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Mhm. Mhm. Hi, everyone. I'm just going to wait till about five past and for more people to arrive, and then we'll get started. Mhm. Mhm. Yeah. Okay, let's get started. So hello, everyone. And welcome to the first webinar in the mind the bleep palliative care series. Um, this series is gonna run every Thursday from seven until eight. PM From now until the end of November, we've got lots of different speakers. We've got a number of different S H. O s with experience of palliative care. We've got some palliative care registrars and we've got some consultants and also some chaplains and palliative care nurses. So it should be a really good series. Today. We've got Doctor Isabella putting talking to us about the management of nausea and constipation. So is she is a foundation year for Doctor who graduated from the University of Edinburgh in 2019. She did her foundation training in north central London and then during her F three years, she worked for six months in the hospital palliative care team in the Imperial Trust. And then she worked for four months on a specialist palliative care unit in the bars trust, which is where I worked with her. And she's now studying for a diploma in tropical medicine and public health in Berlin. So I'll hand over it. Thank you. Know, uh um So, as I said, I'm going to be talking about the management of nausea and constipation, and this will be some general information on nausea, vomiting and constipation and then also a palliative care focus. So the learning objectives from this talk, first of all, will be to define nausea, vomiting, constipation, who understand the underlying physiology to describe the common causes. Make a detailed assessment of a patient with nausea, vomiting or constipation, and to create a management plan. So we'll start with nausea and vomiting. So just some definitions. So, um, this is probably all well known to you, but nausea is a condition of feeling sick and the feeling that you're going to vomit, whereas vomiting is actually the act of injecting the contents of the stomach through the mouth and usually involves involuntary muscular spasms of the stomach and the esophagus. There's some other differentials which are similar but aren't classified as nausea or vomiting. So retching, um, is sort of rhythmic, spasmodic movement of the diaphragm and the abdominal muscles, which is often associated with nausea and maybe followed by vomiting. But not always. There's regurgitation, which is the movement of the stomach contents into the esophagus, Um, or from the esophagus into the mouth. And then there's the esophageal secretions, which often frothy, stringy, white or colorless secretions that come into the mouth without any forceful contraction of either the diaphragm or the abdominal muscles. And this is commonly seen in the esophageal cancer, so some of the physiology behind nausea and vomiting. So this diagram shows different areas, Um, which sends signals to something called the vomiting center. The vomiting center coordinates the vomiting process. It's located in the brain stem, but it isn't really a well defined area. Um, it's sort of location within the brain. Stem varies between different literature, but generally for these, we talked about the vomiting center because it receives these signals from several different stimuli. So just going through the diagram on your top left Number one, we've got the cerebral cortex, so things like fear and pain and can go from the cerebral cortex of the vomiting center, but also low sodium or raised ICP can contribute to nausea, vomiting via the cerebral cortex, and then number two. We've got the vestibular apparatus and also within the brain. And, um, this is things like motion sickness or cerebral tumors can irritate the vestibular apparatus, and then they send signals to the vomiting center in number three. We've got the chemo receptor trigger zone, so this is an important area which is in the fourth ventricle and things like drugs, side effects of drugs or metabolic effects. So electrolyte imbalances, um, affect the chemoreceptor trigger zone, and then that sends signals to the vomiting center and then number four with the G I tracked, um so the GI Tract and the Vegas and Stancik nerves are related, so the gut wall will send signals to the vomiting center via the vagus nerve. And the sciatic nerves and the sciatic nerves provide the autonomic nerve supply to the gut as well as sensory fibers from the gut. Whereas the vagus nerve has an important role in the control of heart rate, breathing, control, sweating, but also in Paracelsus. So that's the movement of the bows to push things through and digestion. So any kind of irritation or distention will then cause these signals to be sent. And then what you'll also see on diagram is you've got different. And so you've got at the top. You got a serotonergic receptors. You've got histamine receptors that h two, and you've got acetylcholine. And then you've also got the same. So different areas basically sent different kinds of different receptors. And this is important later when we go on to talk about the management of vomiting, nausea and vomiting, because different drugs will work on different receptors and in different areas. And that will help, you know, basically where what, what drug to use for what situation. So some causes of nausea and vomiting. So there's lots of different causes. Um, but I'll go through the list and then we'll talk about some of the most important ones. So at the top, you got gastric Stasis and gastric dysmotility. Intestinal obstruction. Any kind of biochemical or metabolic changes, drug associated, nausea and vomiting, chemotherapy and radio radio therapy can cause nausea and vomiting. Raised intracranial pressure, motion sickness, pharyngeal stimulation, sense of smell can also cause nausea and vomiting and fear and anxiety. So it's important to think about not just physical causes but also psychological causes. So let's talk a bit about gastric Stasis and dysmotility. So what does the gastric Stasis mean? It's