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Seminar in Palliative Care

Seminar in Palliative Care. September 26 – October 02, 2010 Salzburg, Austria in Collaboration with. The. EPEC-O. TM. Education in Palliative and End-of-life Care - Oncology. Project.

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Seminar in Palliative Care

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  1. Seminar in Palliative Care September 26 – October 02, 2010Salzburg, Austria in Collaboration with

  2. The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

  3. Constipation Eugenie A.M.T. Obbens, MD PhDPain & Palliative Care ServiceMemorial Sloan-Kettering Cancer Service

  4. Constipation . . . • Straining • Hard stool • Sensation of • Incomplete evacuation • Anorectal obstruction • Fewer than 3 BM / week • 12 weeks duration > 2 symptoms

  5. . . . Constipation Epidemiology • Impact: abdominal discomfort / pain, nausea and vomiting • Prevalence: up to 90 % among cancer patients treated with opioids • Prognosis: can limit prognosis if untreated • Management always possible

  6. Key points • Pathophysiology • Assessment • Management

  7. Medications Opioids Calcium-channel blockers Anticholinergic Decreased motility Ileus Mechanical obstruction Metabolic abnormalities Spinal cord compression Dehydration Autonomic dysfunction Malignancy Pathophysiology

  8. Assessment • Specifically ask about bowel function • Establish what is normal for patient

  9. General measures Regular toileting Gastrocolic reflex Activity Specific measures Softeners Osmotics Stimulants Lubricants Large volume enemas Management

  10. Stool softeners( Detergent laxatives ) • Sodium docusate • Calcium docusate • Phospho-soda enema PRN

  11. Stimulant laxatives • Prune juice • Senna • Casanthranol • Bisacodyl

  12. Osmotic laxatives • Lactulose or sorbitol • Milk of magnesia ( other Mg salts ) • Magnesium citrate • Polyethylene glycol Lederle FA, et al. Am J Med, 1990. Attar A, et al. Gut, 1999.

  13. Lubricants / enemas • Glycerin suppositories • Phosphate enema • Oil retention enema • Tap water, 500 – 1,000 ml

  14. Constipation fromopioids . . . • Occurs with all opioids • Pharmacological tolerance develops slowly, or not at all • Dietary interventions alone usually not sufficient • Avoid bulk-forming agents in debilitated patients Bagnol D, et al. Neuroscience, 1997.

  15. . . . Constipation fromopioids • Combination stimulant / softeners are useful first-line medications • Casanthranol + docusate sodium • Senna + docusate sodium • Prokinetic agents • Opioid antagonists Sykes NP. Palliat Med, 2000.

  16. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience

  17. Bowel Obstruction

  18. Bowel obstruction . . . • Definition: mechanical or functional obstruction of the progress of food and fluids through the GI tract

  19. . . . Bowel obstruction • Impact: misery from nausea, vomiting and abdominal pain

  20. . . . Bowel obstruction Epidemiology • Prevalence • 3 % of all advanced malignancies • 11 – 42 % ovarian cancer • 5 – 24 % colorectal cancer • Prognosis – poor if inoperable • 64 days Krebs HR, Goplerud DR. Am J Obstet Gynecol, 1987. Ripamonti S, et al. J Pain Symptom Manage, 2000.

  21. Key points • Pathophysiology • Assessment • Management

  22. Pathophysiology . . . • Intraluminal mass • Direct infiltration • External compression • Carcinomatosis • Adhesions • Other

  23. . . . Pathophysiology • 2 liters / day orally • 8 liters / day gastric & intestinal secretions • Obstruction causes accumulation • Peristalsis causes distention, pain, nausea, and vomiting

  24. Assessment • Symptoms • Continuous distension pain 92 % • Intestinal colic 72 – 76 % • Nausea / vomiting 68 – 100 % • Abdominal radiograph • Dilated loops, air-fluid levels • CT scan • Staging, treatment planning

  25. Differentiating small vs. large bowel obstruction

  26. Management . . .Medical • Opioids • Morphine – 89 % control • Antiemetics • Prochlorperazine – 13 % control • Steroids • Dexamethasone

  27. . . . ManagementSurgical • Surgical evaluation • Standard • Intravenous fluids • Nasogastric tube – intermittent suction • Inoperable • Stent placement • Venting gastrostomy

  28. Antisecretory agents

  29. Anticholinergics • Antispasmodic and antisecretory • Scopolamine • 10 – 100 mcg / hr SC / IV • 0.1 mg SC q 6 h and titrate • Glycopyrrolate • 0.2 - 0.4 mg SC q 2 – 4 h and titrate Baines M, et al. Lancet, 1985. Davis MP, Furste A. J Pain Symptom Manage, 1999.

  30. Somatostatin • 14 amino acid polypeptide • Serum half-life = 3 minutes • Central action • Inhibits release of GH and thyrotropin • Peripheral action • Inhibits glandular secretion • Pancreas, GI tract

  31. Octreotide . . . • Polypeptide analog of somatostatin • Serum half-life = 2 hr • Relieves symptoms of obstruction Ripamonti, et al. J Pain Symptom Manage, 2000. Mercadante, et al. Supportive Care Cancer, 2000. Fainsinger RL, et al. J Pain Symptom Manage, 1994.

  32. . . . Octreotide • Octreotide 10 mcg/h continuous infusion • Titrate to complete control of N / V • If NG tube in place, clamp when volume diminishes to 100 cc and remove if no N / V • Try convert to intermittent SC • Continue until death

  33. . . . Octreotide • Side effects • Mostly none • Dry mouth • Biliary sludge / stones • Studies in other palliative care settings • Subcutaneous administration

  34. Conclusions • Considerable symptom control challenge • Surgery for selected cases • Pharmacological management relieves symptoms in many patients • Antisecretory agents represent a significant advance

  35. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience

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