Nausea Vomiting and Diarrhea and Bowel Obstruction
- 1. Dr. Viney Kumar Assistant Professor Department of Radiation Oncology Himalayan Institute of Medical Sciences Management of Nausea, Vomiting, Malignant Bowel Obstruction
- 2. • 40-70% patients with cancer. • 20-50% on other terminal chronic diseases like AIDS, CKD, CHF. • Affects patients daily functioning & Quality of Life. • Active Palliative management is important. • Can be controlled in 90% of patients.
- 3. DEFINITION • “Nausea is an unpleasant feeling of the need to vomit, often accompanied by autonomic symptoms (sweating, tachycardia)” • Vomiting is the forceful expulsion of gastric contents through the mouth • Prolonged nausea and vomiting can lead to debility, nutritional deficits, dehydration, electrolyte imbalance and aspiration pneumonia.
- 8. Management of Nausea and Vomiting A. Mechanism-based: • Determine likely etiology and target first medication to the cause • 80-90% effective in the palliative care population • Assesses all causes systematically B. Empiric : • Typically, multiple etiologies • Start with a 5HT3 antagonist (ondansetron) or dopamine antagonist (eg haloperidol) regardless of underlying etiology
- 11. Review dose after 24 hours. If it still persist after 24- 48 hours, review cause. If on parenteral therapy, consider converting to oral after good control to oral regimen. General Measures
- 12. Drugs used in Nausea and Vomiting
- 13. Drugs used in Nausea and Vomiting
- 14. Opioid induced Nausea & Vomiting • Haloperidol and Metoclopramide are first line drugs • Treat aggressively with one or more antiemetic before reducing Opioid doses.
- 15. Drug Induced Nausea and Vomiting • Chemotherapy- Induced • Radiotherapy- Induced These show Emetogenic effect
- 16. Chemoradiotherapy induced nausea and vomiting: Risk factors High dose Receiving chemotherapy and radiation therapy at the same time. Females especially younger than 55 years. H/o nausea and vomiting after chemotherapy or radiation therapy Motion sickness or vomiting with a past pregnancy. Fluid and/or electrolyte imbalance.
- 18. NSAIDs Induced Nausea and Vomiting
- 20. Non-Drug Therapy Behavioral approaches- relaxation, imagery, music, distraction Dietary measures Frequent small meals Avoid fatty / sweet / spicy food Avoid fibre Avoid carbonated drinks Cold, bland food and clear fluids Control of malodour from colostomy, fungating tumor, decubitus ulcer etc Calm environment away from sight and smell of food. Patient should avoid cooking himself
- 21. Management – Failure to respond • Multiple mechanisms • Inadequate dose • Poor absorption • Incomplete or wrong diagnosis • Poor compliance • Un-recognised emotional/psychological factors
- 22. Nausea and vomiting may be due to the primary disease, treatment sequelae (medication, anti-cancer therapies) and co-existing disease. Key to the effective management of nausea and vomiting is a through assessment and appropriate investigations to establish and where possible correct reversible causes. KEY POINTS
- 24. DEFINITION • Malignant bowel obstruction (MBO) is defined as luminal narrowing of small or large bowel with clinical evidence of bowel obstruction in the setting of metastatic or intra-abdominal cancer. • common in patients with abdominal or pelvic cancers • It is most prevalent in ovarian cancer (5.5-42.0 %), colorectal cancer (4.4-24%). • Uncommonly, metastases from extra-abdominal cancers, including breast cancer, lung cancer, and melanoma, can also cause MBO.
- 25. MAJOR CAUSES
- 26. PATHOPHYSIOLOGY • Mechanical compression (extrinsic and intrinsic ) • Motility disorder • Gastrointestinal secretion accumulation • Decrease intestinal absorption • Peri-tumoral inflammation
- 27. CLINICAL PRESENTATION • Crampy, paroxysmal abdominal pain • Loss of appetite, nausea/ vomiting • Inability to have a bowel movement or pass flatus • Abdominal Bloating.
