02.16.2024

Back to Basics: Gastrointestinal Symptoms

“I feel nauseous.”

“I haven’t had a bowel movement in four days.”

Do these statements sound familiar? While we can acknowledge that gastrointestinal (GI) symptoms such as nausea and vomiting, constipation, and diarrhea are common in hospice practice, the assessment and management may be complex.

Let’s take constipation, for instance. As part of the Hospice Item Set (HIS) Comprehensive Assessment Measures 1 available via the Centers for Medicare and Medicaid Services (CMS), at hospice admission, a bowel regimen must be assessed for all patients started on a scheduled or “as needed” opioid regimen. According to the CMS HIS Manual,2 a bowel regimen may include components such as diet, laxatives, and stool softeners and is patient-specific.

But what kind of bowel regimen? What is the best medication to manage nausea? Consider the following:

  • A patient with heart failure using morphine “as needed” and struggling with constipation may be approached differently than a constipated patient with colorectal cancer with metastases to the liver.
  • Likewise, opioid-induced nausea and vomiting may present and be managed differently than nausea and vomiting due to gastroparesis.

Strong clinical assessment skills and a sturdy foundation of hospice symptom management best practices are imperative for positive patient outcomes. Let’s dive deeper into this topic using patient cases to learn more about assessing common GI symptoms and selecting appropriate therapy.

PATIENT CASE #1 – Constipation, Colorectal Cancer and Liver Metastases

OT is a 62-year-old male admitted to hospice 3 weeks ago with a primary diagnosis of colorectal cancer with metastases to the liver. His pain is well controlled; however, his last bowel movement was 4 days ago. OT’s nurse reports he is becoming increasingly confused and agitated. He has normal food, fluid, and medication intake and does not report any nausea.

Current Medications

  • Methadone 10mg – take 1 and 1/2 tablets (15mg) by mouth every 8 hours for pain
  • Oxycodone 30mg – take 1 tablet by mouth every 4 hours as needed for pain
  • Bisacodyl 5mg – take 2 tablets by mouth daily for constipation

Constipation Assessment

A simple way to assess a patient with constipation, or really any symptom, is to use the mnemonic PQRSTU:3

  • P (What precipitates or palliates the symptoms?): Does anything make the constipation worse? Have you tried any medications or non-pharmacological therapies to control the symptoms?
  • Q (What is the quality (or quantity) of the symptom?): Is the stool difficult to pass, infrequent (compared to patient’s normal), smaller than normal, hard?
  • R (region or radiation of symptoms): Where exactly do you feel the constipation? Do you feel the symptoms elsewhere?
  • S (severity or scale): How would you rate the severity of the constipation?
    • Ask the patient to indicate whether, during the past 3 days, they have had NO PROBLEM, SOME PROBLEM, or a SEVERE PROBLEM with each of these items:5
      • Abdominal distention or bloating
      • Change in amount of gas passed rectally
      • Less frequent bowel movements
      • Oozing liquid stool
      • Rectal fullness or pressure
      • Rectal pain with bowel movement
      • Small stool size
      • Urge but inability to pass stool
  • T (time or temporal relationship): When did the constipation begin? When was the last bowel movement? What is your normal frequency of bowel movements?
  • U (How does the symptom affect YOU (the patient)?): Is the constipation causing any other issues? Are you feeling nauseous or have you vomited? Can you keep anything down? Can you take oral medications?

There are some medications that are known to develop and worsen constipation. Some common medication classes include opioids, anticholinergics, anti-diarrheal agents, diuretics, anti-emetics, iron, calcium, and aluminum-containing acids.6 While several of these drug classes are used in hospice patients, it is important to keep in mind that constipation, as a side effect, is common and needs to be addressed.

Laxative Classes and High-Level Refreshers 6

  • Surfactant (i.e., stool softeners) (e.g., docusate sodium) – Ineffective for prevention or treatment of chronic constipation and do not increase GI motility.
  • Stimulant (e.g., senna, bisacodyl) – Recommended for initial treatment, or added “as needed”, for chronic constipation especially with concomitant opioid therapy.
  • Osmotic (e.g., lactulose, polyethylene glycol (Miralax®), sorbitol) – Utilize when cramping occurs with stimulant laxative and patient is not dehydrated. May also be added to existing bowel regimen for persistent constipation but may contribute to dehydration.Glycerin suppositories and sodium phosphate enemas and oral solution (e.g., Fleets) are also considered osmotic laxatives and are reserved for patients unable to tolerate other products. Serum electrolyte changes (including hyperphosphatemia, hypocalcemia, hypokalemia, and hypernatremia), fluid retention, and edema have been observed in patients using sodium phosphate products.7
  • Bulk-forming (e.g., psyllium (Metamucil®)) – Bulk-forming laxatives are typically not recommended for constipation in hospice patients because patients are often unable to tolerate the volume of liquid necessary for administration.
  • Lubricant (e.g., mineral oil) – Mineral oil administered orally can increase risk for aspiration pneumonia, therefore it should be avoided in patients with dysphagia.
  • Saline (e.g., magnesium citrate (Citroma®), magnesium hydroxide (Milk of Magnesia®)) -magnesium-containing laxatives are contraindicated in renal failure.

