Management of gastrointestinal symptoms

Loss of appetite

Loss of appetite or anorexia is common during treatment for cancer and at the end of life. The treatment always depends on causative factors and the overall distress the symptom is causing the pa­tient.

The difficult issue for end of life palliative care is the social and cultural meaning attached to eating and feeding the sick that can make it difficult for patients and families to accept that lack of hydra­tion or reduction in eating is normal in the course of the transition to death. Provision of hydration or other forms of intravenous nutri­tion does not change the outcome or the quality of life (19).

Discussions with the patient and family about hydration and nu­trition form an important part of understanding the process of dying and should be part of the care offered. Sometimes judicious use of intravenous solutions with dextrose, or subcutaneous saline, can be helpful if the patient and family cannot overcome their beliefs and the distraction of their concern about failing to feed their loved one is keeping them from focusing on each other and the other tasks of transitioning to death.

Constipation

Constipation can be a major source of discomfort and nausea, and active management is warranted for prevention, as long as there is no underlying bowel obstruction. The most common source of con­stipation for women receiving palliative care is from other drug use, primarily opioid use for pain control.

Generally, stimulant therapy with senna or bisacodyl should be started concurrently with opioid use and additional agents added as needed to manage constipation. In the setting of palliative care where hydration is limited, the use of bulking agents such as psyl­lium or methylcellulose should be limited as they require hydration for efficacy. Non-absorbed laxatives such as lactulose can be added to find an ongoing balance. Enemas are also helpful, depending on the type of constipation and location. In some cases of severe and

Nausea and vomiting

Nausea and vomiting are common end of life and palliative chal­lenges in women with gynaecological cancers. There are mechan­ical, metabolic, as well as pharmacological aetiologies for this. With ovarian cancer, gastroparesis, large and small bowel involvement, as well as frank obstruction may cause significant nausea. With cer­vical cancer, nausea may be more derived from large bowel, anal, or sigmoid obstruction. If there is a clearly distinct area of obstruc­tion and the patient is otherwise stable, a surgery with limited risk (e.g. loop colostomy) and limited recovery needs may offer palliative relief. Unfortunately, there are often multiple areas of involvement which make surgical options unacceptable. Colostomies or ileos­tomies should be considered as a preventative measure while the patient is well enough or to palliate conditions such as rectovaginal or vesicovaginal fistula where a diversionary procedure is likely to bring a significant relief of symptoms without too much morbidity. However, some patients may not find them acceptable under any circumstances. Other options if available may include gastric per­cutaneous drainage systems placed with endoscopic or surgical ap­proaches or gastrointestinal stents in rare circumstances.

Nausea due to opioids is usually short lived and avoided by using antiemetics such as metoclopramide at the initiation of therapy. Pharmacological management for pain with opioids and other medications can add to the symptoms and as more pain medications or nausea medications are added, the resulting constipation further complicates the picture. Seeking a balance and an optimal plan for management of bowel function along with other symptoms is highly individual and needs frequent revision and tailoring to changes in patient status. Standard treatments exist for most sources of nausea and vomiting such as metoclopramide for gastroparesis, octreotide and glucocorticoids for bowel obstruction symptoms, relieving pressure symptoms with ascites with a port or repeated paracenteses (22), haloperidol for hepatic dysfunction and other metabolic dis­turbances, and cyclizine for brain metastases. Antiemetics used for nausea should work around the clock and, like a pain management strategy, have a strategy for breakthrough nausea and vomiting that allows for escalation of therapy.

Faecal incontinence and fistula management

The uncontrolled leakage of bowel contents occurs with faecal in­continence and enterocutaneous and enterovaginal fistulas in women with gynaecological malignancies. In the palliative care setting, where no further surgical intervention is appropriate, the introduction of suction-based or negative pressure wound man­agement systems has allowed for better control of enterocutaneous fistulas and limited the skin exposure to the often highly caustic material. Lacking access to these approaches, ostomy management with ostomy bags and careful skin protection can limit skin break­down and pain but can be difficult with high output small bowel enterocutaneous fistulas (23).

Enterovaginal fistulas are perhaps the hardest to treat as there is no firm surface on which to place a negative pressure or ostomy bag de­vice and the area is too moist to allow for durable seals. Variations of devices based on a vaginal diaphragm model have been trialled over decades with generally poor management because of the pelvic dis­tortion due to the cancer and/or treatment (surgery and radiation) as well as the other challenges. The best approach is an aggressive approach to skin management in the perineum with skin protective gels and creams applied after gentle cleansing and drying. Often top­ical lidocaine or other analgesic creams or burn creams (e.g. silver­based creams) can assist in relieving pain from these fistulae.

Faecal incontinence as a result of other treatments where the gastrointestinal system is intact can be treated with diet as well as loperamide and psyllium with nearly equal efficacy (24).