Key notes on symptom control issues in Palliative Care

Squashed stomach syndrome
Step one	Make the clinical diagnosis
Step two	Trial of metoclopramide +/- oral steroids
Step three	Ask for help

Is characterised by a combination of anorexia, a feeling of fullness in the hypochondrium, pain and rapid satiation during a meal. Some patients may also vomit or regurgitate rapidly after meals. It is often associated with liver metastases and/or upper gastrointestinal surgery. There is a combination of partial obstruction of the gastric outlet and reduced capacity of the stomach.

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  Advise small, regular, high calorie snacks and supplement drinks rather than big meals.
  
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  Try a combination of metoclopramide 20mg every 4-6 hours with oral dexamethasone 8mg as single daily dose. Remember to prescribe appropriate GI protection. If the patient is vomiting, the drugs may have to be administered parenterally using a syringe driver.
  

Hiccups

Hiccups
Step one	Diagnose the cause and treat if possible	Re-breathing and position
Step two	Antacids and proton pump inhibitor	Trial of metoclopramide +/- oral steroids
Step three	Ask for help

Intractable hiccup is uncommon, but usually occurs in patients with cancer affecting the thorax or upper abdomen, including mediastinal lymphadenopathy and liver metastases. They can be very difficult to manage. Early involvement of specialists in palliative care should be considered.

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  Simple techniques such as re-breathing using a brown paper bag may help as may altering a patient’s position.
  
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  Antacids prescribed with proton pump inhibitors may reduce inflammation in the upper GI tract and thus the frequency and pain associated with the hiccups.
  
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  Oral metoclopramide 20mg every 4-6 hours acts as a prokinetic and may help, particularly if there are associated liver metastases causing a squashed stomach.
  
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  Oral steroids dexamethasone 4-8mg as a once daily dose, with appropriate GI protection, may help to improve both the hiccups and anorexia if present.
  
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  Baclofen 5mg every 8 hours may help, but this is beyond its product licence and needs to be discussed with the specialist palliative care service.
  
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  Major tranquillisers such as chlorpromazine in small doses have found to be helpful in some patients but must be used with caution and under the direction of a specialist.
  

Sweating