Gastrointestinal Symptoms

Published on 09/04/2015 by admin

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33 Gastrointestinal Symptoms

A 16-year-old girl with cystic fibrosis and advanced but stable lung disease was hospitalized with severe abdominal pain, nausea, and anorexia following viral gastroenteritis. There was an initial belief that she may have a partial bowel obstruction but this was ruled out after multiple investigations failed to show any significant organic factors. She adamantly denied anxiety or depressive symptoms.

The gastrointestinal symptoms did not improve with standard psychological and pharmacologic strategies, and her lung function began to deteriorate further secondary to weight loss and immobility. A family meeting involving the psychosocial team, the teen, and her parents provided a forum for her parents to discuss their spiritual beliefs and the teen’s acceptance that she would die from her condition at some stage. This was distressing for the teen to hear and allowed her to talk about her own anxieties about death, her fear that her symptoms represented a terminal illness, and that her death would be sudden and unexpected and that her family could not be present because of that. She had been reluctant to discuss these matters with her parents as she believed they would be disappointed in her.

These revelations opened the way for her primary pediatrician to discuss with her the likely modes of death from cystic fibrosis, and the expectation that her death was not imminent given good nutrition and mobilization. The pediatrician also promised to talk openly and honestly with her when her lung function declined to the point that her death was near. Within several days the young woman was eating well, mobilizing, communicating more openly with her family, and her pain levels were manageable. She lived with a good quality of life for an additional 14 months before dying at home with her family present.

This vignette highlights a number of important concepts of pediatric palliative care and pediatric medicine in general. Arguably, the most important of these is the existence of a strong, inextricable link between the physical and the psychological, or the mind-body link. This link brings into sharp relief the need to work in an interdisciplinary fashion, as no one person and no one discipline has the full skill set to adequately address the needs of a child, and his or her family, with a life-threatening condition.

Adherence to a purely mechanistic and/or biological approach to care provides some degree of success and, in controlling troublesome symptoms, can open the door to address the wider emotional, psychosocial, and spiritual issues that are present. Not addressing these appropriately ultimately means lost opportunities and inferior care. In this example, symptoms were not amenable to a pharmacologic approach and should stand as a warning that properly investigated and treated symptoms that remain uncontrolled indicates the need to deal with an underlying psychological, emotional, and/or spiritual issue.

A well-functioning interdisciplinary team is critical to the management of gastrointestinal symptoms in pediatric palliative care. The nature of the interdisciplinary work in a specific team is often shaped by the members of the team and the range of disciplines included. In addition to the holistic child and family focused skill set expected of all team members, there are some particular skills that are more specific to nurses, medical practitioners, or psychosocial clinicians.

Nurses often provide overall case management that incorporates ongoing symptom assessment, medication management, and psychosocial care, but they also have unique skills in the assessment and provision of physical care and comfort to the dying child. Some of these skills include providing and/or teaching family members developmentally appropriate strategies for feeding, toileting, wound care, line management, medication administration, and positioning and pressure area care.

Physicians have particular skills and training in diagnostic assessment, particularly where there are complex symptoms, in palliative treatment and/or management planning, and in pharmacologic interventions.

Psychosocial or mental health clinicians may come from a variety of disciplines including psychology, psychotherapy, social work, child life, chaplaincy, and psychiatry. Specific skills include the assessment of more complex mental health issues for children and family members and of challenging family interaction or communication difficulties. They can provide psychotherapeutic input such as play therapy, cognitive behavioral therapies for such things as anxiety, depression, pain, nausea, hypnosis training, focused family and couple work, and in some instances, systems interventions where communication difficulties are present among teams involved in the child’s care.

Gastrointestinal symptoms and distress are relatively common in children and are not limited to those receiving palliative care. Tummy-aches and vomiting are integral to the childhood portrayed by Shakespeare with his ‘mewling and puking’ infant, and the nursery rhymes and songs of childhood where ‘Miss Polly had a dolly that was sick, sick, sick’ and on the good ship Lolly-pop where ‘if you eat too much, oh, oh, you’ll awake with a tummy-ache.’ As many as 30% of otherwise healthy children will experience recurrent abdominal pain during childhood, one in six adolescents report functional gastrointestinal symptoms consistent with irritable bowel syndrome (IBS),1 and abdominal discomfort maybe the primary presenting symptoms for the child with anxiety and emotional difficulties.

