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Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.

138

Cachexia, Anorexia, and Nutrition

Cachexia and anorexia are commonly experienced symp-

toms of advanced malignant and non-malignant diseases,

and up to 10% of patients with cancer in the community will

have a body mass index of less than 20 m

/kg. The associ-

ated distress can be marked, especially in terms of body

image and quality of life. Cachexia has been found to be

associated with a shorter prognosis for many diseases

including cancer [3], chronic obstructive airways disease

[4], heart failure (HF) [5], liver disease [6], and acquired

immunodeficiency syndrome (AIDS) [7].

Detailed discussion of pathophysiology is beyond the

scope of this book but might include the following:

•

Unresolved nausea.

•

Mechanical effects of tumours and ascites.

• Cytokines (e.g. tumour necrosis factor) causing

increased basal metabolic rate; increased hepatoglucono-

genesis, using protein as substrate; increased glucose intol-

erance; altered lipid metabolism; and anorexia.

• Adverse effect of medications.

• Jaundice and obstructed biliary system.

• Poor oral hygiene.

• Psychological factors including low mood and anxiety.

•

Unresolved pain.

Management requires active involvement of the multidis-

ciplinary team (MDT), and best outcomes are gained by

using a range of approaches that aim to ameliorate the

The Management of

Gastrointestinal Symptoms and

Advanced Liver Disease

Andrew Chilton, Christina Faull, Wendy Prentice and Monica

Compton

With thanks to Dr Laura Clipsham for reviewing the chapter for the 4th edition of The Handbook

of Palliative Care

Introduction

Patients with advanced disease, of whatever nature, com-

monly have symptoms related to the gastrointestinal

(GI) tract. All such patients should be specifically asked

about dry and sore mouth problems, eating, nausea, and

constipation. Unrelenting nausea can be more disabling

than pain, and effective management requires a logical,

systematic, and persistent approach. Constipation is

often neglected and can be prevented for most patients.

Cancer may obstruct the GI tract causing well-defined

syndromes and the options for palliation of these symp-

toms are described in detail in this chapter.

Eating and defecating can be a major point of refer-

ence for patients and their carers about their health, and

their dysfunction may carry enormous significance

about sustaining life and the approach of death. The

importance of this in caring for patients should never be

underestimated.

The palliative care needs of patients with advanced liver

disease are now more recognised [1, 2]. Given the dramatic

and often highly symptomatic complications of end-stage

liver disease, many of these patients spend the last months

of their lives in acute hospitals where many of them will

also die. A small number of patients have access to spe-

cialist palliative care services, and further work is needed

to support this increasing number of patients to receive

appropriate palliative care delivered according to need and

if possible in a place of their choosing.

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The Management of Gastrointestinal Symptoms and Advanced Liver Disease 139

it increases patient tolerance of chemotherapy; in alcoholic

cirrhosis may influence prognosis; and nutritional supple-

ments benefit people during acute exacerbations of illness

[12]. In advanced disease previously advised dietary

restrictions, such as reducing salt to assist in managing

ascites, should be regularly reviewed as they can exacer-

bate a reduced intake and outweigh the benefits.

The causes of insufficient nutritional intake in

advanced disease are multifactorial and can place emo-

tional strain on both the patient and the carer. In most

situations, patients are unable to meet requirements in

both the macro and the micronutrients. Improvements

can be made concentrating on energy and protein

sources in the diet with a multivitamin mineral tablet to

provide micronutrients. The key message to the patient

is to think differently about his/her diet, there is no such

thing as “bad” food. Cream and chocolate provide a ben-

eficial source of energy. Additionally, the following

advice can be helpful:

•

Eat when and what is enjoyable. Little and often can

assist in reducing nausea.

•

Make foods interesting and if possible plan ahead.

• Have snacks freely available around the house, or when

going out, to maximise when the patient has an appetite

and/or nausea is reduced.

• Use a small plate (it gives the impression of finishing a

complete meal. Some patients feel defeated when seeing

large portions, reducing intake further).

• Softer foods that reduce chewing can sometimes be

better tolerated.

•

Readymade meals reduce energy expenditure for

fatigued patients.

•

Encourage the family and carer to create a rota system

for supplying hot meals (can be frozen and used later).

• Provide emotional support to the patient and carer to

ensure meal/food related tension and anxiety are reduced.

• Make use of aperitifs.