Patient Case #1 Assessment

Patient is already on a stimulant laxative for symptom management that is recommended as initial treatment for chronic constipation, including opioid-induced constipation. However, this patient continues to experience constipation with additional symptoms of confusion and agitation.

While it’s important to perform a complete history and physical assessment, there are a few things to consider right away to identify the root cause of his constipation:

  • Is this opioid-induced constipation with the current bowel regimen not working effectively?
  • Has an impaction or obstruction from the colorectal cancer been assessed?
  • What is the source of the confusion and agitation?

This patient’s current bowel regimen is not working effectively as evidenced by persisting constipation. In addition, the patient has a decline in mental status. Considering the patient’s diagnosis of colorectal cancer with metastases, specifically to the liver, further assessment is needed.

Damage to the liver (liver disease) can cause a buildup of toxins that can no longer be filtered from the blood, causing mental symptoms such as confusion and agitation known as hepatic encephalopathy. 8 With this knowledge, patient recommendations can be made.

Patient Case #1 Recommendations

Consider lactulose, an osmotic laxative, for the treatment of both constipation and mental status. Lactulose is widely used as an initial therapy for hepatic encephalopathy to reduce blood ammonia levels that are often elevated in patients with liver disease. 8

  • Initiate lactulose 10mg/15ml: 7
    • Take/give 30ml by mouth every 1-2 hours until 2 stools daily, then
    • Titrate the dose to maintain 2-3 stools a day (e.g., 15-60 ml by mouth four times a day)

Consider changing the directions on bisacodyl tablets to “as needed for no bowel movement for 2 days”.

Constipation Clinical Considerations

  • All patients prescribed opioid therapy should have a bowel regimen in place; if the opioid is taken on a scheduled basis, the laxative needs to be taken on a scheduled basis.
  • If patient is impacted, perform fecal disimpaction prior to initiating a bowel regimen. Pre-medicate with sedative and analgesic, if clinically appropriate.
  • Treat persistent constipation or fecal impaction with enemas, as needed; however, use sparingly, as frequent use negatively affects normal colon mucus, a stool lubricant.
  • Laxatives may be discontinued when death is imminent. Manage discomfort with suppositories or enemas, as needed.

Now let’s review another set of common GI symptoms, nausea and vomiting…

PATIENT CASE #2 – Nausea and Vomiting with Metastatic Prostate Cancer

MG is a 55-year-old male admitted to hospice care with a primary diagnosis of metastatic prostate cancer. He has been started on opioids for pain control and stimulant laxatives to prevent constipation, which have kept him regular. Today, MG’s caregiver reported persistent nausea and vomiting. The nausea is not associated with movement or with any type of food or smell. He has tried ginger ale and flat cola to help relieve his symptoms, but they did not help.

Current Medications

  • Morphine extended-release 15mg – Take 1 tablet by mouth every 12 hours for pain
  • Senna-S – Take 2 tablets by mouth two times a day for constipation

Nausea and Vomiting Assessment

It is important to complete a full physical assessment including the pattern of nausea and vomiting, triggering factors, causative agents, and effects of nausea and vomiting on the patient. In addition to an assessment, understanding the root cause of nausea and vomiting helps drive treatment options.

The VOMIT acronym is useful in identifying the causes of vomiting:9

  • Vestibular (affecting cholinergic and histaminic receptors) (i.e., motion sickness)
  • Obstruction of bowel due to constipation
  • Drug DysMotility of the upper gut
  • Infection, Inflammation
  • Toxins stimulating the Chemoreceptor Trigger Zone (e.g., opioids, antimicrobials)

Use of the mnemonic PQRSTU is also useful to assess this symptom:

  • P: Does anything make the nausea and vomiting worse? Have you tried any medications to control the symptoms?
  • Q: What is the consistency/contents of the emesis? Does it contain food, blood, mucus, etc.?
  • R: Where do you feel the nausea? Do the symptoms radiate to any other part of the body?
  • S: How many times a day are you vomiting? Are you able to rate the severity?
  • T: When did the nausea and vomiting begin? Is the nausea constant or intermittent?
  • U: Is the nausea and vomiting causing any other issues such as feeling anxious, weak, dizzy, or having muscle cramps? Can you keep anything down? Can you take oral medications?