Gastrointestinal symptoms are prominent among children receiving palliative care. Six studies examining the prevalence of distressing symptoms in a total of 592 children with malignant and non-malignant diseases reveal that the majority of dying children experience pain, 53% to 92%, and fatigue, 52% to 97%, during their end-of-life period. In addition, a large percentage suffer from gastrointestinal symptoms such as vomiting and/or nausea, 40% to 63%, constipation, 27% to 59%, and diarrhea, 21% to 40%.27

Many of these children will have previously experienced abdominal pain, nausea and vomiting, anorexia, and disturbed bowel function in association with their primary disease, or as a consequence of treatment and treatment complications. The result is that they and their parents may be particularly anxious and sensitized to any recurrence of symptoms, as this may be perceived as a heralding event to deterioration and the onset of the final stages of the child’s illness. In addition, any alteration or loss of the normal bodily rhythms of eating and toileting is disquieting for families; the inability to feed and nourish their child may symbolize failure of the most fundamental parenting role, and loss of bowel control may be humiliating and seem like the final insult for a young person with a life-threatening illness. For these reasons alone, the evaluation and management of the many potential contributors to gastrointestinal distress is challenging and requires a holistic approach.

This chapter aims to provide treatment algorithms for individual gastrointestinal symptoms as originally proposed in 2000.8 The evidence for any recommendations made is often poor due to the lack of randomized controlled trials (RCTs) in pediatric palliative care and, unfortunately, pediatrics continues to be hampered by the common, unacceptable problem of many medications not being approved for use in children or for the specified indication resulting in off-label use.

Nausea and Vomiting

Nausea and vomiting is one of the most distressing symptoms for ill children and their caregivers. Gastrointestinal, central nervous system (CNS), metabolic, pharmacologic, and psychological factors may all contribute, and prolonged episodes of nausea and vomiting may themselves contribute to the development of anticipatory nausea and conditioned vomiting. Treatment approaches are best based on the presumed, following careful assessment, underlying pathophysiology and management should include integrative therapies, such as cognitive behavioral therapies, aromatherapy, and acupressure, where appropriate.

Pathophysiology

Vomiting is controlled by two distinct brain centers, the vomiting center and the chemoreceptor trigger zone (CTZ). Both are located in the medulla oblongata with the CTZ lying outside the blood-brain barrier in the area postrema at the floor of the fourth ventricle, while the vomiting center is located inside the blood-brain barrier.

Excitation of the vomiting center results in nausea and vomiting and the reflex may result from the following input:

Toxins commonly associated with nausea and vomiting during the pediatric end-of-life period include medications such as chemotherapeutic agents, antibiotics, and opioids, and metabolic byproducts of uremia or hepatic failure.10

The majority of receptors in the vomiting center and CTZ are excitatory, that is, they induce nausea and vomiting with stimulation. An important exception is the presence of the μ-opioid receptor in the vomiting center. Opioids seem to have a dose-dependent interaction on emesis. At standard doses, opioids may cause nausea by stimulating D2-receptors in the area postrema but at high doses opioids are often not emetic. This is postulated to be due to an antiemetic or inhibitory effect at the μ-opioid receptor in the vomiting center.9,11

Treatment algorithm

Step 3: Implement Integrative and Supportive Therapies

The combination of supportive and integrative modalities with pharmacologic management should be seen as a gold standard to any pain and symptom management approach in the twenty-first century.14 Integrative and supportive approaches include the provision of small meals chosen by the child, frequently offering favorite drinks, good oral care, and the avoidance of discomforting smells.

Management of anxiety for the child and his or her family is paramount and should start with careful explanation of the likely factors contributing to the symptoms. A number of therapeutic techniques can be used to help the child to relax, feel calmer, and have a greater sense of control. These include cognitive behavioral strategies such as simple relaxation exercises, controlled breathing, and focusing on positive self messages and imagery. Younger children may need a parent to cue them and help them with guided imagery and stories, while older children can be taught self-hypnosis to manage symptoms. Pleasant masking aromas of the child’s choosing can also be used if there are particular odors that trigger nausea. Scheduling enjoyable distracting activities including music, or acupressure or acupuncture may also be useful for some children.9,1520

D2-Receptor Antagonists

Dopamine2-receptor antagonists such as metoclopramide (Reglan) and haloperidol (Haldol) are prokinetic and have been clinically effective in treating nausea and vomiting in pediatric palliative and hospice care. Stress, anxiety, and nausea via peripheral dopaminergic receptors at the plexus myentericus may cause a slowing of gastrointestinal passage, the so-called dopamine break. This effect is antagonized by metoclopramide (Reglan) and domperidone (Motilium).30 Other D2-receptor antagonists may have a similar effect.