When attempts at diet manipulation do not improve,

commercially prepared supplements may be helpful in

some situations [13]. Patients undergoing treatments or

having episodic illness seem to benefit the most with sup-

plements. There are many types of supplements varying in

composition and presentation, such as milk and juice-

based drinks (sweet and savoury flavour), puddings, pre-

thickened drinks, and powders made into drinks. They are

available on prescription in the United Kingdom and are

therefore free to most patients. Nutritional companies are

continually introducing new products with varying

nutrient formulations.

underlying cause and address symptoms directly. Patients

and carers need to be fully involved in decision-making

and goal-setting. It is often the carer’s job to prepare meals,

and this sustaining role is of vital importance to them.

Before embarking on enteral nutritional support, clear

goals and plans need to be thought through and discussed

with the patient. Enteral tube feeding is considered to be a

medical treatment in UK law. Its initiation, stopping, and

withdrawal are medical decisions; however, these need to be

made in concert with the patient [8]. If the patient is not com-

petent to make decisions, then it is incumbent on the doctor

to make these decisions in the “best interests” of the patient in

consultation with those who know the patient best, the wider

multi-professional team and taking into consideration any

previously expressed wishes. In some countries, there is legal

provision for an individual to nominate another individual to

be involved in health-care decisions for them, if they are to

lose the capacity in the future [9].

Drugs to Increase Appetite and Weight

Gain

The following drugs have been shown to have some effect

on the symptoms in cancer patients [10]. They should ini-

tially be used on a trial basis, with treatment being

continued only if benefit is confirmed.

Steroids

Dexamethasone 2–4 mg (or equivalent dose of an

alternative steroid) is useful for increasing appetite and

energy but not weight gain. The side effects of these drugs

can limit their use (e.g., diabetes, psychological effects,

immunosuppression, fluid retention, and proximal muscle

weakness).

Progesterones

Megestrol acetate 160 mg daily (increased up to 800 mg if

required), and medroxyprogesterone acetate 480–960 mg

daily, can improve appetite and weight in cancer and per-

haps also AIDS patients. These drugs are usually well tol-

erated but can cause mild oedema, impotence, and

vaginal bleeding. Unlike steroids their effect is not

immediate but may occur within 2 weeks and is generally

more sustained [11].

In cardiac cachexia, both angiotensin-converting

enzyme (ACE) inhibitor and beta blockers can reduce

weight loss.

Nutritional Support

Nutritional support has benefits for nonterminal patients

in terms of quality of life and other outcomes. For example,

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140 Chapter 11

• Preparation for surgery in severely malnourished

patients [14].

•

Post-surgery complications impeding oral nutrition.

• As a trial to assess effectiveness and tolerability (e.g.,

patients with motor neurone disease) before commencing

more permanent feeding options if appropriate.

There are many practical difficulties in using the NG

tube in the community; most importantly is the risk of

tube displacement into the lungs. The risk is minimised by

checking the pH of aspirated tube contents (should be less

than 5.5 unless taking a proton pump inhibitor [PPI])

before each administration of feed, water, and medication.

In secondary care an X-ray is conducted if the pH cannot

confirm position; however, this is not practical in primary

care. The safest option for the patient without confirma-

tion is to withhold the feed and consider having a new tube

placed [14]. There may be limited professionals in the

community with competency to pass NG tubes, requiring

the patient to have it passed in secondary care. The arduous

process limits the feasibility of this option.

Percutaneous Endoscopic Gastrostomy (PEG) Tube

Fixed placement of a tube through the abdominal wall into

the stomach is useful for patients who require long-term

interventional nutrition (months to years) or those under-

going treatment for head and neck cancer. The procedure

is well tolerated even by quite sick patients and is generally

done under benzodiazepine sedation (Figure 1). It may be

placed endoscopically (the majority), radiologically, or by

a mini laparotomy. It is a day case procedure endoscopi-

cally, but patients may remain in hospital while learning

about the enteral feeding apparatus and techniques.

Around 6% of people will die within 30 days (around 40%

of endoscopic deaths), and robust consideration of risks by

the MDT is needed to assure selection of appropriate

patients [16].

Box 1 outlines the indications and contraindications

and Box 2 describes the possible complications of PEG.