basically delayed gastric emptying in the absence of any mechanical obstruction and then gastric medicine until it is slightly different. So it's inadequate emptying of the stomach, but it's usually due to changes in the speed, strength of or coordination of, the digestive organs. And some causes for these are anti cholinergic drugs opioids. And so you might know that opioids can cause, um, constipation. And that's also part of the same thing that can cause this sort of slowing of the gut, and that can contribute to nausea, vomiting as well, and then an autonomic neuropathy and then any kind of compression of the stomach. And so not an obstruction but compression by either having an enlarged liver so cardiomegaly or having lots of fluid in the abdomen. Ascites and then some of the clinical features associated with gastric Stasis and dysmotility are having intermittent large vomits, which can relieve the symptoms, but only temporarily. You might also feel that you get full much quicker, so that's early satiety and then having reflux or hiccups, and there's often a little bit of nausea, but not until immediately before the vomit. And then you've got bowel obstruction. So this is a really important cause of nausea, vomiting and something that you know. It's very important to rule out if you suspect it at all. So there's different types of obstruction, depending on what level of the obstruction that so you might have a soft agio obstruction. And particular patient has cancer of the esophagus, and it's causing a partial or complete obstruction. You can get gastric outlet obstruction, and you can get a small bowel and large bowel obstruction, and it can be either complete obstruction or it could be a partial obstruction. So not, you know, there's still some something passing through. But, um, it's causing symptoms so different causes of obstruction so there might be a mechanical cause, so an important one is a tumor compression. So if you have bowel cancer, um, or if you have metastases in the peritoneum, they might cause an obstruction of the bow. Uh, there might be a functional obstruction. So, um, not something, you know, physically there. But then there might be infiltration of the nerves that supply the bow and that could cause an alias or paralysis of the bow means it's not able to to move, um, and kind of features of that might be difficulty swallowing abdominal pain, and you might have really large volume of all of it. And if there's a complete destruction, um, you might get fecal matter coming up and and then constipation or overflow diarrhea, important things to look out for as well, and then some intracranial causes. So raised intracranial pressure is a really important cause of nausea and vomiting. Um, there might be some testicular dysfunction like we talked about before when looking at the diagram of different areas, and you might have movement related nausea and the be due to different things. So if you have a lesion in the brain, if you have an interest rebel metastases. If you have a base of school tumor, um, all of these things can cause raised intracranial pressure and cause nausea. Um, you might have auto toxicity. So, um, an example of a medication that can cause that is gentleness in the antibiotic, Um, and then that could cause vestibular dysfunction and then lead to nausea, vomiting and any kind of middle ear issues. And so if you have a middle ear infection, um, that might make you feel nauseous and then clinical features of that. So, um, particularly feeling nauseous in the morning? Um, so maybe in an exam, if you get the stem of a question and it asks you about someone who you know, breaks up with a headache or feels nauseous in the morning. And that points to raised intracranial pressure and also projectile vomiting. So you know, very forceful expulsion of the vomit and that is also associated with raised intracranial pressure. Having headaches, any kind of altered conscious level and having vertigo or any movement related sickness will point towards an intracranial cause. So next is biochemical and metabolic, so there's various different causes. I'll go through them so uremia. So if you have renal failure and you have a build up of toxins, um, particular urea that can cause you to feel really nauseous and from it having a high calcium level. So and for palliative care, it's important that if somebody's feeling nauseous, then we check their calcium because and high calcium is quite common in people who have metastatic cancer, um, particularly in breast cancer and lung cancer. And there's also if they have bone metastases that can lead to a high calcium. And then some cancers also, um, produce parathyroid related peptide and and that can lead to calcium basically being, you know, it's excreted by the parathyroid gland, um, and then having a low sodium, um, having a high blood sugar. So if you go into DKA, a having very, very high blood sugar can cause delayed gastric emptying, which then can cause nausea, vomiting, any kind of infection. If someone septic, they might feel really sick. Um, if they've got Addison's disease, then they're in an Addisonion crisis. Um, any kind of circulating toxins and then hormone imbalance as well and then drug related causes. So, um, I've just put some of the important ones to remember. There's lots of drugs that can cause nausea and vomiting, but some of the most common ones are here, So cytotoxic drugs, particularly chemotherapy, um, is a very common side effect of chemotherapy, nausea and vomiting. Opioids like I said earlier, and people tend to get very nauseous after starting opioids, but it does tend to settle after a few days of use. So sometimes we have to reassure patients that it will get better, um, and sets so ibuprofen and those can cause nausea, vomiting, any kind of suspensions or liquids. So this is something to think about if someone is not able to swallow tablets because they find it difficult to, you know, swallow big things, but and you change the monitor suspensions or liquids? Actually, those can be quite loopy and sometimes very sweet, and they can cause