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Gastrointestinal (GI) Problems

Problems swallowing (dysphagia) | nausea & vomiting | appetite loss (anorexia)/weight loss/cachexia | constipation | diarrhea | incontinence | bowel obstruction (update 1/17/2005)

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Among the most common problems of terminal illness are those of the gastrointestinal (GI) system. GI and related problems include problems swallowing (dysphagia), nausea, vomiting, appetite loss (anorexia), weight loss (cachexia), constipation, diarrhea, incontinence, and bowel obstruction.

Dysphagia (problems in swallowing)

Dysphagia may include difficulty swallowing, inability to swallow, drooling, pain (odynophagia), or frequent choking when swallowing. There may be difficulty swallowing solids only (including large pills) or difficulty swallowing solids and liquids. Some people are able to swallow when taking liquids slowly, and others have difficulty under any circumstances. There may also be differences in which liquids a particular person is best able to swallow.

Eating and quality of life are inextricably bound together, hence dysphagia has negative impact on the quality of life experience and if there is resultant decreased food intake, results in shortened life span. The use of a feeding tube is experienced by many patients as decreasing the quality of life. Dysphagia may also present immediate risk to life as aspiration is not uncommon among patients who are unable to adequately swallow.

Causes of dysphagia include dysfunction of the tongue or narrowing or lesions of the esophagus from infection, the presence of tumor, or as a sequela of treatment - especially radiation and surgery (including laryngectomy, tracheotomy, glossectomy, mandibulectomy, and others). Patients with head and neck cancer (pre and post treatment) are especially likely to experience dysphagia. Dysphagia in people with AIDS is most often due to esophageal candidiasis or cytomegalovirus infection. Neurological problems may be a cause of dysphagia in either cancer or AIDS.

Managing Dysphagia

When dysphagia is due to infection, medications are given according to the specific type of infection. Palliative management of dysphagia as the infection is resolving or when the dysphagia due to other causes (and is not total) include:

• The patient should rest in a sitting position before eating.
• The patient's head and torso should be kept elevated during meals and for at least 30 minutes after meals.
• In most cases, the head should be tilted slightly forward as the patient takes solids or liquids. Avoid tilting the head back to drink.
• Give only soft foods and the liquids that are best tolerated. Avoid hard or dry foods. Cut solids into small pieces. Liquids should be taken small amounts and at frequent intervals. It is better to offer small amounts of fresh liquids in a small glass rather than suggest the patient drink only a small portion from a large glass.
• Most patients have difficulty tolerating spicy, acidic, salty, sticky, and excessively hot or cold foods when dysphagia is caused by infection. Popsicles may give some symptomatic relief from pain due to infection.
• The patient should avoid alcohol and tobacco as these tend to worsen dysphagia.
• Having a suction machine available may help if choking is a problem.
• Medications may be given to decrease swelling or saliva production.
• Palliative radiation may give symptomatic relief in some cases.
• When the patient has a lengthy life expectancy, palliative surgery, including insertion of a tube in the esophagus, may be performed to allow swallowing or provide an alternative route for nutritional intake.

Nausea and Vomiting

Nausea and vomiting (N&V) is relatively common in cancer and AIDS. Nausea may range from vague abdominal discomfort to severe nausea and retching. The specific cause(s) of nausea and vomiting are often interrelated and difficult to determine or treat, and treatment is thus symptomatic in many cases. Physiologically, N&V occurs when the vomiting center (VC) of the medulla is stimulated by afferent impulses from one or more of the following anatomic areas:

• Chemoreceptor trigger zone (CTZ) which is stimulated by metabolic products produced by uremia, ketoacidosis, hypercalcemia; tumor generated toxins, chemotherapeutic agents; radiation; and opioids. Note that nausea and vomiting resulting from opioid use is usually a side effect of opioid therapy initiation and will resolve (tolerance to side effect) in most patients in less than a week. Needless to say, the N&V should be palliated until it resolves.
• Cerebral cortex which is stimulated by anxiety and thoughts (e.g., anticipatory nausea); sights, smells, and tastes; and increased intracranial pressure (>ICP) which causes vomiting without nausea.
• Vestibular system (the source of motion or position nausea) via the labyrinth of inner ear – the sensitivity of which can be increased by opioids.
• Upper GI tract stimulated by pressure, distension, obstruction, or irritation with impulses from vagus and splanchnic nerves as is common in gastrointestinal cancers, GI metastases, and other disease processes. GI tract stasis may also be affected by opioids and mechanical processes such as ascites.