They may, however, be underused due to an overemphasis on possible extrapyramidal reactions. Metoclopramide has been associated with a dyskinetic syndrome and reported to occur with an incidence of 1:5000 in teenagers.31 Any such reaction can be treated with either a centrally acting antihistamine, such as diphenhydramine (Benadryl), or central anticholinergic, such as benztropine. This concern extends to a lesser extent to phenothiazine derivates (psychotropics) such as haloperidol (Haldol), prochlorperazine (Compazine), and chlorpromazine (Thorazine). Chlorpromazine and prochlorperazine are also H1– and AChm– receptor antagonists.

Domperidone does not cross the blood-brain barrier and therefore does not cause extrapyramidal side effects. The intravenous form of domperidone was discontinued following reports of cardiovascular adverse effects.

Prokinetics should not be administered concurrently with antimuscarinic agents, such as diphenhydramine or scopolamine, as these block the final common pathway for prokinetic agents. The concurrent administration of diphenhydramine and metoclopramide to prevent a dyskinetic syndrome, as practiced in some centers, will therefore result in the loss of metoclopramide’s prokinetic effect, however not of its antiemetic effect. The concurrent intravenous administration with 5-HT3-receptor antagonists increases the risk of cardiac arrhythmia. Droperidol (Inapsine), a butyrophenone neuroleptic similar to haloperidol, can no longer be recommended because of the risk of QT prolongation.

NK1-Receptor Antagonists

Aprepitant (Emend), a neurokinin-1 receptor antagonist, possesses antidepressant, anxiolytic, and antiemetic properties. NK1 receptors can be found in the central and peripheral nervous system, as well as the gastrointestinal tract. RCTs indicated it to be superior to ondansetron 24 to 48 hours post-surgery when given as a single pre-operative dose32,33 but, in general, pediatric data is scarce.34 One RCT (n = 46) in adolescents with chemotherapy-induced nausea and vomiting showed the combination of aprepitant (125 mg IV TID), dexamethasone, and ondansetron to be superior to dexamethasone and ondansetron alone.35

Cannabinoids

The activation of the endocannabinoid system suppresses behavioral responses to acute and persistant noxious stimulation, and d-9-tetrahydrocannabinol (THC) has been shown to have an antiemetic effect.36 THC can also stimulate appetite in addition to minimizing nausea.

Two types of cannabinoid receptors have been identified, CB1 and CB2. CB1 receptors are found in the central nervous system, including periaqueductal gray, rostral ventro-medial medulla and in peripheral neurons, where activation produces a suppression in intestinal neurotransmitter release.37 Dronabinol and nabilone do not fully replicate the effect of total cannabis preparations38 but a meta-analysis of 30 RCTs (n = 1366 patients)39 showed cannabinoids to be effective for controlling chemotherapy-related sickness in adults. Adverse effects included dizziness, dysphoria, depression, hallucinations, paranoia, and arterial hypotension.

Propofol

Propofol possesses antiemetic properties at subhypnotic doses.45,46 The mechanism of action of this short-acting hypnotic and general anesthetic is not well defined and possibly includes potentiation of GABA-A receptor activity,47 sodium channel blocking activity,48 and activation of the endocannabinoid system.49 One adult case study reports successful nausea management in palliative cancer care at 0.6–1 mg/kg/h intravenously.50 Little pediatric data is published51 but the experience of the program in Minnesota with low-dose propofol in 12 children and teenagers52 points to it having an important role in managing refractory pain and nausea at the end-of-life when other agents fail (Table 33–1).

Constipation

Hardly any other topic in palliative care provokes more discussion than the treatment of constipation. This could be in part due to it being such a common symptom, at 27% to 59% in children at the end of life, that healthcare workers feel sufficiently knowledgeable about its treatment to have an opinion. Yet, constipation can be quite difficult to manage, resulting in a significant impact on the child and their family. This makes prevention of constipation of utmost importance in pediatric palliative care.