nausea and vomiting. Antibiotics often cause nausea and vomiting and antidepressant, uh, specifically SSRI, and they commonly cause nausea and vomiting, particularly on starting them. And again, it's something that tends to go away after a few days or a few weeks of treatment. But it's something to warn people about when they start and then anticonvulsant drugs for anti epileptics and digoxin or any other cardiac drug and alcohol. So when you're assessing for nausea and vomiting, it's really important to take a clear history. Um, so these are some of the things to ask about, so I've broken down into nausea and vomiting separately. But there's a lot of overlap, so for nausea. It's really important to ask about timing. So that is there any particular time of the day when you feel nauseous? Like I said before with raised intracranial pressure, people might find that they are more nauseous when they wake up. Are there any triggers? Is it related to food? Are there any stressful events that cause cause them to feel really nauseous? Um, and is there anything that relieves the nausea as well? Um, because they might have tried things at home already. That will help you, um, what their bowel habit like, So I'll go on to talk about the patient later, but it's really important to ask about bowels every time you ask about, um, nausea and vomiting. And what medications are they on? So the last slide had lots of medications that can cause nausea and vomiting, so it's good to go through all of those and see if they might be contributing, particularly medications that might be started recently. And so, for example, iron tablets. First fumarate can cause people to feel very nauseous when they start, and and if you see that someone has recently started a new medication, then that might be the cause. Um, do they have any associated symptoms? Are they very thirsty? Do you think they might be dehydrated? And then what's the psychological and social impact of feeling nauseous? And I'm sure, you know, everyone can testify that when they feel nauseous, it's really horrible feeling and you don't really want to do anything. And it's difficult to engage with others. So people who constantly nauseous might find it difficult to join in at meal times. They might have really real difficulty cooking. They might not want to interact with others and then vomiting. So it's important to ask about the color. Is it green? Is it, um, is there blood in there? Um, is it sort of coffee ground? All of these things point you towards the cause. And then what? The content. So is it undigested food partially digested food? Is it bile? Is it particular matter? And what what's the volume? Like someone having lots of small vomits? Are they having a really large vomit? Um, and again, what? The timing of the day. And do they have any warning? So some people might not have any warning before they vomit? Some people might be feeling nauseous for quite a long period before they vomit. And do they have any kind of post form it? Relief. So with gastric, um, Stasis. Often people find that they feel very relieved after vomit. But then that builds up again. And then again, are there any triggers for the vomit? So continuing with our assessment, it's really important that you examine the patient and do both a general exam and also look more in depth and both into the sort of neurology and also do a GI eye exam. So when you're doing your general exam, you want to look out for any signs of dehydration. If someone's been vomiting a lot, they might have lost a lot of fluid and they might show signs of dehydration so they might have, um, you know, a week pulse. They might feel cool peripherally. They might have a really dry mouth. Um, they might have, you know, things like sunken eyes. Um, any signs of sepsis? So they really hot. They really tachycardia because their BP low and and any signs of drug toxicity that might push you towards the course. And then it's really important to look into the neurology as well. So we know that nausea and vomiting is not just related to the gastrointestinal system. It can be related to the nervous system. So look for signs of confusion, and that might go in towards brain metastases. Any signs of raised and intracranial pressure, things like Papilledema. Um, it's really important to look out for. And then you should obviously do your abdominal examination. So some signs you might see it could be jaundice. Um, if somebody has liver metastases, uh, any sort of distention of the abdomen. If they have societies, any visible Paracelsus and and then is the abdomen tender? Do they have organomegaly? Do they have a really big liver and also listening to bowel sounds? So often we talk about tinkling bowel sounds when there's an impending obstruction or absent bowel sounds. If you think there's a complete obstruction, it's not the most specific way of, you know, diagnosing a bowel obstruction. It's really important to do, but you need to do more tests after that, and then it's always important to do a rectal examination. So even if we think you know someone's vomiting, how could it be, you know, related There's a really strong links between, um nausea and vomiting and constipation and also in bowel obstruction. So make sure you do your rectal examination and then further investigation, so it's important to take some blood tests. Things you might want to look for are your electrolytes. So if you think that someone is you're anemic or their in renal failure, um, you need to do some using these liver function tests. So, um, there's often albumin is really important marker, especially in palliative care, because a low albumin and um can be a sign that someone has very progressive cancer. Um, and it's also a marker of prognosis. Um, but also things like, you know, a L T A S T u M might be raised. If you have, um, liver cancer or liver metastases, your LP might be raised if you have bone metastases. So these are all really important tests and then calcium. So you want to check for hypercalcemia and glucose like you said before, having a high glucose can cause delayed gastric