N&V may be due to one or more of the above, e.g., opioid use can result in chemical stimulation of the CTZ, increased sensitivity of the vestibular system, and gastric stasis and decreased peristalsis. Specific etiologies of N&V in cancer or AIDS include:

Side effect (initiating) of certain medications, especially opioids such as morphine, codeine, hydromorphone, etc.: N&V from opioids begins when first starting opioid medications or switching from one opioid to another. It is critical to understand that N&V as an opioid side effect usually decreases after several days. In the meantime, medications and other measures are instituted to manage N&V.

Medication reaction: N&V is sometimes associated with taking medications other than opioids including digoxin, antibiotics, and NSAIDs (aspirin, ibuprofen, etc.).

Treatment sequela: N&V is common during cancer treatment, especially chemotherapy and brain and/or whole body radiation.

Hypercalcemia: N&V with anorexia, constipation, excess thirst and urination, and mental changes. Hypercalcemia is most common in cancer of breast and lung with bony metastasis; immobility and dehydration increase risk of hypercalcemia.

Bowel obstruction (usually lower intestine): N&V is accompanied or preceded by colicky (crampy, intermittent) abdominal pain, increased bowel sounds, abdominal distention, and diarrhea; and later, constipation. Bowel obstruction is most common in abdominal or pelvic tumors.

Increased intracranial pressure (ICP), i.e., increased pressure on the brain from tumor or fluid: N&V with progressive headache (especially before and shortly after arising from bed in the morning), changes in consciousness, weakness, and visual changes. Increased intracranial pressure is usually due to primary or secondary brain tumor(s) and/or related swelling.

Uremia (result of kidney failure): N&V with decreased urine output; cardiac changes, anorexia, sores in the mouth, blood in stool, diarrhea, constipation; lethargy and mental changes. Uremia (result of kidney failure) is most often associated with primary or secondary bladder, breast, or kidney tumor(s); or far advanced disease.

Pancreatic disease: N&V with anorexia and weight loss; phlebitis. Pancreatic disease may be due to primary or secondary pancreatic tumor.

Gastric irritation: N&V with abdominal pain and unexplained by previously noted causes. Gastric irritation is most commonly from carcinoma of stomach or acute GI infection unrelated to the primary disease

Other: Psychological distress, uncontrolled symptoms such as pain, and otherwise unexplained nausea and anorexia are all potential (but not inclusive) causes of N&V.

Managing Nausea and Vomiting

In addition to medical interventions directed to the etiology or etiologies given above, N&V is managed palliatively as follows:

• Medications are selected according to the process that causes N&V in a particular patient, and combinations of medications are sometimes required. Common medications for N&V include Compazine, Haldol, Reglan, Zofran, and others (see below). Marijuana is used by some patients. When palliating a symptom such as nausea and vomiting, it is essential to give medications on schedule so that the problem is prevented. Oral medications are given when possible; and in other cases, rectal suppositories or injections (IV or IM) are used.
• If significant fluids are being lost, increase fluids, especially electrolyte preparations such "Pedialyte"or "sports drinks." Even if significant fluids are not being lost, be sure to give extra fluids to prevent dehydration, except that liquids should be minimized before, during, and immediately after meals.
• Fluids and foods best tolerated include soft drinks, soda crackers, salty foods, fresh fruits, non-acidic juices, chicken soup or broth, jello, bland and/or soft foods, non-gas-forming foods, cold foods, and any other fluids or foods that the patient thinks will be tolerated.
• The person's head should be kept elevated for at least 30 minutes after meals and longer if lying flat increases nausea. The room should be kept cool.
• Meals should be small and taken when nausea and vomiting are least problematic; fasting is necessary in some cases, especially when vomiting is intractable or the person is close to death.
• Fatty, fried, strong-smelling foods should be eliminated; and the smells and sights of cooking minimized.
• Conflict and/or anxiety should be addressed.

