Buku Medicine

Bowel obstruction

Quick Tip: It is important to distinguish between complete and incomplete, reversible and irreversible bowel obstruction because the management is very different.

Risk factors/possible causes:

Disease: presentation, progression or recurrence of intra-abdominal malignancy (especially bowel, ovary, pancreas). Adhesions from previous surgery/radiotherapy. Acute ischaemia, incarceration of hernia or other GI catastrophe.
Medication: opioids, anticholinergics (e.g. tricyclic antidepressants, hyoscine salts), diuretics, 5HT antagonists (ondansetron), phenothiazines, chemotherapy.

Clinical presentation:

Pattern and severity of symptom(s) depends on whether high (vomit early, less distension) or low obstruction (early constipation and distension, later vomiting), or obstruction at multiple levels.

Vomiting may be large volume and faeculent; nausea may be relieved by vomiting.

Constipation and/or overflow diarrhoea may be present.

Abdominal pain - constant or colicky; abdominal distension, palpable tumour mass, tympanic percussion, tinkling/abnormal bowel sounds.

Immediate action – is admission appropriate?

Consider patient’s wishes, documented emergency health care plans or other records, and guidance from family/others.

If YES - admit as emergency. Give medication for symptom relief during transfer, i.e. stat dose opioid analgesic (appropriate to analgesic history) and stat dose of anti-emetic (either metoclopramide 10mg SC if no colic or cyclizine 50mg SC if colic).

On admission check blood count and renal function; perform erect and supine abdominal X-ray/consider CT scan; seek urgent surgical opinion; start IV fluid resuscitation; consider decompression of distended gut with NG tube. Exclude constipation or manage appropriately.

If NO – or if admitted but surgical decision is for supportive care only...

In cases of advanced cancer, consider trial of corticosteroids with dexamethasone (e.g. 9.9mg injectable formulation SC or IV), review effect after 5 days and stop if no effect. Reduce gradually if benefit. Change to oral when possible.

Suspected incomplete obstruction/no colic; start metoclopramide 30mg/24 hours SC via syringe driver and 10mg SC as required (max total dose 60mg/24h). Use metoclopramide for prokinetic effect but stop if colic develops and switch to complete obstruction management.
Suspected complete obstruction/colic present; start cyclizine 150mg/24 hours SC via syringe driver for nausea and hyoscine butylbromide 60mg/24 hours SC via syringe driver plus 20mg SC prn (max total daily dose 120mg) for colic. Haloperidol 1.5mg daily or levomepromazine 12.5mg SC OD/SC syringe driver can also be used for nausea.

NCA handbook

http://www.northerncanceralliance.nhs.uk/wp-content/uploads/2018/11/NECNXPALLIATIVEXCAREX2016.pdf

Bowel obstr. flowchart

Bowel obstruction pdf
280.35KB

Major Haemorrhage

Quick Tip: Appropriate management depends on whether resuscitation is appropriate for the patient and how severe the haemorrhage is.

Recognition

Bleeding of all types occurs in 14% of patients with advanced disease.
Haemorrhage causes death in approximately 6% patients.
Catastrophic external haemorrhage is less common than internal unseen bleeding.

Clinical Presentation

Cardiovascular compromise – hypotension, tachycardia (>100 beats/min = significant recent bleed).
Identifiable bleeding source, e.g. haematemesis, melaena, haemoptysis, PV or PR bleeding, haematuria.
Erosion of an artery by a malignant ulcer or superficial/fungating tumour.

Anticipatory management

Massive haemorrhage is often preceded by smaller bleeds. Oral/topical treatment may help (see below).
When planning ahead review resuscitation status and treatment options with patient and family, if possible agree an Emergency Health Care Plan.
Review risk:benefit balance of anticoagulants. Correct any coagulation disorder if possible.
Consider referral for radiotherapy or embolisation if patient has an erosive tumour.
Dark towels should be available nearby to reduce the visual impact of blood if haemorrhage occurs.
Prescribe anticipatory midazolam (10mg IV/IM/SC/buccal/sublingual) as a crisis one-off dose.

Immediate action

If a patient is close to death from underlying cancer, it is usually appropriate to regard major haemorrhage as a terminal event and not to intervene with resuscitation measures.

Emergency Health Care Plan, if present, should guide management.