emptying. And so it's important to check somebody's not in DKA. Um, well, they're not hypoglycemic and then imaging so often we start with more simple imaging and then go into more detail. But it depends what you think that causes. So if you think somebody's constipated and that's causing them to be nauseous or vomiting, then you might want to do an X ray and look for vehicle impaction. So abdominal X ray. If you think that they're obstructed, then you might want to just go straight to a CT because it's better at looking for obstruction. And it will tell you the level of the obstruction and then also an MRI should be considered because if you think that there's an intracranial cause, you might want to look for any cause of raised ICP like brain metastases. So I'll just go through some sort of management of nausea and vomiting. We'll start with non pharmacological measures first, so mouth care is really important, especially if somebody is vomiting to the point where they can't have anything to eat. So they might have a really dry mouth so you can stop any anti cholinergics. They might contribute to nausea, but they also can cause dry mouth. Um, you can give artificial saliva, even either as a gel or as a spray, just to help relieve that feeling of dry mouth, and you can also use mouthcare sponges. Or you can give people ice to suck on just to relieve that feeling and then nutrition, so you might want to review their meals. And if someone's feeling nauseous a lot, you might want to, you know, have lots of meals smaller and often, rather than having really large meals. If you think it's related to food, might be useful to involve a dietician. And then if somebody has an obstruction and it's really important that you have a riles tube, so that's an N G tube that's on free drainage and then hydration. So have a look. If there weren't any diuretics that might be causing renal failure, um, and also will cause them to be dehydrated if they're vomiting a lot, Um, giving people sips of water so not so much to cause them to vomit, but just little sips, or even just wash your mouth out with some water and then consider IV and sub cut fluid. So, you know, if somebody who isn't a part of your patient who is in the last sort of hours or days of their life and is nauseous and vomiting and the vomiting a lot. Then you should definitely, um, replace what they've lost with IV fluids. And the conversation about nutrition and hydration towards the end of life is a bit different. Um, it's a sort of risk benefit. Often we talk about when you give fluids IV. They might be going into the wrong places so they might be going to the chest and causing someone have lots of respiratory secretions they might be pulling in the arms or in the legs or the abdomen, which we call third spacing. Um, but if you think that someone is very dehydrated and they're uncomfortable because they're dehydrated, then you can always consider. Fluids often give fluids subcutaneously if we think that inserting a cannula to give IV fluids is going to be too distressing or is not a problem appropriate for a patient who's dying? Um, but it's something that we review regularly and palliative care. It's not a sort of back of my answer. Um, it's not something that we say no to. It's, it's It's really a sensitive topic as well. For families. Um, so it's definitely something to be discussed and to be reviewed daily. And then we talked a bit about bowels. So make sure that you treat constipation if it's there and then complimentary therapies. So having a holistic approach to your management is really important. Um, palliative care and where you and I worked before, we had a really wonderful complimentary therapy team who went around and saw patients on our ward, and they were able to offer things like massage and reiki therapy, reflexology and then other things like acupuncture can really help with the sensation of nausea and then psychological therapy. So if you think somebody's, um, nausea and vomiting may be related to anxiety, then it's important to look into that and help manage them. So pharmacological management of nausea and vomiting, Um, like I said earlier, really depends on what you think the cause is and where you are trying to target using your medication. So you think that the nausea and vomiting is related to the cerebral cortex. So if it's someone's hyponatremic, if they've got raised, ICP, um, fear pain is not so much something that you can manage with medications, but it's important to think about. So if somebody has a intracranial pressure the way to manage it. First of all would be high dose steroids if you think that they have, Yeah, cerebral metastases, Um, or yeah, a primary brain cancer. So often we give 16 mg of dexamethasone. Um, help reduce any edema in the brain. And that helps, um, reduce. Yeah, the pressure basically on the cerebral cortex and reduce the sensation of nausea and vomiting and then in terms of anti emetics. So the two that we tend to use for, um, intracranial causes are cyclizine and leave over promazine. So, um, they both have side effects. Um, leave over promethazine can often make people feel quite drowsy. And so you have to be quite cautious about that. Um, and then cyclizine, um, we often give you, um, either by mouth or subcutaneously. Um, because it can Yeah, it can make people feel a bit dizzy or a bit so funny. Um, and then other things to think about would be radiotherapy. Um, if you think that will help reduce the size of a space occupying lesion, and also surgery can be considered if it's appropriate, and then the drug and metabolic causes that affect the chemo receptor trigger zone. And first of all, you would want to treat the underlying cause. So there's a drug cause you want to stop the offending drug. If there's a metabolic cause, um, then you probably also want to treat the underlying course. But there are some other things you can do. So if someone is hypercalcemic, we usually treat that by giving them IV fluids. But you can also consider bisphosphonates like alendronic acid, because that helps lower the calcium quite quickly. And