Commonly Used Medications for N&V Procholorperazine (Compazine) is commonly used and usually effective. Available PO, PR, IV, and IM. Other phenothiazines are also effective, as is haloperidol. Promethazine (Phenergan) is commonly used post-operatively, but less often in palliative care. Available PO and PR. Metaclopromide (Reglan) is effective in N&V due to opioids, gastroparesis, and organomegaly, but is contraindicated when bowel obstruction is the etiology. Available PO and IV. Corticosteroids are effective in a variety of etiologies. Odansetron (Zofran) or granisetron (Kytril) are commonly used when etiology of N&V is multifactorial or unknown. Octreotide (Sandostatin) is indicated when the etilogy of N&V is bowel obstruction. Protocol for nausea and vomiting in patients with terminal illness: Treat cause (hypercalcemia, >ICP, infection, etc.) if possible and palliate symptoms concurrently. If etiology is not apparent or not amenable to intervention, proceed as below. Begin with metoclopramide (except when obstruction is the etiology). If metoclopramide is not effective add a second medication according to the suspected etiology of N&V: Haloperidol if CTZ or dexamethasone if >ICP or etiology is unclear. If the two drug regimen is ineffective, add an antihistamine (if not already used with the metoclopramide). If the three drug regimen is ineffective add dexamethasone 4 mg if not already in use. If the four drug regimen is ineffective add 5-HT3 antagonists such as ondansetron. Odansetron is recommended by some as the initial drug). Phenergan is commonly used in the acute hospital setting, but seldom in hospice or palliative care.

Anorexia, Weight Loss, and Cachexia

At some stage of illness almost all patients with advanced cancer or AIDS develop anorexia (loss of appetite) and begin losing weight. Anorexia may be related to many processes, including unmanaged pain, stomatitis (sores in the mouth), taste changes, early satiety (feeling full after only a few bites of food), poorly fitting dentures, nausea, constipation, fatigue, difficulty breathing, or other physical problems. Psychological problems that contribute to anorexia include depression and anxiety.

With anorexia and weight loss common, and in most cases inevitable, among patients with terminal illness, identifying specific causes is an extremely challenging, and ultimately a futile task. Nevertheless, anorexia and weight loss from some etiologies is treatable, hence assessment of anorexia and weight loss is an integral part of quality palliative care. The fundamental cause of weight loss is decreased intake. A general assessment includes intake patterns, food likes and dislikes, and determining the meaning of food or eating to the patient and family. Early in the disease, comprehensive and frequent assessments are appropriate, but later, assessments – even as basic as weight – are not helpful to the patient. Common causes of anorexia and/or cachexia include the following:

• A host of physical symptoms often contribute to, or cause anorexia, such as pain, alterations in taste (especially aversion to meat), stomatitis, dysphagia, odynophagia, dyspnea, nausea, vomiting, diarrhea, constipation, fatigue, various infections, early satiety, etc. Each of these, and other symptoms, are discussed elsewhere in this book. In general, most people who are seriously ill and/or suffering distressing symptoms have poor appetites. Cancer or AIDS treatment are well-known to often have deleterious effects on appetite or result in side effects leading to poor appetite and/or weight loss. Patients with HIV disease may develop primary muscle disease leading to weight loss.
• Metabolic alterations are common in cancer and some may result in cachexia, including glucose intolerance, glucose turnover, insulin resistance, increased lipolysis, increased whole body turnover, increased skeletal muscle catabolism, negative nitrogen balance, and in at least some patients, increased basal energy expenditure. The presence of cytokines (interleukins and tumor necrosis factor) produced by tumor or as an immune response to tumor are thought to mediate these metabolic abnormalities. In AIDS, metabolic alterations leading to wasting include hypermetabolism, endocrine dysfunction, and the presence of cytokines.
• Paraneoplastic syndromes, including hypercalcemia, may also cause anorexia or symptoms such as fatigue that lead to anorexia. Anorexia-cachexia is considered by some to be a paraneoplastic syndrome caused probably by cytokines as noted above.
• Other problems of the GI tract leading to anorexia include hepatomegaly, splenomegaly, gastric compression, delayed emptying, malabsorption, and obstruction.
• Side effects of medications (especially those used in HIV) may directly result in anorexia (acyclovir, foscarnet, zidovudine, and others) or have side effects such as nausea, taste changes, and diarrhea that lead to anorexia.
• Psychological or spiritual distress may be another cause of anorexia; and may include anxiety and/or depression, or feelings of hopelessness or uselessness, all of which may result in little enthusiasm or energy for preparing or eating food.
• Poorly-fitting dentures and other causes of dental or oral pain may also play a role in anorexia.
  

Weight loss due to poor appetite alone, and in earlier stages of disease can be remedied with nutritional support such as diet supplements. As the illness progresses, anorexia is less and less amenable to nutritional or medical intervention. At some point in the illness cachexia (with weight loss) may develop. Weight loss that is due to cachexia, a complex and progressive negative nutritional state common in advanced disease, is not reversible with nutritional support.