- 28. INVESTIGATIONS PLAIN ABDOMINAL X-RAY • Multiple fluid level may be unremarkable because tumor encasement of the bowel wall may prevent the classical sign of bowel dilatation seen in non-maligant bowel obstruction. Small Bowel Obstruction
- 29. • Small bowel contrast: Using either barium or gastrograffin opinions are divided on this. • Ba Enema: • If this shows obstruction in addition with small bowel blockage this suggests multiple levels of obstruction consistent with carcinomatosis •Enteroclysis Studies • Duodenum is intubated directly under fluoroscopy and contrast injected directly under pressure. Needs an expert in this procedure
- 30. •CT-Scan: • This is essential in all cases of MBO if surgical treatment is being considered. • It is now the gold standard in diagnosing malignant bowel obstruction. • Sensitivity: 78 –100% • Specificity: > 90% • These will show the sites of obstruction, possible bowel strangulation or ischaemia. Small bowel obstruction caused by metastatic ovarian carcinoma on CT scan
- 32. PRIMARY GOAL OF TREATMENT • Reduce symptoms of nausea or vomiting or pain • Increase oral intake of patient • Return patient home or a nursing facility
- 33. NON-OPERATIVE TREATMENT 1.NASO-GASTRIC TUBE DRAINAGE ; Nasogastric tube This is very uncomfortable. Used only on a time-limited basis for decompression. 2. IV FLUID; REHYDRATE. 3. NUTRITION; PARENTERAL 4. PHARMACOLOGICAL ; The goals are: • Reduce pain; • Check nausea, • Check vomoting, • Intestinal inflammation and oedema
- 34. PHARMACOLOGICAL OCTREOTIDE (Somatostatin Analogue) • Reduces G. I. Secretions, increases smallbowel transit time, delays onset of oedema and ischaemia in anti- mesenteric border of intestines. • Response is-75 – 100% • Dose: 0.3 – 0.6 mg/day (S/C)
- 35. ANTIEMETICS: Oral medications should be avoided because of vomiting. • Prochlorperazine given rectally • Promethazine given rectally • Hydroxyzine given rectally • Haloperidol given subcutaneously. • Haloperidol is believed to be the drug of choice, for it controls nausea, vomiting and agitated delirium. With anti-emetics, complete relief of emesis is achieved in only 30% of patients.
- 36. ANTICHOLINERGICS • They decrease peristalsis, secretions, vomiting and intestinal colic • Scopolamine might be more cost effective than Octreotide. It is given subcut or as a transdermal patch CORTICOSTEROIDS • This reduces peritumoral oedema, • Activate central and peripheral anti-emetic effect • It is co-analgesic in intestinal obstruction related pain. Dexamethasone dose is 2 – 60mg per day. Usually prescribed for terminal patients.
- 38. SURGICAL TREATMENT • Operative Mortality = ( 5 – 32%) • Operative Morbidity = (42%) • Re-obstruction = (10 – 50%) • Therefore proper consideration must be given before performing surgery. NO RUSH TO SURGERY. • Obstruction usually partial • Gangrenous bowel is rare
- 39. SURGICAL OPTIONS The quickest and the safest is preferred • RESECTION with or without anastomosis • INTESTINAL BY-PASS especially for radiation-induced obstruction • INTESTINAL STOMA, enterostomy, entero-colostomy,entero- gastrostomy • GASTROSTOMY is essentially for drainage to relieve nausea and vomiting which are really very troublesome symptoms.
- 41. ENDOSCOPIC TREATMENT • Usually for a single site obstruction • Patients NOT fit for operation • Extensive disease • Patients refusing operation • SEMS show success of about 90%. Show to maintain patency longer.
- 42. • PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) • Usually well tolerated • Alleviate nausea and vomiting • Allows intermittent oral intake. • Patients with ascites are poor candidates for PEG
- 43. ALGORITHIM FOR MANAGEMENT OF MBO
- 45. CONCLUSION • MBO is a common and difficult problem. • Objectives are to relief pain, nausea,vomiting, early removal of N/G tube, • keep patient out of the hospital as much as possible and to restore ability to eat. • Non-surgical interventions should be considered in all patients. • The decision to pursue surgical vs non-surgical treatment hinge on variety of factors ; general patient condition and the extent of the malignancy.