then if someone hypoglycemic, you want to check that they're not on any steroids, because steroids can cause your blood sugar to go high and manage any sort of diabetes. And then the anti emetics that are really helpful for the chemo receptors Trigger zone. So metoclopramide haloperidol and leave them a promazine, Um, and then ondansetron is an anti emetic that is used a lot in hospitals. Um, and there's a bit of a bug bearing palliative care because, according to um, the licensing, it's actually only licensed for, um, postoperative nausea and vomiting. And also chemotherapy and radiotherapy induced nausea and vomiting and and it has lots of side effects, so it causes constipation. That's the main thing. Um, constipation is a really big problem in politic, generally in the hospitals, and so you'll see people probably use ondansetron a lot, but actually, it's it's not really licensed for general use. Um, some problems with haloperidol are that you shouldn't give it to somebody who has Parkinson's disease or anyone who has a history of seizures or epilepsy, because it can lower the seizure threshold, and it also can make Parkinson's symptoms worse. So if you're ever prescribing haloperidol, make sure you check the past medical history and then for, um, motion sickness and cerebral tumors that might affect the vestibular apparatus. Um, so for motion sickness, you can give higher seen hydrobromide or scenario seen. So, um, I think the uh, brand name for high seen hydrobromide is sometimes quells. I think. I think, um um, So it's similar tablets, basically, that you can get over the counter. Um, we also use high seen hydrobromide in palliative care to reduce respiratory secretions at the end of life. Um, so it's got a dual use and then looking more at the GI tract. So going back to some of these causes, like bowel obstruction. So if somebody has an obstruction, you want to avoid oral medications because they're not going to be absorbed. And it's really important to avoid pro kinetics like metoclopramide. And if there's a complete obstruction because metoclopramide can cause increase, is parous dialysis? And, as you can imagine, if you have an obstruction, then that's really bad. It's it's going to make everything a lot worse than it could also cause a perforation. So the anti emetics that are best for balance traction are leaving. The promazine cyclizine are tired as, um, it's not an anti emetic, but it has reduced, um, intraabdominal secretions. And so it's important medication used in bowel obstruction and then high seen beautiful bromide. So it's a bit different to Hydrobromide house in beautiful Brown Road. Um, it's the same as this compan. So, um, that really helps with any, um, abdominal spasms or cramps so that can help with the abdominal pain. But it should be used in caution. And if there is a complete bowel obstruction, it can be helpful if there's partial obstruction. But always, yeah, always check before prescribing it, and then if you have hepatomegaly or intraabdominal lymphadenopathy, which is causing maybe delayed gastric emptying. Um, steroids can be really useful. So if somebody has liver metastases, um, or like you have basically any intra abdominal lymphadenopathy or metastases, then steroids can help reduce the swelling A bit like in, um, intracranial causes. So you can give someone dexamethasone and that might actually help with the nausea and vomiting and then for gastric Stasis and dysmotility pro kinetics are usually the first line antiemetics so metoclopramide and on paradigm, Um, because they increased Paracelsus. So, um, if you've got very slow transit through the gut, having a medication that helps speed things up will really help that feeling of nausea and any vomiting. So the issues with metoclopramide m palliative care. Um, sometimes we don't think about that so much, but it's important to remember for the rest of the hospital. Metoclopramide can cause some dystonic reactions, particularly in young women. Um, so it should be used with caution. You also don't tend to prescribe it for more than five days, but within palliative care, it can be really useful anti emetic. Um, so we do sometimes prescribe it for longer. Um, with all of these medications, um, if somebody is nauseous and vomiting. As you can imagine, they probably don't want to take oral medications or they can't take oral medications. Or we don't think that the oral medications will be absorbed. And so, if you have a patient who is very nauseous and vomiting a lot and you want to give them an anti emetic, it's important to think about other routes of administration. And we use the subcutaneous route a lot in palliative care, and you can give medications like you would so say Metoclopramide. You give three times a day and you can give that as three sub Q injections. But you can also put it into a syringe driver, which is basically a syringe of medication that sits within an electronic pump. Um, and it is attached to the patient, um, via very small subcutaneous needle. It runs over 24 hours, so it's a really good way of giving medication. Um, yeah, basically, for over that time, um, and you can always adjust it if you think the dose isn't quite right. Um, so that's something to consider, so I'll move on to constipation. So the definition of constipation is a passage of small, hard feces in frequently or with difficulty and less often than normal for the individual. So that's an important thing to mention because often some patients, uh, it's regular for the bowels to open every three days every four days, and you need to know what they're normal. Bowel habit is so the physiology behind constipation. So there are two things to consider. Um, if they have altered gut transit so slow transit through the bowels. And if the stool is sitting in the bowel for a long time, more and more water will be absorbed, so the stool becomes harder. And also any changes the fluid balance, which results in the formation of a hard stool. So there are a lot of constipation causes. I've just put them in two different categories here. I won't go through all of them. I'll