Jejunal Tube Feeding

Some patients have considerable problems with enteral

feeding into the stomach with symptoms of reflux, hiccup,

aspiration, nausea, and vomiting. If prokinetic agents (e.g.,

metoclopramide) do not resolve this, then jejunal

placement of the NG or PEG tube (usually endoscopically)

may alleviate symptoms. However, patients with jejunal

feeding tubes will be unlikely to tolerate bolus feeds since

there is no longer the gastric reservoir and therefore will be

more practically constrained by the time required for feed

to be given.

The most appropriate type and quantity of supplement

should be determined based on the patient’s food prefer-

ences, medical condition, nutritional requirements, and

nutrient deficit [14]. If there is not a clear understanding of

the specific composition when selecting the supplement, the

patient’s diet will be further imbalanced negating any poten-

tial improvement. Regular reviews are essential to ensure

tolerance and effectiveness. Nutritional supplements can

leave an unpleasant after-taste, are rich in texture and can

lead to a monotonous diet; therefore, it is unlikely the patient

is able to sustain this as an effective long-term option.

Supplements should be used for short periods of time tran-

sitioning back to food as the patient’s intake improves.

Dietitians provide more detailed advice on nutritional needs

of patients and are an excellent source of information on

dietary supplementation. The Royal College of Physicians

and the British Society of Gastroenterology have published

an excellent resource to guide decision-making for patients

with oral feeding difficulties towards the end-of-life and is

recommended to the reader [15].

As the patient deteriorates further, the main aim of

nutritional intervention shifts to the emotional support

since there is little clinical benefit from nutritional supple-

ments, and supplements can have a deleterious effect on

the GI system and mouth care. The carer may feel they are

providing the best for the patient by offering nutritional

supplements; however, they should be reassured that sips

of soup and favourite drinks are equally beneficial, if not

superior, to the quality of the patient’s death.

For some patients, the inability to meet nutrition and

hydration requirements or ability to administer medications

orally will severely impact on the quality of life, necessitating

the decision to proceed with enteral nutrition. If the patient

has a functional GI tract, the patient should be referred to

the Nutrition Team or Gastroenterologist in secondary care

to conduct an assessment, present the most appropriate plan

of care and to assist in coordinating community support

with the Community Home Enteral Nutrition Team. Enteral

feeding tube options available to the patient are nasogastric

(NG) tube or gastrostomy tube.

Nasogastric Tube

An NG feeding tube is generally 5–8 French gauge, placed

in the nostril and fed down into the stomach. Professionals,

who have competency to pass NG tubes, typically insert

them at the bedside. They are generally indicated for short

term and dependent on the material of the tube can be left

in-situ up to six weeks before requiring replacement.

Indications are:

•

Patients undergoing chemotherapy/radiotherapy.

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The Management of Gastrointestinal Symptoms and Advanced Liver Disease 141

or prescribing advisors supporting the general practitioner

(GP) can provide advice. If the tube does become blocked,

the Home Enteral Nutrition team may be contacted to pro-

vide support. Techniques available are:

• Inspect the tube to see if the blockage is visible. Wrap a

warm flannel around the tube and once cooler massage the

tube at the blockage. With a 50-ml syringe gently attempt

to aspirate alternating with flushing warm water. If this is

Daily Care for Patients Requiring Enteral Feeding

Risk can be minimised with good daily care and the

Community Home Enteral Nutrition team can be a

valuable resource for the patient and carer providing

training and support.

Flushing before and after each administration with

either freshly drawn tap water or cooled boiled water will

reduce the risk of the tube becoming blocked with feed

and/or medication residue. Any medicine administered

through the enteral feeding tube must be in the liquid form

or a dissolvable preparation. The community pharmacist

Figure 1 Positioning a PEG tube. (a) Gastric puncture with

a sheathed needle and introduction of a string or metal wire

through the sheath after the removal of the needle. While grasp-

ing the string or the metal wire, the endoscope is removed. (b) The

loop of the gastrostomy tube is knotted at the string projecting

from the mouth and by pulling at the abdominal end of the string

the gastrostomy tube passes through the oesophagus and stomach

and finally pierces the abdominal wall. (c) The retention disc of

the gastrostomy tube is apposed against the gastric wall. (d) The

outer retention disc, and (e) the feeding adaptor are put in place.