If resuscitation is inappropriate

Try to remain calm, this will help a dying patient to achieve a peaceful death.
The priority is to stay with the patient, giving as much reassurance/explanation as possible to patient and family.
Use dark towels to absorb blood loss.
Consider the use of crisis midazolam (10mg by appropriate route) to relieve distress in a patient that may be imminently dying.

If resuscitation is appropriate

Admit as emergency. Secure IV access.
Start rapid infusion of 0.9% saline.
Cross match and follow local haemorrhage protocols.
Apply local pressure to any obvious bleeding.
Seek specialist help on further management.

Follow up

Ensure support available for family and staff following experience of haemorrhage.
If the patient survives the haemorrhage consider transfusion or iron infusion.
To prevent rebleeding:
ORAL:
- Tranexamic acid 1g PO/IV 8-hourly (avoid in haematuria/acute thrombosis – a history of ischaemic heart disease is not usually a contraindication unless there has been recent ACS or angina)
TOPICAL
- Sucralfate paste (2g/5mL aqueous gel) applied directly to ulcer under non-adherent dressing
- Adrenaline 0.1% (1mg/ml) soaks (10ml on gauze)
- Tranexamic acid (500mg/5ml injectable formulation) soaked on gauze
Consider diathermy, radiotherapy or embolisation.

NCA Handbook

http://www.northerncanceralliance.nhs.uk/wp-content/uploads/2018/11/NECNXPALLIATIVEXCAREX2016.pdf

Malignant hypercalcaemia

Quick Tip: Exclude in any patient with advanced cancer whose condition deteriorates rapidly. Onset may be insidious with symptoms not evident until corrected calcium is well above normal, or the patient may be symptomatic with modest elevation of calcium.

Recognition

Commonest paraneoplastic syndrome in patients with advanced cancer.
May occur in the absence of bone metastases. Strongly associated with breast, lung, haematological and genito-urinary tract malignancies.
Reflects poor prognosis. Median survival 3-4 months, worse if resistant to treatment.

Clinical Presentation:

Confusion, drowsiness and eventually coma.
Thirst and polyuria. Dehydration may lead to pre-renal failure.
Nausea and vomiting. Constipation.
Worsening pain or pain responding poorly to treatment.

Immediate action

Assessment

Check ‘Adjusted Calcium’ level in venous blood. Normal range usually 2.20 - 2.60 mmol/L.
If normal but clinical suspicion remains, recheck in 1 week. Also check renal function (U&E).

Management

Admit to hospital/hospice unless it is agreed that intervention is not appropriate.
Stop thiazide diuretics – may increase calcium levels
Rehydrate with IV 0.9% sodium chloride. Aim for 2-4L/day. Caution if risk of fluid overload.
After 1-2 litres sodium chloride (to prevent renal damage) give IV bisphosphonate
Check vitamin D level when bisphosphonates are given and replace if deficient
Consider using denosumab (SC injection) for patients with poor renal function (eGFR<30) or where IV access is not possible, seek advice from endocrinology or specialist palliative care.

Bisphosphonate treatment (drug of choice may depend on local guidance)

(If eGFR less than 30mL/min seek advice on whether bisphosphonates are suitable)

Disodium pamidronate: advised to be reconstituted in sodium chloride 0.9%. The infusion rate should not exceed 60mg/hour (1mg/min) (see product SPC).

Corrected calcium (mmol/L)	Pamidronate dose
<3.0	15-30mg
3.0-3.5	30-60mg
3.6-4.0	60-90mg
>4.0	90mg

Zoledronic acid: standard product preparation is 4mg in 100mL. Doses should be given over at least 15 min. Dose adjusted for eGFR (see product SPC);

EGFR (mL/min)	Zoledronic acid dose
>60	4mg
50-60	3.5mg
40-49	3.3mg
30-39	3mg

Adverse effects of bisphosphonates: ‘Flu-like syndrome/pyrexia is common – treat with paracetamol. Osteonecrosis of jaw is a rare but significant side effect. In non-emergency situations, dental review is critical before therapy.

Rebound hypocalcaemia may occur.

Follow up

Expect clinical improvement in 24-72 hours. Check for biochemical improvement in 4-7 days.
If effective, treatment may be repeated for subsequent episodes, consider prophylaxis with oral bisphosphonate.
After 7 days, if no clinical/biochemical response consider giving additional 4 mg Zoledronic acid.
If no response, seek advice on use of denosumab or calcitonin and need for further investigation e.g. PTH.
On discharge, ask primary care / community team to monitor symptoms and check calcium and renal function if there is clinical suspicion of recurrent hypercalcaemia.