just mention a few from each area. But, um, some of them, you probably know already so dietary lack of fiber of fluid intake motility um so postoperative. Often people take quite a while to open their bowels after they've had a big operation, particularly if it's an intra abdominal operation. And constipation is a really important thing to consider if you have a surgical patient, um, structural. So, like I said before with nausea and vomiting, if you have a colon cancer that can cause constipation or diverticular disease, um, any kind of medication cause. So if you have crone's fissures or hemorrhoids drugs. So opiates, Um, any anticholinergic drugs is very similar for nausea and vomiting. Calcium channel blockers or something to remember can cause constipation, um, diuretics and supplements and some antacids. And then your neurological causes are really important to remember. So if someone has M s, they might suffer from constipation any kind of spinal cord lesion. Um, if they have had a stroke in the past, if they have Parkinson's or any Parkinson's related disease, and then metabolic and endocrine causes diabetes, high calcium again and low potassium and hypothyroidism and then other causes. So depression is something to remember. Um, any kind of illness that causes immobility, increasing age and hospital environment. So some of the clinical features of constipation I've broken it up into bio psychosocial because I think it's important to remember and that it causes not just physical symptoms. So, and the bias biological physical symptoms are abdominal pain and cramping, nausea and vomiting. And I recognize the weight loss, Um, not eating flatulence and bloating, feeling really tired, hemorrhoids, anal fissures, obstruction and then overflow diarrhea or something to remember. So if someone is very, very constipated and they have a build up of hard stool in the rectum, the stool that comes behind that is often softer, Um, and what can sometimes happen is you get over flow of the loose stool around hard stool so it might look like somebody's got diarrhea, but actually, they're just really constipated. So that's why doing a rectal examination is really important. Um, and your your attention as well, um, is an important thing to think about. If someone's constipated, they may also go into retention. And then the psychological features. So embarrassment, frustration. They often talk about total pain and palliative care, and that sort of not just physical pain. It's psychological pain and social pain and spiritual pain. So it's important to think about, you know, the effects of, um on on their mood so people might have low mood or they might be very anxious. You know, they really struggling with constipation, and, you know, they're trying to open their bowels, but it's not coming. That might make someone really anxious and then the social side so constipation can result in hospital admissions. It can also be made worse by hospital admissions, and it might limit social engagement and where people are able to socialize because they might need to be near a toilet. Um, and like with nausea and vomiting, people might not want to socialize if they suffering from really bad symptoms. So the assessment of constipation so your history is really important. So you want to know what somebody's normal bowel habit is and what their current bowel habit is, so that includes the frequency of opening their bowels. Do they go once a day? Do they go twice a day? Do they go every four days? Is what the consistency is, Um so hard, soft liquid and the ease of passage? And are they sitting on the toilet for a really long time? Does it hurt to open their bowels? And then is there any presence of blood? And they have pain when they're passing stool and then always ask if somebody's already taking any laxatives and then your examination should include an abdominal examination, and some people have the stoma, and then they can still become constipated. So it's important to examine the stoma and then a rectal examination. So, like I said before, and it's really important to know whether somebody has an empty rectum. So they may not be constipated if they have a really hard stool sitting there, which might cause overflow, or they've got lots of soft stool, but they're just going to pass it and then some sort of further investigation, So blood tests can be really helpful. A full blood count might point towards anemia, which could signify that there's a potentially a malignant cause, your urine electrolyte seeing if somebody is dehydrated or if there's any kind of electrolyte imbalance liver function test. Like I said before, my point again point towards the malignant cause, um, and you get a good idea of how the how the liver is working and then calcium so looking for hypercalcemia and also tumor markers. So in bowel cancer, they tend to use a see a, um, a tumor marker. So you might want to check that if somebody has a known bowel cancer and then you may have seen the Bristol stool chart already, but this is how we classify stool, um, on the ward. So the nurses tend to record what type of stool patients have when they pass it. Um, with type one being really hard lumps and very hard to pass, and type seven is completely liquid school. So the ideal is probably about five. Um, that's passed easily. Um, but it's really important that you know what they said on that chart and then imaging. So again, an abdominal X ray might be really useful. If you think that someone's got fecal impaction, you might have to see the stool on the x ray sitting in in the rectum or in the rest of the bowel. A CT if you think somebody has an obstruction and then an MRI spine is also really important. So, um, with in oncology, um, malignant spinal cord compression is, um uh, oncological emergency and something that should be ruled out if somebody has, um, you know, any changes to their, um, neurology in their legs and but also, if they're struggling to open their bowels or they're in urinary retention or they've got lots of perianal sensation. So if you think the constipation is tied into