Giving food has important symbolic value related to nurturing and love for many people, and it may be very difficult for some to not try forcing food on patients who are ready to stop eating. Late in the illness, food does no good whatsoever for the patient. Many people are physically unable to eat or digest food. One simply has to accept that there is a time to stop eating; and this is a good time to sit quietly with the person who is sick. The need is for love and presence rather than food.

Managing Anorexia, Weight Loss, and Cachexia

If anorexia is due to an identifiable problem such as other symptoms, early satiety, taste disorders, poorly fitting dentures, then act on those problems. Early satiety, for example, can be partially managed by increasing nutritional value and size of morning meals and giving increased fluids later in the day. Palliative treatment of anorexia/cachexia includes:

• Megestrol acetate 160-800 mg PO daily (qid) in liquid suspension improves appetite and reduces N&V and alterations in taste. It is most useful for patients expected to live for weeks or months. Side effects may include fluid retention, menstrual irregularities, and tumor flare in patients with breast cancer. Megestrol is contraindicated in patients with thrombophlebitis.
• Metoclopramide 10 mg PO tid is most helpful for patients with delayed gastric emptying or gastric paresis (leading to early satiety). Side effects include dystonic reactions (trismus, torticollis, facial spasm, oculogyric crisis, anxiety), akathisia, and tardive dyskinesia (involuntary chewing, vermicular tongue movements).
• Corticosteroids, e.g., dexamethasone 4-8 mg qam are most useful in patients with limited life expectancy or when a rapid effect is needed. Side effects include euphoria, other mood changes, fluid retention, GI irritation.
• Cannabinoids, e.g., dronabinol 2.5-5 mg PO q3-6 h improve appetite and decrease nausea. Some patients prefer to smoke marijuana rather than take oral medications as a source of cannabinoid. Side effects include sedation and euphoria. Older patients my have unpleasant feelings from cannabinoids.
• Antidepressants are used when depression is an etiology in anorexia (and serious consideration should be given to treating depression either as an etiology or sequela of anorexia).
• Enteral and parenteral nutrition are useful only in a small subset of patients with anorexia and advanced terminal illness–specifically, those with bowel obstruction and lengthy life expectancy (Fainsinger, 1997).

Non-medical management of anorexia includes:

• Oral nutritional supplements help early in the illness, but cannot take the place of a balanced diet. Total parenteral nutrition (TPN) is seldom helpful for patients with advanced terminal cancer.
• Homemade milkshakes or Carnation Instant Breakfast are more enjoyable to some people, and thus have greater value (and are much less expensive) than commercial supplements, such as Ensure.
• Meals should be smaller, more frequent, and based on the person's tastes. It is worthwhile to make servings more attractive. Large servings are overwhelming to many patients and just looking at a large, full plate can destroy whatever appetite may exist. Experiment with foods with different tastes, textures, temperatures, seasonings, etc. Give foods remembered from childhood.
• Take meals together as a family as long as the patient is able.
• Allow the patient to rest before meals. Avoid dressing changes and other treatments or psychological upsets (negative or positive), or other activities prior to meals.

As disease advances, options to address anorexia decrease and eventually there are no options to improve appetite.

Constipation

About one half of all patients with terminal cancer are constipated. Problems of constipation include discomfort at an early stage, and if not resolved, fecal impaction with diarrhea and incontinence (impaction should always be considered in terminally ill patients with diarrhea and/or incontinence), anorexia, nausea and vomiting, urinary retention and incontinence, and confusion. Mild constipation is manifested by straining at the toilet and difficulty cleaning afterwards. Severe constipation may decrease the absorption of oral medications, thus increasing pain or other problems.

Causes of, or contributing factors to constipation in terminal illness include medications (especially opioids), some chemotherapeutic agents, inadequate fluids or dietary fiber, decreased activity or immobility, depression, and a lack of privacy. Taking opioids such as morphine essentially guarantees constipation. Some people have a lifelong pattern of constipation. In patients with far-advanced cancer, constipation may be due only to diminished intake and not necessarily a problem.

Medications that commonly cause constipation Medications are a common cause of constipation. In terminal illness, opioids are probably the most common cause. Other medications that may cause or contribute to constipation include anticholinergic agents such as scopolamine or amitriptyline, antacids, anticonvulsants, phenothiazines, NSAIDs, antiemetics such as odansetron, and certain chemotherapeutic agents such as vinca alkaloids.