Note...

Resistant/refractory hypercalcaemia may herald the end of life. If so, manage symptomatically. Consider use of an Emergency Health Care Plan to prepare for this situation.

NCA Handbook

http://www.northerncanceralliance.nhs.uk/wp-content/uploads/2018/11/NECNXPALLIATIVEXCAREX2016.pdf

Seizures

Quick Tip: For any palliative patient at risk of having a seizure, it is helpful to ensure that an Emergency Health Care Plan is prepared.

Recognition

Seizures can be frightening for the patient and their family.
Seizures (generalised or partial) occur in 10-15% of palliative care patients.
Common causes include pre-existing epilepsy, brain tumours, raised intracranial pressure, metabolic disturbance (hypoglycaemia, electrolyte abnormalities, hepatic encephalopathy, renal impairment) and infection.
Seizures may become more severe or frequent at the end of life. If the patient is no longer able to take or absorb their oral anticonvulsants, subcutaneous antiepileptic medication should be prescribed instead. Midazolam 20-30mg SC/24hr via syringe driver should be commenced; alternatively, sodium valproate or levetiracetam can be given subcutaneously.

Immediate action for treatment of status epilepticus

Exclude other causes of loss of consciousness or abnormal limb/facial movement. (e.g. vasovagal episode, postural hypotension, arrhythmia, hypoglycaemia – check BM; extrapyramidal side effects from dopamine antagonists, alcohol).

Put the patient in the standard recovery position if appropriate. Ensure safety and protect airway.
Community/inpatient: if seizure does not resolve spontaneously after 5 minutes, give midazolam 5-10mg via the buccal route (using oro-mucosal solution or injectable formulation) or SC/IM using injectable formulation. Repeat after 10-20 mins if seizure not resolved. OR
Inpatient: IV lorazepam 2mg/min up to 4mg. Repeat once after 10-20 mins if seizure not resolved.
If further treatment needed, seek advice from Neurologists or SPCT. Drugs such as phenobarbital or phenytoin may need to be considered.

Follow up – seizure management in the non-dying patient

Consider investigation for reversible causes.
If history of seizures, review and optimise patient’s anti-epileptic medication. Exclude drug interactions reducing regular antiepileptic medication efficacy.
After a first seizure, consider commencing regular anti-epileptic medication. Seek advice from local neurology team if needed

Follow up – seizure management in last days of life

At this stage, it is usually inappropriate to investigate.
To prevent further seizures, commence midazolam 20-30mg/24hrs subcutaneously via syringe driver over 24hrs.
Prescribe midazolam 5-10mg buccal or 5-10mg SC/IM as required for further seizure control.

Alternatively, or additionally, sodium valproate and levetiracetam can be given via the subcutaneous route. Seek advice from Specialist Palliative Care Team if needed.

NCA handbook

http://www.northerncanceralliance.nhs.uk/wp-content/uploads/2018/11/NECNXPALLIATIVEXCAREX2016.pdf

Spinal cord compression

Quick Tip: Patients with suspected MSCC must be assessed as a priority. Consider this possible diagnosis in any cancer patient who goes ‘off legs’. Do not wait for late sign/symptoms to appear as weakness is often irreversible at this stage.

Early detection

Inform patients with, or at high risk of developing, bone metastases about the symptoms of spinal cord compression and what to do if they develop these symptoms.
Contact the MSCC coordinator (available in most centres-if not the oncology on-call service) urgently (within 24 hours) to discuss the care of patients with cancer and any of the following symptoms suggestive of spinal metastases:
pain in the middle (thoracic) or upper (cervical) spine
progressive lower (lumbar) spinal pain
severe unremitting lower spinal pain
spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)
localised spinal tenderness
nocturnal spinal pain preventing sleep.
Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency:
neurological symptoms including radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction
neurological signs of spinal cord or cauda equina compression.

Signs and symptoms:

Pain – severe, recent onset or worsening, felt as a band around the body or radiating down arm(s) or leg(s), exacerbated by coughing or straining, not relieved by rest. Often precedes neurological signs. The diagnosis of spinal cord compression should be considered in any cancer patient with severe back pain in a nerve root distribution.