some of those symptoms, then you might want to do an MRI spine urgently if you suspect that there is called compression and then the management of constipation. So we've got non pharmacological logical management, so encouraging good oral intake. We aim for two liters a day of fluid reviewing their dietary intake. So again, considering a dietician review, do they need more fiber in their diet and yeah, and then ensuring patients have privacy and access to toilet facilities? So this is really important and and particularly their position when they're going to the toilet, and you might want to teach them, you know, the best position to help with passing stool. You might want to give them a footstool to help keep their knees elevated, encouraging daily exercise if they're able to, um, based on their ability just to help keep the bowels moving, address any kind of reversible factors that might be contributing to the constipation. And then we'll look at the pharmacological management, so that's laxatives. There's lots of different types of laxatives, so we'll go through each one how it works, and then we'll talk about, you know, sort of first line, second line. So you've got your stool softener. So that's docusate. Sodium. Um, stool softeners work by attracting our retaining water in the intestine. So they increase the amount of water that's contained in the stool. You've got your osmotic laxative, so lactulose and macro goals both come under osmotic. So, um, lactulose creates the osmotic gradient across the bowel. And so the gut secrete fluid and that increases stool maths and stimulates movement of the gut as macro goals have balanced electrolytes within them that retain water during transit through the GI tract. And then you've got your stimulant laxatives. So Senna and biisacodyl and the stimulate Paracelsus, which basically pushes everything through the bow and you've got your bulk forming laxatives. So Espanola husk, which is also known as fibre gel, um, and these retain water, which keeps the stool large and soft and also stimulates Paracelsus. And then less known. Laxatives are usually the periphery acting new opioid receptor antagonists. So these are things like in the Aloxi goal which are becoming more and more popular, particularly palliative care. And we often have patients who are on high doses of opioids and and have tried lots of different laxatives that haven't been effective. And basically these work by, um, antagonizing the opioid receptor receptors and in the gut. But they also preserve the centrally mediated receptors, so you still get the Androgel and the analgesic effects of the opioids, but it basically blocks the constipation effects. Um, the issue with blocks. The goal is that it's very expensive, and so we don't tend to prescribe it as a first line medication. But it's definitely something to consider if you've tried lots of different laxatives for someone and it hasn't worked and they're on very high doses of opioids. So some key points when starting the laxatives. So whenever you're prescribing laxatives, there's always things to think about. So that's prescribing should always be based on the detailed clinical assessments. So we've gone through, you know, the assessment from the history, the examination, the investigations. All of these things should be taken into account when you're prescribing laxatives. So you know you're describing the right one for the right cause. Laxatives should always be co prescribed with opioids. Often people are on opioids and they don't have any laxatives. And this is only going to lead to constipation. So, um, it's important that they prescribed and then stimulant laxatives might cause abdominal colic because they're basically just pushing everything through. And so if you're not using them with a softener, that can cause pain because you're basically pushing hard stool through the bow and through the rectum, and and laxatives can take a couple of days to have an effect. So don't prescribe something one day and then change it the next day because it hasn't Someone hasn't opened their bowels and immediately using oral laxatives, Um, and then, like I should be titrated according to patient tolerability and how well they're working. Usually best to, you know, start a certain day and increase it if you need to. Um, and also it's important to think about reducing laxatives or stopping laxatives because sometimes you're going too strong and cause people to have diarrhea, and that can be really distressing. So it's important that they are reviewed regularly, and you ask someone about their bowels very regularly. So, um, I think within, uh, medicine when you're working in the hospitals, people always struggle with what laxative to prescribe because there are so many. And how do you know you're prescribing the right one? Um, this is the Scottish palliative care guideline, Um, which is a really useful resource. They suggest that your option a would be prescribing a stimulant laxative and a softener together. So using senna with docusate sodium. Um, but like I said, if you get colic, um, then the stimulant should be discontinued, and you can just use a stool softener. And also, it's important to avoid using stimulants like, um, center in bowel obstruction because again, that will cause lots of pain. Um, and then your option B would be using an osmotic laxative like macro goals. And if it's very severe constipation, you can give a much higher dose. Um, macro goals can go up to very, very high dose is usually we use sort of 123 sessions a day, but they can go up. And then if those two have been ineffective, um, you can always go to Option C. So I haven't talked about this so much, but you also have rectal treatment. So, um, suppositories or enemas. Um, these can be really useful if somebody is not open their bowels quite a long time or if you, you know, want them to open their bowels quite quickly. Um, but it's important to do your rectal examination before this. So, um, if they've got lots of soft stool in the bowel, then you might want to consider, um, something like a phosphate enema just