(Reproduced from Reference 16)

Box 1: Factors to assess before PEG insertion

Indications Contraindications

Ileus

Oropharyngeal disease Blood coagulation disorder

Oesophageal obstruction-but

may be technically

problematic

Poor wound healing

Ascites

Neurogenic dysphagia with

risk of aspiration

Sepsis

Neurological injury and

neurodegenerative disease

Tumour infiltration of

stomach

Respiratory insufficiency

on lying flat (radiologically

inserted gastrostomy

[RIG] may be possible)

Major oral surgery

Preradiotherapy

If it is impossible to site a gastrostomy endoscopically, it may

be possible radiologically with ultrasound guidance (RIG)

Box 2: Complications of PEG

Major Minor

Perforation with peritonitis Wound infection/stomal leak

Haemorrhage

Haematoma

Regurgitation and aspiration

(consider jejunal placement)

Death Ileus, abdominal bloating,

diarrhoea

Tube migration/extubation

Anorexia

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142 Chapter 11

can present a significant challenge. These problems can be

addressed by alteration of feed type and mode of feeding.

Close liaison with the Community Home Enteral Nutrition

team is essential.

Parenteral Nutrition

If the gut is functional use it! Parenteral nutrition (PN) is

not physiological and is fraught with pitfalls. PN is never

an emergency. Electrolytes and micronutrients must be

corrected to prevent the re-feeding syndrome in malnour-

ished patients.

In the United Kingdom, most home PN is given for

intestinal failure due to the short bowel syndrome. In parts

of Europe and the United States however, the bulk of home

PN is provided for malignant disease. There is, however,

no convincing evidence that PN enhances either quality of

life or survival in patients with advanced malignancy.

Patients with advanced cancer who currently receive PN in

the United Kingdom have usually either been commenced

on it before diagnosis or before potentially curative

treatment and have continued on it. PN may occasionally

be used in cancer patients who have intestinal failure

(complete bowel obstruction) with no other disease spread;

further guidance can be taken from the ESPEN guidelines

for clinical nutrition in cancer [22]. For patients with

cachexia due to advanced nonmalignant disease, the place

of PN is equally uncertain. This is an area of practice that

is likely to continue to challenge us all in the coming years.

Care for patients with oral feeding difficulties should

have their needs carefully assessed by the MDT. As far as

possible the oral route should be preserved by detailed

assessment and modification of food and liquid to facili-

tate maintenance of oral nutrition.

Mouth Care

Mouth care is very important. Studies have shown that in

the elderly aspiration pneumonia is related to poor oral

hygiene [19, 20]. The aim of oral hygiene is to keep the lips

and oral mucosa clean, soft, and intact and the basis for

this is daily tooth brushing, dental flossing, and

consideration of a mouth wash (one teaspoonful of sodium

bicarbonate per large cup of water). Commercial mouth-

washes may cause pain in patients with stomatitis since

they contain alcohol, lemon, and glycerine.

Oral complications including a dry mouth (xerostomia)

are common and a major problem for many patients with

advanced disease [22]. Saliva helps us to chew, talk, and

swallow. It protects against infection and begins digestion

of food. Normally about 1–1.5 L of saliva containing

not successful, rest and repeat in 30 min. Do not force flush

the tube.

• Pancreatic enzymes such as Pancreatin only help if the

blockage is due to feed [18].

•

If all attempts fail, seek specialist advice or replacement.

Many patients do not feel it is necessary to continue with

mouth care if not eating and drinking orally. However, daily

oral, dental, and pharyngeal hygiene will help to minimize

incidence of oral thrush, tooth decay, and halitosis.

Evidence also suggests oropharyngeal microorganisms can

migrate into the respiratory tract causing infections [19,

20].

PEG Care

To minimise the risk of infections the puncture site (stoma)

requires daily cleaning with warm soapy water. Discharge can

be common and is not always indicative of an infection.

Dressings may assist in managing the discharge however

should be balanced with the risk of infections caused from ideal

breeding conditions. The Home Enteral Nutrition team and/or

District Nurse can support the patient and provide advice.

Trouble Shooting

The tube can be displaced regardless of the type of fixation

device used. In the United Kingdom, National Patient

Safety Agency (NPSA) put out a Rapid Response Alert in

2010, recommending that in the first 72 h.

If there is pain on feeding, prolonged or severe pain post-

procedure, or fresh bleeding, or external leakage of gastric

contents, stop feed/medication delivery immediately,

obtain senior advice urgently and consider CT scan, con-

trast study, or surgical review [21].