Managing Constipation

As much as possible, increase dietary fiber and fluids and avoid constipating foods such as dairy products and fried foods; and maintain as much activity as practical. It is difficult to overstate the importance of adequate fluid intake in preventing hard, dry, difficult-to-pass stool. Constipation caused by medications should be treated palliatively or a change in medication.

Privacy in the bathroom or with the bedside commode may help. Bathroom assistive devices such as a rail by the commode should be installed if the patient is able to walk to the bathroom. When the patient is taking opioids, constipation is certain and should thus be prevented with an effective regime such as the following:

• Daily fiber supplement such as Metamucil.
• Daily stool softener, e.g., diocytyl sodium sulfosuccinate and a laxative, e.g., Doxidan or Senokot S.
• If there is no bowel movement in 48 hours of treatment as above, continue the stool softener and discontinue the previous laxative and start another laxative such as Senokot, Dulcolax, or Milk of Magnesia.
• If there is no bowel movement within 24 hours, check for impaction. If there is no impaction, continue the stool softener and a laxative such as Dulcolax suppository, magnesium citrate or Fleets enema.

There may be contraindications (e.g., presence of neutropenia or thrombocytopenia) to removing an impaction; and there may be physiological changes following the removal.

Diarrhea

Diarrhea is sometimes a problem in patients with cancer; and often a problem in patients with AIDS. Diarrhea may be profuse or there may be a pattern of expelling small amounts of watery stool. Diarrhea is also associated with fecal incontinence. Skin breakdown and pain may result from chronic diarrhea.

Causes of diarrhea include cancer treatment (radiation or chemotherapy), pancreatic insufficiency (characterized by steatorrhea, i.e., pale, bulky, greasy stools and gas), GI infection from a variety of causes (including in confused patients, scratching or otherwise putting their fingers in their anus), drug toxicity (from laxatives, antacids or antibiotics), and supplemental feedings. Fecal impaction or intestinal obstruction may result in small amounts of watery stool expelled around the blockage. Please see obstruction section at the end of this chapter. Chronic diarrhea may also be due to diverticulitis, ulcerative colitis, colon tumor, hyperthyroidism, or diabetes. Common causes of diarrhea in patients with AIDS include microsporidium, cryptosporidium, and salmonella infections; as well as diarrhea due to other and/or unknown causes. Stress can be a precipitating or contributing factor in diarrhea.

Managing Diarrhea

As in all other aspects of hospice and palliative care, the cause of the problem should be treated if possible, i.e, antibiotics if the etiology is responsive to antibiotic treatment. General measures to manage diarrhea include:

• If over-the-counter antidiarrheal medications are not effective, either (1) opioids, e.g., codeine, tincture of opium or (2) Lomotil or Lomodium are usually effective. The diarrhea of advanced AIDS is very challenging to manage. Octreotide is sometimes successful in controlling diarrhea in patients with AIDS and is also used in patients with cancer.
• Fluid should be increased to prevent dehydration, especially in very old or young patients with advanced illness. At least two-three quarts noncarbonated fluids should be taken each day - more if diarrhea is profuse. "Sports drinks" help replace some of the electrolytes lost in diarrhea.
• Meals should be small and frequent, with increased simple carbohydrates (e.g., crackers, toast) and decreased dairy products. Spicy, greasy, (GI) irritating foods such as caffeine, and extremely cold or hot foods should be avoided (unless a cultural imperative).
• Diarrhea lasting only a day creates skin discomfort, and chronic diarrhea causes skin breakdown and significant discomfort. Comfort measures should be started immediately and include protective ointments or anesthetics to the rectal area, e.g., A&D Ointment, hydrocortisone, or Tucks; and use of squeeze bottles, one with warm soapy water to cleanse and the other with clear water to rinse in place of toilet paper.
• Caregiver or patient hygiene, or other habits related to infection may need to be changed.

Fecal Incontinence

Fecal incontinence is usually related to diarrhea and may be temporary. Many patients feel very ashamed of fecal incontinence and some attempt to deny and hide it. Fecal incontinence other than that associated with diarrhea, is often associated with dementia. In some cases, incontinence is related to difficulties toileting, including inability to get to the toilet or remove clothing.

Managing Fecal Incontinence

Diarrhea is treated as discussed in the section on diarrhea. If death is imminent, incontinence is simply accepted and the patient is kept clean. Attends (adult protective pants) help keep the bed clean. Incontinence associated with dementia and an expected life-span of months is a challenging problem. When death is not imminent, it is necessary to institute a bowel regime. A typical bowel regime might include:

• After breakfast and coffee or at the person's usual bowel movement time, insert a glycerin suppository and place the patient on the toilet.
• If the above is not effective, constipation can be induced with a schedule of small amounts of codeine given every 6 hours for two days, then after a medication-free night, force evacuation with laxative suppositories or a Fleets enema.

