Overview
Gastrointestinal symptoms are common in patients with advanced illness.
Symptoms include: nausea/vomiting, anorexia, constipation, bowel obstruction, chronic diarrhea, ascites, tenesmus, proctitis, fistulas (entero-cutaneous, entero-vesicular).
I must admit that when I started my fellowship at San Diego Hospice, it was perhaps this topic that first caught my eye and made me realize the amount I did not know that July of the fellowship year. I, like many others, had no formal approach to managing nausea. I just tended to order the "latest and greatest" of antiemetic agent, thinking it must work for all types of nausea. I have come to appreciate a more targeted approach to managing this very common and distressing symptom.
Learning Objectives
Gastrointestinal symptoms are common in patients with advanced illness.
Symptoms include: nausea/vomiting, anorexia, constipation, bowel obstruction, chronic diarrhea, ascites, tenesmus, proctitis, fistulas (entero-cutaneous, entero-vesicular).
I must admit that when I started my fellowship at San Diego Hospice, it was perhaps this topic that first caught my eye and made me realize the amount I did not know that July of the fellowship year. I, like many others, had no formal approach to managing nausea. I just tended to order the "latest and greatest" of antiemetic agent, thinking it must work for all types of nausea. I have come to appreciate a more targeted approach to managing this very common and distressing symptom.
Learning Objectives
- Develop a systematic approach to assessing and treating GI symptoms;
- Understand pharmacologic principles in management of GI symptoms, utilizing, when possible, a targeted therapy;
- Understand principles of palliative surgical and interventional approaches to management of GI symptoms;
- Educate and support patients, their families and other members of the interdisciplinary team on practical management of GI symptoms
General reading
- Palliation of nausea and vomiting in malignancy*** doi: 10.7861/clinmedicine.6-2-144Clin Med March/April 2006 vol. 6 no. 2144-147(FREE ARTICLE)
- The EPEC-O CD-rom is a great resource for this chaplter. In particular, refer to modules 3b (anorexia), 3d (ascites), 3e (bowel obstruction), 3f (constipation), 3i (diarrhea), 3o (mucositis), and 3p (nausea).
- Treating nausea and vomiting in palliative care: a review Glare P, Miller J, Nikolova T, Tickoo R. Clin Interv Aging. 2011; 6: 243–259. Published online 2011 Sep 12. doi: 10.2147/CIA.S13109
- Management of Intractable Nausea and Vomiting in Patients at the End of Life: "I Was Feeling Nauseous All of the Time . . . Nothing Was Working" Markowitz and Rabow JAMA. 2008; 299: 1826 ***
- Management of Constipation in Patients with Cancer (pdf)
- Guidelines for treating N/V - Scottish/UK guidelines
- Chemotherapy-Induced Nausea and Vomiting - Hesketh P, NEJM 2008 DOI: 10.1056/NEJMra0706547
- Case 6-2005 A 58-Year Old Man with Esophageal Cancer and Nausea, Vomiting, and Intractable Hiccups - Eric L. Krakauer, M.D., Ph.D., Andrew X. Zhu, M.D., Ph.D., Brenna C. Bounds, M.D., Dushyant Sahani, M.D., Kevin R. McDonald, M.D., and Elena F. Brachtel, M.D. N Engl J Med 2005; 352:817-825 February 24, 2005DOI: 10.1056/NEJMcpc049037
- Common Gastrointestinal Symptoms in Pediatric Palliative Care: Nausea, Vomiting, Constipation, Anorexia, Cachexia Santuro and Mack, Pediatric Clinics of North America. 2007; 54: 673-689
HIV/AIDS related GI symptoms
- Antimotility agents for chronic diarrhoea in people with HIV/AIDS Nwachukwu CE, Okebe JU. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005644.
- Chronic diarrhoea in AIDS Chronic diarrhoea in AIDS. Hicks S, Phillips A. Gut. 1997 Sep;41(3):417. PMID: 18668946
- The Challenge of Chronic AIDS-Related Nausea and Vomiting Paul Han, Bob Arnold, Charles F. von Gunten. Journal of Palliative Medicine. March 2001, 4(1): 65-68. doi:10.1089/109662101300052040.
Surgical and Oncologic approaches to bowel obstruction, oncologic GI symptoms
- Palliation of colorectal cancer Wasserberg N, Kaufman HS. Surg Oncol. 2007 Dec;16(4):299-310. Epub 2007 Oct 29.
- Palliative Use of Percutaneous Endoscopic Gastrostomy and Percutaneous Endoscopic Cecostomy Tubes Holm AN, Baron TH. Gastrointest Endosc Clin N Am. 2007 Oct;17(4):795-803. Review. PMID: 17967383
- Current concepts in malignant bowel obstruction management Eric Roeland and Charles F von Gunten Curr Oncol Rep 11:298 (2009) PMID 19508835
- Surgical management of malignant bowel obstruction Krouse RS. Surg Oncol Clin N Am. 2004 Jul;13(3):479-90. PMID: 15236730 doi:10.1016/j.soc.2004.03.006
- Surgical Approaches to Malignant Bowel Obstruction Lucy Helyer and Alexandra M Easson J Support Oncol 6:105 (2008) PMID 18402300
- Treatment of malignant gastric outlet obstruction with endoscopically placed self-expandable metal stents Gaidos JK, Draganov PV. World J Gastroenterol. 2009 Sep 21;15(35):4365-71. Review. PMID: 19764086 DOI: 10.3748/wjg.15.4365
- Bowel obstruction in patients with metastatic cancer INTERNATIONAL JOURNAL OF GASTROINTESTINAL CANCER Volume 35, Number 2, 127-133, DOI: 10.1385/IJGC:35:2:127
- Detailing of gastrointestinal symptoms in cancer patients wi... : Current Opinion in Supportive and Palliative Care Abernethy, Amy P; Wheeler, Jane L; Zafar, S Yousuf Current Opinion in Supportive & Palliative Care: March 2009 - Volume 3 - Issue 1 - p 41-49 doi: 10.1097/SPC.0b013e32832531ce