iPall: Learn Palliative Care
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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
  1. Develop a systematic approach to assessing and treating GI symptoms;
  2. Understand pharmacologic principles in management of GI symptoms, utilizing, when possible, a targeted therapy;
  3. Understand principles of palliative surgical and interventional approaches to management of GI symptoms;
  4. Educate and support patients, their families and other members of the interdisciplinary team on practical management of GI symptoms

General reading

  1. 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)
  2. 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).
  3. 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
  4. 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 ***
  5. Management of Constipation in Patients with Cancer (pdf) 
  6. Guidelines for treating N/V - Scottish/UK guidelines
  7. Chemotherapy-Induced Nausea and Vomiting - Hesketh P, NEJM 2008 DOI: 10.1056/NEJMra0706547
  8. 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
  9. 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

  1. Antimotility agents for chronic diarrhoea in people with HIV/AIDS Nwachukwu CE, Okebe JU. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005644.
  2. Chronic diarrhoea in AIDS Chronic diarrhoea in AIDS. Hicks S, Phillips A. Gut. 1997 Sep;41(3):417. PMID: 18668946
  3. 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

  1. Palliation of colorectal cancer Wasserberg N, Kaufman HS. Surg Oncol. 2007 Dec;16(4):299-310. Epub 2007 Oct 29.
  2. 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
  3. Current concepts in malignant bowel obstruction management Eric Roeland and Charles F von Gunten Curr Oncol Rep 11:298 (2009) PMID 19508835
  4. 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
  5. Surgical Approaches to Malignant Bowel Obstruction Lucy Helyer and Alexandra M Easson J Support Oncol 6:105 (2008) PMID 18402300
  6. 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
  7. 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
  8. 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
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