If late displacement occurs (i.e., once the tract is mature),

the stoma tract can potentially close within hours. Some

Home Enteral Nutrition teams have staff competent in

changing balloon gastrostomies and may be available for

immediate support, or the patient should be instructed to

go to hospital as soon as possible bringing spare tubes if

available. If indicated a urinary Foley catheter can be

inserted to maintain the integrity of the tract.

Gastroesophageal reflux is common and can be treated

with a PPI. Positional change and avoidance of overnight

continuous feeding is also helpful. Aspiration occurs fre-

quently in both NG and PEG feeding and may present with

pneumonia. Patient position, type of feed and prokinetic

medication may be useful. Jejunal feeding may benefit

patients with persistent problems.

Nausea, bloating, and cramps occur frequently.

Diarrhoea occurs in approximately 30% of patients and

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The Management of Gastrointestinal Symptoms and Advanced Liver Disease 143

Management of Xerostomia

Table 1 outlines the measures that may help patients with

dry mouths. Sialogogues increase the production of saliva,

and chewing gum (sugar free) has been shown to be help-

ful and liked by patients with advanced cancer who are

able to produce some saliva [23]. Most salivary substitutes

provide relief for only a short time, and those that contain

mucin improve symptoms more than those that don’t.

However, the mucin is derived from pigs and may there-

fore not be suitable for some patients. Salivary substitutes

that have a low pH may cause demineralisation of teeth.

A few additional tips: Salivary substitutes should be

applied or sprayed beneath the tongue and between the

buccal mucosa and the teeth (i.e., mimic the pooling of

saliva) and not in the back of the throat, the mouth should

be moistened with water before spraying; lemon and glyc-

erine swabs and mouthwashes containing glycol should

not be used due to adverse effects of irritation and rebound

drying effects; moist cotton swabs (e.g., Moistir) or sponge

swabs on sticks dipped in water may help very frail patients.

Cholinergic agonist agents such as pilocarpine have

been shown to increase saliva production post-irradiation.

It is very useful in patients with post-radiotherapy xerosto-

mia in head and neck cancer (start with 5 mg TDS with

meals). However, it is often poorly tolerated, usually

because of sweating or GI side effects. It is contraindicated

in obstructive airways disease and asthma.

Prevention and Management of Oral

Infections

Thrush

Attention to the care of the oral cavity, teeth, and dentures

will help minimise infection. Patients on steroids, antibi-

otics, or those who have diabetes are at particular risk.

Thrush is the commonest infection. Candida prefers an

acid environment and sodium bicarbonate mouthwashes

repeated regularly (2 hourly), coupled with gentle

amylase and bicarbonate are produced daily. A reduction

in this is most commonly a side effect of drugs (e.g., opi-

oids, antihistamines, anticholinergics, diuretics, beta

blockers, and anticonvulsants) but dehydration, anxiety,

and mouth breathing also result in a dry mouth. Patients

who have had radiotherapy to the head and neck may have

considerable problems with dry mouth, altered anatomy,

and function leading to debris accumulation and pain.

Dentures in patients who have lost weight can become ill-

fitting and cause soreness and abrasions.

As well as keeping the lips and mucosa moist, clean and

intact patients may need extra mouth care in order to:

• prevent infection;

• alleviate pain and discomfort thus enabling greater oral

intake;

•

prevent halitosis;

• enhance taste and appetite;

• facilitate speech; and

• minimise psychological distress.

Table 1 A summary of approaches to the management of a dry mouth.

General measures Cleanliness/tongue coating Salivary substitutes Increased salivary secretion

Sips of water Pineapple Carboxymethycellulose Chewing gum

Pilocarpine

5 mg TDS with or after food

Ice poles

Brushing with soft toothbrush

Moistened sponges on stick

Mild bicarbonate mouth wash

Effervescent vitamin C Mucin

Key Point in Mouth Care

The frequency of mouth care is of greater importance than

what is used to clean it.

Painful Mouth

Mouth ulcers can be helped by choline salicylate gel

(Bonjela) or, if persistent, corticosteroid in the form of a

hydrocortisone buccal tablet (2.5 mg), dissolving slowly in

contact with the ulcer up to four times a day. The bioad-

herent gel, Gelclair, can also sooth and promote healing.

A sore mouth, from whatever cause, may be helped by

sucking anaesthetic lozenges or using local anaesthetic

mouthwashes or sprays. Severe pain may require opioid

analgesia often by subcutaneous (SC) rather than oral

administration.