Late symptoms/signs include:

Limb weakness, altered gait, unsteadiness, falls
Urinary retention, dribbling or incontinence; faecal incontinence or constipation
Altered or reduced sensation.

Cauda equina syndrome – tumour pressure below L1/L2 – may present with:

Sciatic pain, often bilateral
Weakness/wasting of gluteal muscles
Bladder problems including retention, overflow and incontinence
Sacral (saddle) anaesthesia, loss of anal sphincter tone.

Management

Corticosteroids
- Give 16mg dexamethasone PO daily as soon as possible after assessment (closest practical parenteral dose is 13.2mg if IV/SC. If given SC, consider dividing volume between two sites, 2mls each)
- Standard practice after surgery or the start of radiotherapy is to reduce gradually over 5‑7 days and stop. If neurological function deteriorates the dose should be increased temporarily. Check local practice.
- For patients with MSCC who do not proceed to surgery or radiotherapy, standard practice is to reduce gradually and then stop dexamethasone. If neurological function deteriorates at any time the dose should be reconsidered.
- Monitor blood glucose levels in all patients receiving corticosteroids.
Prescribe PPI for gastric protection
Give adequate analgesia (opioid if necessary) to enable comfortable transfer for admission/investigation.
Aim to nurse the patient flat if mechanical pain suggestive of spinal instability or neurological symptoms of MSCC.
Consider thromboprophylaxis. This should be an individualised assessment based on ongoing risk factors, overall clinical condition and likelihood of return to mobility.
Assess and monitor bladder and bowel function and undertake a risk assessment for pressure ulcers.

Investigations

MRI of the whole spine is the investigation of choice for patients with suspected MSCC. This should be done in time to allow definitive treatment to be planned within 1 week of the suspected diagnosis in the case of spinal pain suggestive of spinal metastases, and within 24 hours in the case of spinal pain suggestive of spinal metastases and neurological symptoms or signs suggestive of MSCC.

The MSCC coordinator will discuss with oncology and surgical teams to determine whether patients are eligible for radiotherapy, vertebroplasty or spinal surgery.

LINKS

See NICE CG75: Metastatic Spinal Cord Compression: https://www.nice.org.uk/Guidance/CG75

NCA Handbook

http://www.northerncanceralliance.nhs.uk/wp-content/uploads/2018/11/NECNXPALLIATIVEXCAREX2016.pdf

Malignant SVCO

Quick Tip: 95% of cases of superior vena cava obstruction (SVCO) are caused by malignant tumour in the mediastinum preventing venous drainage from the head, arms and upper trunk.

Recognition

Commonest in lung cancer. Can also occur in lymphoma and some other cancers.
Onset usually over weeks or months, but occasionally occurs rapidly over days.

Clinical Presentation

Facial swelling, redness, headache, periorbital oedema, engorged conjunctivae.
Swelling of the arms, prominent distended veins on neck and chest wall.
Breathlessness, cough, chest pain, stridor, cyanosis.
Visual disturbance.

Immediate action

Steroids may be helpful. Give dexamethasone 16mg stat (oral or equivalent dose IV or SC) and continue 16mg daily as morning dose; also prescribe PPI for gastric protection.
Give oxygen if available & required and manage other symptoms (see guidelines on breathlessness and agitation).
Discuss URGENTLY with the local Acute Oncology Team and arrange appropriate imaging.
Anticoagulation may need to be considered if evidence of thrombus.

Follow up

If the obstruction is resolved by stent insertion or other intervention, the dexamethasone should be reduced gradually and possibly stopped. Consider ongoing prophylactic anticoagulation. Ongoing care should be provided and guided by team managing the malignancy.
If the obstruction cannot be resolved with intervention, the dexamethasone should be gradually reduced to the lowest dose that manages symptoms.

If SVCO suspected in patient at end of life/too unwell for/unwilling to have investigations:

Manage symptoms in patient’s preferred care setting. Agree an Emergency Health Care Plan.
Consider steroids (as above), anticoagulation with treatment dose low molecular weight heparin, symptomatic measures and nursing at 45 degrees for comfort.

NCA Handbook

http://www.northerncanceralliance.nhs.uk/wp-content/uploads/2018/11/NECNXPALLIATIVEXCAREX2016.pdf