Rearranging furniture may help, including use of a bedside commode or installing rails by the bathroom toilet when the person is mobile. Modifying clothing may also help.

Bowel Obstruction

Bowel obstruction is relatively common in patients with abdominal tumors, especially ovarian (15%-42%) and colorectal (10%-28%); and also gastric, uterine, and to a lesser extent, other cancers. Bowel obstruction presents difficult decisions. Practitioners skilled in palliative care may be comfortable with treating the problem palliatively, while those used to acute care tend to treat obstruction aggressively, except when the patient is obtunded.

Etiologies and Assessment

Bowel obstruction results from tumor mass occluding the bowel lumen, tumor mass or organomegaly compressing the bowel, dysfunction of the neural plexus of the intestine resulting in adynamic ileus or “narcotic bowel” and pseudo-obstruction, intussuception, treatment injury such as adhesions, radiation injury, or neurotoxicity, and non-malignant lesions such as those in diverticulitis. Some patients, especially those with ovarian cancer, may have more than one etiology.

In the early stages of obstruction, there is usually intermittent colicky abdominal pain, increased bowel sounds, abdominal distension, and diarrhea. If the obstruction is high, there may be little distension, but profuse vomiting with vomitus containing bile and mucous. If the obstruction is due to adynamic ileus, there may not be colic. Few patients complain of constipation early in the process. In later stages, the pain becomes continuous with colicky components, abdominal distension increases and the patient experiences nausea and vomiting and constipation. Visible peristalsis, intermittent borborygmi, and anorexia are common. The most prevalent symptoms are nausea and vomiting, intestinal colic, and other abdominal pain.

Managing Obstruction

In the early or partial stages, patients with mechanical bowel obstruction can be treated with liquid or soft diet, stool softeners, analgesics, and antiemetics as follows:

• Nausea and vomiting from a high obstruction are treated with haloperidol 1.5 mg qd, hydroxyzine 25-50 mg qid, octreotide 0.3-0.6 mg by continuous SQ infusion over 24 hours. N&V from a low obstruction may be treated with haloperidol 1.5 mg qd or metoclopramide 60 mg if the obstruction is incomplete, hydroxyzine 25-50 mg qid, octreotide 0.3 mg by continuous SQ infusion over 24 hours. Dexamethasone 4-100 mg qd has also been effective in treating N&V and has sometimes restored bowel function. Note that in bowel obstruction some N&V is likely to occur no matter what interventions are attempted. Waller & Caroline state a goal of vomiting no more than once or twice daily. There is some indication that metoclopamide may help prevent complete obstruction.
• Colicky pain is treated by discontinuing stimulant laxatives (senna, biscodyl) and gastrokinetic agents (metoclopramide, cisapride) and using antispasmodic agents such as loperamide 2 mg PO qid or if the patient is unable to tolerate oral medications, transdermal scopolamine or hyoscine. Hyoscine also reduces the frequency and volume of vomiting, hence is a first-line treatment which in some cases results in no further need for a nasogastric tube.
• Continuous abdominal pain is treated with morphine PO or continuous SQ infusion.
• Constipation and/or diarrhea are treated as discussed earlier.

Additional measures include:

• Gastrointestinal intubation is used to remove gases and secretions as a means of resolving obstruction (25% success rate), palliate symptoms, instill medications, or to prepare for surgery. Nasogastric suction is not usually considered a viable option in the ongoing management of obstruction in terminal illness.
• Surgery (resection, colostomy or ileostomy, bypass, or stent placement) to resolve bowel obstruction in terminal illness is not automatically undertaken. Candidates for surgery should have a life expectancy of more than two months, good general performance status (ECOG = 2 or better; or Karnofsky Performance Status of 50), no previous obstruction or abdominal surgery in the past year, no malignant ascites or liver failure, no lung metastases or pleural effusion, and no carcinomatosis or palpable abdominal mass. Even with careful patient selection, morbidity and mortality from the surgery are high, with mortality ranging from 18%-35%.
• An alternative to the above surgeries is the simpler percutaneous gastrostomy which allows venting as needed.
• Patients with “narcotic bowel syndrome” or adynamic ileus and advanced terminal illness can be treated by adding metoclopramide 60 mg/24 hours via continuous SQ infusion.

 

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