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144 Chapter 11

• Hyoscine hydrobromide (Kwells), 1–2, tablets sublin-

gually QDS.

•

Hyoscine hydrobromide SC 1.2–2.4 mg/24 h.

• Hyoscine butylbromide SC 40–120 mg/24 h (less

sedating than hydrobromide).

•

Glycopyrronium bromide SC 0.6–1.2 mg/24 h (less

sedating than hyoscine hydrobromide).

Nebulized water or saline may help reduce the tenacity

of mucus secreted by the cancer, and nebulised local anaes-

thetic (5 ml of 0.25% bupivacaine) may be helpful in very

advanced disease if the pharynx is dysfunctional and swal-

lowing of saliva or mucus results in aspiration with dis-

tressing bouts of coughing.

Endoluminal Recanalisation

Exophytic growth of tumours into a lumen will lead to

obstruction. Endoscopic procedures that recanalise the

oesophagus may offer alternatives or additional options to

endoluminal stenting (see following section) for dysphagia:

• Argon plasma coagulator (APC): This is a safe and effec-

tive method. APC provides predictable penetration of

normal and abnormal mucosa. The equipment is relatively

cheap and has multiple other applications. The main draw-

back is that it may take a number of sessions to achieve the

desired outcome.

• Laser (YAG): Not widely available and has statutory

restriction on its use. Very “powerful” with limited room for

er ro r.

•

Injection of absolute alcohol: Cheap with good results if

injected into exophytic tumour. It usually requires multiple

sessions and can give rise to mediastinal discomfort at the

time of injection. Will cause ulceration of the normal

mucosa if injected into it.

• Dilatation: Useful for constrictive rather than exophytic

tumours. Dilatation can be done with bougies over a guide

wire or balloons under direct vision. Balloon dilation of

the oesophagus, pylorus, duodenum, and colon can be

undertaken. The perforation rate is 1–5%.

A combination of the above modalities focused on the

nature of the individual clinical problem should be employed.

Nausea and Vomiting

Nausea and/or vomiting are common in advanced disease

and can be a major cause of poor quality of life. The preva-

lence in patients with advanced cancer is up to 70% and up

to 50% in those with advanced non-malignant disease

[24]. The symptoms may be more distressing than pain.

brushing of the teeth (or cleaning dentures) twice per day

is effective prevention [23].

Established thrush is treated with nystatin or micon-

azole topically. Patients should be instructed to keep the

gel or suspension in contact with as much of the oral

mucosa as possible, for as long as possible. Ice lollipops

made with diluted nystatin are soothing and engender a

long duration of mucosal contact. Miconazole acts both

topically and systemically. If the patient is severely

affected, has symptoms suggestive of oesophageal infec-

tion, or is taking antibiotics and/or steroids a systemic

antifungal is indicated; for example, fluconazole 50 mg

OD for 7–14 days, or itraconazole 100 mg OD for 10–15

days. To avoid reinfection, dentures must be cleaned in

Sterident or Milton with or without nystatin. If oral

thrush persists then mouth swabs should be taken to

evaluate further.

Herpes Simplex

Herpes simplex infections present as very painful, vesicular,

and ulcerating lesions. Oral acyclovir 200 mg five times

daily, or valacyclovir 500 mg BD for 5 days is indicated.

Oesophageal Problems

Swallowing may be difficult for patients with oesophageal

cancer for several common reasons:

• Oesophageal compressive and/or obstructive lesions

• Functional dysphagia

• Odynophagia (painful swallowing)

• Oro-Oesophageal thrush.

In addition, patients may experience copious thick,

tenacious mucus, which may also cause coughing.

Treatment options include surgery (not for disease

with metastatic spread), external beam and endoluminal

radiotherapy, chemotherapy, endoscopic recanalisation,

and expanding metal stents. Endoscopic interventions

are discussed below. General symptom control is vital

whatever the cause of obstruction or possibility of

intervention.

Pain should be managed by the standard titration of

analgesics as per the World Health Organisation (WHO)

analgesic ladder. Strong (non-oral) opioids, such as SC dia-

morphine/morphine or transdermal fentanyl, may be

required to control background pain. Sucralfate will coat

ulcerated tumour and may reduce bleeding and pain.

In total obstruction of the oesophagus, coping with

saliva and secretions can be distressing for the patient. The

following may be helpful:

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The Management of Gastrointestinal Symptoms and Advanced Liver Disease 145

Control of symptoms using one antiemetic is possible in

60% of patients. However, about one-third of patients

require concurrent administration of a second antiemetic.

