Reduce Bowel wall odema - Steroids2. Stimulate Gut Motility
- Metoclopramide
If not resolved (? Complete obstruction)� Reduce intestinal secretions� Treat nausea and vomiting
Factors Indicating Poor Surgical Prognosis
� Advanced age� Ascites� Palpable abdominal mass� Previous radiotherapy to abdomen/pelvis� History of combination chemotherapy� Multiple sites of obstruction� Poor performance status
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Antiemetics
� Metoclopramide- dopamine antagonist, in higher doses 30- 120mg/ 24 hours via s/c infusion. Start with 10mg Q8H s/c. Gradually increase dose day by day basis
� 5 HT3 antagonist, and prokinetic, only in partial obstruction, dose 40-120 mg/day s/c
� Haloperidol-for nausea and vomiting 2.5 to 5 mg /24 hours via s/c infusion
Anticholinergics
� Hyoscine butyl bromide(Buscopan)-120 mg/day/SC, acts at peripheral ACh receptors
� Hyoscine hydro bromide(Scopolamine)-900-1200 micrograms/day/SC, acts at central and peripheral Ach receptors
� Not to be given with pro kinetics
Corticosteroids
� Dexamethasone 16 mg/day/IV� To be given before 3 PM, as late administration interferes
with sleep� Given for 3 days trial� If vomiting subsides, continue oral steroids� Steroids act by reducing peritumoral oedema
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� Not to be given with pro kinetics
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Somatostatin analogues Medical Management in a nutshellDrugs used -
� Octreotide 300 micrograms/day� Will reduce the secretions, slow down the motility,
reduces splanchnic flow, increases the absorption of water and electrolytes, potent anti vasoactive intestinal peptide effect.
� Also tried as preventive step� Depot preparation 20 mg/ 4week� Along with steroids in carcinomatosis
Drugs used -
� Dexamethasone : 8 –16mg S.C / I.V – 3 days trial
� Metoclopramide : 30 to 120mg / 24h S.C. Infusion
OR
� Hyoscine butylbromide : 40-100mg / 24h S.C.
infusion
� Haloperidol : 3-5mg / 24 h SC infusion
Other measures :
Nasogastric Tube : ?
Venting Gastrostomy : almost never! Diarrhoea
Causes� Imbalance of laxative therapy� Drugs� Faecal impaction – overflow diarrhoea� Radiotherapy – 2-3 rd week of therapy� Malabsorption of fat and water
- Ca Pancreas- Gastrectomy- Vagotomy- Ileal resection- Colectomy
� Fistulae� Colonic or rectal tumour
Patterns of diarrhoea
� Anal incontinence� Colonic diarrhoea� Faecal impaction� Alternate diarrhoea/ constipation� Pale white- malabsorption
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� Colonic or rectal tumour� Endocrine tumour
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Treatment of Diarrhoea Managing intermittent diarrhoea
� Is the patient dehydrated?� Oral rehydration solution orally or through nasogastric feed.� IV fluids- Ringer Lactate should be administered in severe
dehydration. � Loperamide – 10 mg tab, choice no crossing BBB.� Glycopyrrolate / atropine – 0.4/0.6 mg� Octreotide 300 – 600 mcg sc
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� Exclude spurious diarrhoea due to neglected constipation or partial bowel obstruction, irritable colon, anxiety and fear
� Check nasogastric feeding – exclude high osmotic load in the feed, increase the feeding time and dilute the feeds
� Exclude infection
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Pharmacological management
� Stool mixed with blood/ discharge, add anti biotics� Fungating rectal or colonic tumors:
metronidazole 400mg 8-12 hourly or sucralfate paste PR for bleeding
� Consider palliative radiotherapy for bleeding rectal tumors
� Exclude infections and inflammation (NSAIDS, radiotherapy)
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Diarrhoea management
�Specific Drug treatment
Pancreatin, Ondansetron, Metronidazole,
Somatostatin (if affordable) / Buscopan
�Nonspecific Drug TreatmentOpioids – Codeine / loperamide
� Radiation induced diarrhoeaondansetron
Hiccups� Close to 100 different causes� GI causes – Most common� Extremely distressing� Pharmacological and non-pharmacological management
� A good clinical assessment is important
Causes� Medications- Corticosteroids� Metabolic- Renal failure/Uraemia- Hyponatraemia� Intracranial disease- tumours- brain stem� Infection� Idiopathic
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Idiopathic
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Management� Remove causes
Drug Management- Baclofen – 5-10mg tid� Remove causes
� Decrease distension by smaller frequent meals� Prokinetic – Metoclopramide /Domperidone 10mg Qid� Gas absorbing – Simethicone/ Dimethicone 5mls Qid� Gastritis – Omeprazole 10mg Qid
� Sugar/crushed ice� Long slow sips of water� Breath holding� NG tube� Massage external auditory canal
- Baclofen – 5-10mg tid- Chlopromazine- Nifedipine- Haloperidol- Phenytoin- Gabapentin
� Drugs used for management can cause hiccups !!
"I saw few die of hunger; of eating, a hundred thousand"- Benjamin Franklin
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