to basically expel it. Um, if there's heart still there, then if you give them an enema, they're going to be passing really hard stool, and it's going to be incredibly painful. So it's better to use a glycerin suppository first and then to give an enema afterwards, once that's had a chance to soften the stores sitting there and make it easier to pass. Um, and if there's a very hard stool, sometimes we consider something called atarax or enema that's less commonly used in the hospitals. But it's something that we can always consider, and you can give that first and then give a phosphate and, um uh, the following morning if you give it at night. So now I've got, um, a couple of cases just based on the presentation. Um, if it's possible for people to go onto www dot minty dot com and There's just two cases. I know we're close to nine o'clock. I'm in Berlin to eight o'clock. Um, so people could go on there, and I'm just going to get the presentation up. So the code is sorry. Is it your? Oh, yeah, Sorry. The presentation wasn't visible, but it's reappeared. Perfect. Um, do you want to see that? It's still got the code at the top, so just see if that's working and just answer the questions. I'll hover over here. It's just a couple of cases. So the first one is. Ms. X has breast cancer with bone and lung metastases. She develops headaches with vomiting in the mornings, and imaging of the brain by CT shows six large cerebral metastases surrounded by edema. And you think her symptoms are due to raise ICP, which treatment options would be appropriate? I'm just going to check. Actually, there is a, uh, this might be the first one, Actually, number two. Let's see. There we go. Let's try this one first. So an 85 year old woman with diabetes, heart failure and renal failure, who's taking furosemide? 80 mg a day, lisinopril 10 mg a day and digoxin 200 micrograms a day develops nausea with vomiting associated with a normal bowel habit. Um, what do you think are the most likely cause is for her nausea and vomiting, and I'll give you a hint. There's more than one answer. Yeah, just like a few more people answer before I show you. Okay, so So the three possible options here are gastric Stasis, renal failure and digoxin toxicity. So this is a lady with diabetes. First of all, um, it may be that because she's dehydrated and her diabetes control might not be very good, she might be hyperglycemic, which can cause gastric Stasis and cause nausea and vomiting. And she also has renal failure. She's on diuretics. She's on Antihypertensives, and she's been vomiting so again, she's probably quite dehydrated, so renal failure could be causing her to, You know, it's sort of a vicious cycle, but it might also be contributing to the nausea and vomiting. And then she is also on digoxin, so cardiac drugs can cause nausea and vomiting. Okay, that's good. So it seems like everyone's got, um, most of those. And then everyone started answering already, which is great. So, um yeah, so This is a lady with breast cancer with bone and lung metastases. She got headaches with vomiting in the mornings, and imaging of the brain has shown six large cerebral metastases surrounded by edema. And we think her symptoms are due to raised intracranial pressure. Which treatment options would be appropriate. Just wait for a couple more people to answer. Okay, Fab. So, um, I think the three answers are the most popular, Which is great. So, um, discussing with an oncologist is really important. She has known cancer, but she's got a new diagnosed cerebral metastases. And she's, I think she's got raised ICP. So it's important to speak to her oncologist and and, yeah, basically see if there's anything other than, um, anti emetics, um, and other medications that might help, Like radiotherapy or surgery. Um, any anti cancer treatment and then high dose dexamethasone. That's great. So that will help reduce the edema and help with the nausea and vomiting and then leave over promazine, um, or cyclizine a good drugs for raising intracranial pressure. So that's great. Um, and yeah, that's the end of my presentation. Thank you so much for listening. I think I know it's a bit late, but if there's any questions, you might have a few moments for that. And here are some references. So, um, I don't know whether anyone's got access to the the learning for healthcare, but they've got a really wonderful end of life care series. Um um and they've got presentations on causes of nausea, vomiting, assessment management and also of constipation and loads of other symptoms and communication skills. And then, um, the Scottish party care guidelines are really, really helpful. And they've got an amazing glossary of terms and pages on medications and how to manage common symptoms. So I really recommend those amazing thank you so much is the That was that was really brilliant, very, very thorough. If anybody has any questions, please feel free to put them in the chat. Um, and if not perhaps seeing as we had just gone eight o'clock, maybe we'll leave it tonight. But yeah, brilliant. I think that was really useful. Lots of really good stuff, both for clinical practice and for exams there. I'm just going to post in the chat the link for next week's talk, which is going to be about palliative emergency so also will be useful both for working and but definitely, for example as well. So yeah, I hope you will enjoy tonight and looking forward to seeing some of you next week. Thanks very much. We have a question. Sorry is the We do have a question. Do you use a lands up in for nausea? Oh, that is a good question. It can be used. It's not very commonly used. Um, I think it tends to usually be used more for things like agitation. Sometimes we use in palliative care. Um, but not so much for nausea that I've seen commonly, I don't think there's any I don't know if it's actually, um, What's the word If there's any sort of regulations about using a landscape in in nausea? Um, but it's Yeah, it might be one of the sort of emerging medications. Well, thank you. Okay. Good night, everyone. Thanks very much. Bye. Thank you. Bye. Yeah,