In these patients antiemetics of different mechanisms of

action should be combined (e.g. cyclizine and haloperidol).

A third-line choice would be a broader spectrum anti-

emetic, which has risks of more side effects. This is dis-

cussed further below under the section “Persistent nausea

and vomiting.”

Acupuncture and ginger are two commonly used com-

plementary techniques. Other approaches such as relaxa-

tion therapy, hypnosis, or neurolinguistic programming

(NLP) are invaluable for patients with a high degree of

anxiety or to combat the anticipatory nausea induced by

chemotherapy treatments.

Table 2 provides a quick view of the range of antiemetics

and gives prescription guidance.

Five components are the key to management:

1. Careful assessment of the patient to try and identify

possible avoidable and reversible aetiologies.

2. Knowledge of common syndromes.

3. Reversal of the reversible (where appropriate).

An understanding of the mechanism of action of anti-

emetic drugs (Figure 2).

5. Consideration of the route of administration of anti-

emetic and other drugs. Since nausea can cause gastric

stasis, the SC or rectal routes may be needed even when

there is no vomiting.

Figure 3 outlines the management. An aetiological based

approach to management generally underpins most guide-

lines although an empirical-based approach may be as

effective [24, 25]. Generally the first-line choice of anti-

emetic is one of metoclopramide, haloperidol, or cyclizine.

Figure 2 A schema of the pathways of

emesis (nausea and vomiting), important

neurotransmitters, and site of action of

antiemetics. The neurokinin receptor and

antagonist is not shown as this is an area

of specialist only prescription in oncology.

Receptor types – GABA; H, histamine;

D, dopamine; Ach(m), acetylcholine

muscarinic; 5HT, serotonin (5-hydroxy-

tryptophan). Subscript denotes receptor

subtype:+denotes agonist or enhancing

stimulus;−denotes antagonist or blocking

stimulus; ? denotes limited evidence for

effect through this mechanism.

https://t.me/med1917

146 Chapter 11

the stomach. It is also common in patients with advanced

congestive cardiac failure because of ascites and in patients

with diabetics because of autonomic neuropathy. It is a

component of the nausea induced by opiates. Nausea is of

varying intensity. It may be very transient, just before vom-

iting and is often relieved by vomiting. The vomitus can be

Common Syndromes of Nausea and

Vomiting and Their Management

Gastric Stasis and Outflow Obstruction

This is common in patients with GI malignancy because of

ascites, liver enlargement, and direct effects of tumour on

Think—why is this

patient vomiting?

In light of your

assessment;

reverse the

reversible, use the

most appropriate

non drug and drug

methods to control

it (see table)

If prescribing an

antiemetic, then

must have a very

good reason to use

oral route

Explain to patient

and family and

review the patient

early

A reasoned judgment as to the cause of a patient’s nausea and/or vomiting

is important in controlling this symptom. Consider:

• the disease process itself

• complications of the disease process

• side effects of drugs

• previous drugs used

• complications of other treatments

• psychosocial factors

• the characteristics of the nausea and vomiting

If you cannot discern a reason for

your patient’s nausea and vomiting

Other drugs

Domperidone

10–20 mg tds oral

25–50 mg tds oral

Metoclopromide

10–20 mg tds oral

30–90 mg/24 h SC

Laxative and

glycerine or

bisacodyl

suppositories

Cyclizine

50–100 mg/24 h SC

Trial of octreotide

200 µg up to

600 µg/24 h SC

Classifications

Upper GI

stasis/outflow

obstruction

Unknown

cause

Chemically

induced

Constipation

Raised

intracranial

pressure

Intestinal

obstruction

Anxiety

Causes

• Tumour

• Anticholinergic

drugs

• Hepatomegaly

• Drugs

• Metabolic

• Toxic

• Drugs

• Because of

cancer

• Immobility

• Cerebral mets

• Cerebral

hemorrhage

• Malignant

• Nonmalignant

• Any cause

First-line drugs

Metoclopramide

10–20 mg tds oral

30–90 mg/24 h SC

Cyclizine

50–100 mg/24 h SC

Levomepromazine

6mg OD oral

6.25 mg–25 mg/24 h SC

Haloperidol

1.5–5 mg oral

1.5–5 mg/24 h SC

Stimulant and

softening laxative

(e.g., senna 15 mg at

night and sodium

docusate 200 mg

twice daily)

