Key notes on symptom control issues in Palliative Care

Nausea and Vomiting (continued)
Raised intracranial pressure

This may be due to a primary brain tumour, brain metastases and / or meningeal spread. High dose oral steroid 12mg dexamethasone given as single daily dose first thing in the morning (with appropriate GI protection) is the drug of choice. The dose should be titrated downwards over the subsequent days or weeks depending on the patient’s response. This may need to be combined with cyclizine or levomepromazine (as above).
Movement related

This may be due to a middle ear infection, vestibular problems or tumour at the cerebello-pontine angle. Cyclizine is the drug of choice (as above).
Regurgitation

This is common with oesophageal tumours or where there is mediastinal lymphadenopathy, causing extrinsic compression of the oesophagus. Interventions such as stent insertion, endoluminal radiotherapy and laser therapy, where available, may help. Metoclopramide is the anti-emetic of choice. Antacids combined with a proton pump inhibitor may help the gastritis and oesophagitis that occurs.
Anxiety

Fear and anxiety may contribute to nausea and vomiting. Stress relieving measures such as relaxation techniques as well as anxiolytics such as diazepam may help. Acupuncture may help some people. Occasionally some patients undergoing chemotherapy or radiotherapy develop anticipatory vomiting. This often needs specialist input to ensure that compliance with therapy as well as good symptom control is achieved.


Intestinal Obstruction

Intestinal obstruction
Step one	Diagnose the cause and treat if possible	Consider palliative surgery
Step two	Commence syringe driver with appropriate anti-emetics	Trial of hyoscine butylbromide and /or dexamethasone
Step three	Trial of octreotide	Ask for help

Any patient with cancer that affects the abdomen or pelvis may develop bowel obstruction, but it is most common in patients with ovarian and colorectal cancers.