Commonly Known Medications That May Cause Nausea and Vomiting:

  • Chemotherapeutic agents
  • Opioids
  • Aspirin and NSAIDs
  • Antibiotics
  • Anticonvulsants

Antiemetic Classes and High-Level Refreshers 9,10

  • Antihistamines (e.g., hydroxyzine, diphenhydramine, promethazine, meclizine)
    • Useful for vestibular causes of nausea and vomiting. Antihistamines are weak antiemetics that are usually indicated for vestibular-mediated nausea and vomiting, and for preventing extrapyramidal (motor control) side effects from dopamine antagonists (e.g., haloperidol, prochlorperazine).
  • Dopamine Antagonists (e.g., haloperidol, prochlorperazine)
    • Effective for managing opioid-induced nausea and vomiting, intractable nausea and vomiting and nausea and vomiting due to unknown etiology or related to a metabolic imbalance.
    • Agents with stronger antihistaminic actions (e.g., phenothiazines such as prochlorperazine) can be effective for nausea and vomiting related to motion sickness, vestibular disorders or increased intracranial pressure (e.g., cerebral metastases) compared to other dopamine antagonists.
  • Prokinetic Agents (e.g., metoclopramide)
    • Effective for nausea and vomiting related to decreased motility (i.e., dysmotility) in the upper gastrointestinal tract (e.g., gastroparesis)
    • Chronic use of metoclopramide has been linked to tardive dyskinesia, which may include involuntary and repetitive movements of the face and body, even after metoclopramide is stopped.
  • Serotonin (5-HT3) Receptor Antagonists (e.g., ondansetron)
    • Effectiveness increased when given in combination with dexamethasone for its anti-inflammatory actions. When dexamethasone (or any corticosteroid) is administered in divided doses, it is suggested that the last dose be given in the early afternoon to avoid insomnia.

Patient Case #2 Assessment

MG has tried multiple non-pharmacological therapy interventions to alleviate nausea and vomiting. While additional non-pharmacological methods could be offered, time is limited in our patient population and pharmacological support will manage symptoms more promptly.

Here are a few things to consider based on this patient’s symptoms to determine the root cause of the nausea and vomiting:

  • Is nausea and vomiting cancer-related, medication-related, multifactorial, or something else?
  • Is the nausea and vomiting reversible and can corrective action be taken? Or are we simply palliating the symptoms?

In this case study, since the patient just started on opioids for pain control and is now experiencing these symptoms after opioid introduction, it’s highly probable that the nausea and vomiting is opioid-induced.

Patient Case #2 Recommendations:

Patients often become tolerant to opioid-induced nausea and vomiting over time. In the interim, initiating dopamine antagonist pharmacological therapy is indicated. Initiate one of the following:

  • Haloperidol 0.5mg – Take 1 tablet by mouth every six hours as needed.9
  • Prochlorperazine 5mg – Take 1 tablet by mouth every six hours as needed.8

Further Reading

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REFERENCES

  1. Centers for Medicare & Medicaid Services (CMS). Hospice Item Set (HIS). Accessed 9 Feb 2024. Link
  2. Centers for Medicare & Medicaid Services (CMS). Hospice Quality Reporting Program: Current Measures. Accessed 14 Feb 2024. Link
  3. The PQRSTU Assessment. In: LibreTexts: Medicine. 8 Mar. 2020. Link
  4. Continence Foundation of Australia. Bristol Stool Chart. 2020. Link
  5. Chang VT. Approach to symptom assessment in palliative care: Constipation Assessment Scale. In: UpToDate, Smith TJ, Givens J, eds. Waltham, MA: UpToDate, Inc., Updated Feb 28, 2022.
  6. Enclara Pharmacia Palliative Pearls. Opioid-Induced Constipation Case. 17 Sep 2018. Link
  7. Clinical Pharmacology [database online]. Tampa, FL: Elsevier/Gold Standard, Inc.; 2024.
  8. American Liver Foundation. Complications of Liver Diseases: Hepatic Encephalopathy. 2024. Link
  9. Kamell A, et al. Fast Facts #5: Nausea and Vomiting-Common Etiologies and Management. Palliative Care Network of Wisconsin. 28 Jan 2019. Link
  10. Enclara Pharmacia Palliative Pearls. Nausea and Vomiting, Sources and Palliative Management. 17 Jul 2019. Link

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