Trial of steroids

Dexamethasone

8–16 mg/24 h

oral/SC/IV

Hyoscine

butylbromide

60–120 mg/24 h SC

Diazepam

2–5 mg tds

Characteristics

• Epigastric

discomfort

• Worse on eating

• Eased by vomiting

• Variable nausea

• Constant nausea

• Variable vomiting

• Nausea and

feculent vomiting

• Nausea worse

in the morning

• Projectile vomiting

• Worse on head

movement

• Vomiting with

abdominal pain,

distension, and

constipation

• Symptoms worse

when anxious

Figure 3 Summary of the approach to the management of nausea and vomiting.(Adapted from Faull C and Woof R. 2002. Palliative Care:

An Oxford Core Text with permission from the publishers Oxford University Press.)

https://t.me/med1917

The Management of Gastrointestinal Symptoms and Advanced Liver Disease 147

not yet established. These drugs are also used in the post-

operative period.

Raised Intracranial Pressure

Nausea may be worse in the morning, and the vomiting

can be projectile in nature. Nausea and vomiting provoked

by head movement is associated with vestibular pathway

aetiology. There is usually headache, which may be worse

in the morning. Neurological signs may be absent. Steroids

and cyclizine are the treatments of first choice. If there are

signs of vestibular pathway aetiology, hyoscine hydrobro-

mide may be useful.

Persistent Nausea and Vomiting

Thirty percent of patients require the concurrent use of

two antiemetics. These should be selected for different

mechanisms of action that are compatible in effects.

Haloperidol with cyclizine is a good choice. Both cycli-

zine and hyoscine hydrobromide will counteract the pro-

kinetic effect of metoclopramide and domperidone but

will not counteract the central antiemetic effect of

metoclopramide.

Alternatively, low-dose levomepromazine can also be

useful. It is a “broad-spectrum” antiemetic (antihistamine,

anticholinergic, anti-dopaminergic, and serotonin antago-

nist activity) and in low doses does not generally cause

troublesome sedation or hypotension.

Corticosteroids are potent antiemetics although their

mechanism of action is not fully understood. They are

thought to potentiate the effects of other antiemetics but

of considerable volume and may contain undigested food.

Vomiting may be provoked by movement of the torso. A

succussion splash and other features of autonomic failure

may be present.

Metoclopramide or Domperidone are the drug treat-

ments of choice. Erythromycin may be helpful in a few

patients but needs to be given intravenously. Flatulence

may be relieved with dimethicone.

In complete obstruction prokinetic drugs should be

stopped. PPIs may be helpful in reducing acidity and

volume of secretions. A NG tube (for aspiration or free

drainage) may help to relieve symptoms and is tolerated

well by some patients but many prefer to have intermittent

vomiting and no NG tube, especially if nausea is con-

trolled. Insertion of a gastrostomy tube (see previous sec-

tion) for venting purposes has been found to be effective

and acceptable but is not commonly used in the United

Kingdom [26].

Chemically Induced Nausea

A vast array of drugs cause nausea. The initiation of opi-

oids causes nausea in up to 30% of patients but usually set-

tles within 3–4 days although it can reappear with an

escalation of dose, and it persists in a small percentage of

patients. Metabolic causes of nausea are common in

advanced disease: renal failure, liver failure, hypercalcae-

mia, hyponatraemia, and ketoacidosis. Anti-dopaminergic

are the drugs of choice, for example, haloperidol. 5HT3

antagonists are useful for highly emetogenic chemotherapy

and perhaps in cases of intractable vomiting of metabolic

cause, but their cost-effectiveness in other circumstances is

Table 2 Antiemetic prescription.

Drug Oral dose Subcutaneous dose Rectal dose

Metoclopramide 10–20 mg TDS 30–90 mg/24 h

Domperidone 10–20 mg TDS –

Levomepromazine 5–25 mg OD 6.25–25 mg/24 h, may be given once daily

Haloperidol 1–5 mg OD 1.5–5 mg/24 h, may be given once daily

Ondansetron 8 mg BD 8–16 mg/24 h 16 mg OD

Granisetron 1–2 mg OD 1–2 mg/24 h

Cyclizine 50 mg TDS 50–100 mg/24 h

Prochloperazine 3–10 mg TDS Not suitable

Hyoscine hydrobromide 300 μg QDS

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