Normal stool frequency varies in children from three times per day to once every 3 days, and in the case of a breast-fed infant, up to once every 2 weeks. Common reasons for constipation in pediatric palliative care include dietary changes, a decrease in fluid and/or food intake, and a decrease in mobility and activity as colon peristalsis is, in part, stimulated by activity.

Chronic constipation is common in children with underlying neurologic impairments related to longstanding poor tone and immobility, while in children with cancer intra-abdominal tumors can cause direct compression of the gut or spinal cord compression.10

Treatment algorithm

Stool Softener

Stool softeners include liquid osmotic laxatives, such as lactulose, sorbitol, and polyethylene glycol, which draw water into the bowel by osmotic effect and surfactant laxatives including docusate sodium, which increase water penetration.

Outside the United States, the most commonly used stool softener in pediatrics appears to be the sugar lactulose, a combination of galactose and fructose (Enulose).54,55 Lactulose does not affect the management of diabetes mellitus. In North America, polyethylene glycol (Miralax) is frequently used instead, and has also shown to be effective and safe.54,5658 Lactulose’s advantage over polyethylene glycol is the much smaller volume, which is beneficial in the pediatric palliative care setting, where children often have trouble taking medication orally. All laxatives, including stool softeners, may cause abdominal pain and meteorism.

Suppositories and Enemas

As mentioned previously, in cases of severe impaction a child may need to receive a rectal suppository or enema for relief. Some young people are acutely embarrassed and resistant to even the thought of using a suppository or enema. This may be a particular issue in early adolescence when bodily concerns, increased self-consciousness, and concerns about privacy are prominent. Careful explanation of the choices and reasons for use of enemas or suppositories is needed, along with negotiation about who the young person would feel most comfortable with to assist them. In cancer patients with neutropenia and/or thrombocytopenia, the rectal administration needs to be weighed against the risk of infection and/or bleeding. Glycerine suppositories promote defecation by softening and lubricating the mass as well as stimulating defecation. The Pain & Palliative Care team in Minneapolis has gathered good experience with the polyphenolic bisacodyl suppositories, which act principally by promoting colonic peristalsis.

Enemas may be required if the constipation is unresponsive to combined scheduled stool softeners and stimulant laxatives. Adult data shows that sodium phosphate/sodium biphosphate enemas, or saline rectal laxatives, and docusate sodium/glycerin mini-enemas, or surfactant rectal laxatives, are equal in efficacy.62 However, the latter is usually preferred in pediatrics because of its much smaller enema volume of 2.5–5 mL compared with 130 mL.

If a manual evacuation is considered, adequate analgesia and sedation would be the expected standard of care.

Naloxone

The oral administration of naloxone anecdotally seems to have good effect in adult palliative care. Dose suggestions include 20% of oral morphine equivalent divided into one or several doses.63 There is no published data about the intravenous administration of ultra-low-dose naloxone for constipation management, however the Minneapolis team has had several pediatric cases with very good results in their pediatric palliative care population with a dose of 0.25–1 mcg/kg/hr.

Diarrhea

A significant number of children (21% to 40%) experience diarrhea during their end-of-life period. Fecal incontinence is often particularly humiliating for older children and adolescents who have been previously independent in their personal cares.

Treatment algorithm

Step 2: Treatment of Underlying Causes

Severe diarrhea resulting in dehydration may require oral rehydration with electrolyte/glucose solution. If possible and feasible in the individual child, underlying causes of diarrhea should be treated. Frequent treatable causes include:67,68

Step 4: Pharmacologic Management

RCT in the management of diarrhea in pediatric palliative care do not exist, however some studies include children with life-limiting conditions.

Loperamide

Loperamide is a potent μ-receptor opioid agonist and, although well absorbed from the gastrointestinal tract, it is almost completely metabolized by the liver and excreted via the bile. Loperamide does not cross the blood-brain barrier. As a result this agent acts via a local effect in the GI tract. However, it may take 16 to 24 hours for loperamide to show maximum effect in diarrhea treatment.70 As with morphine and other opioids, loperamide decreases propulsive activity, but unlike other opioids also has an antisecretory effect.71 If toxic substances are the pathophysiologic basis of diarrhea and need to be excreted, then the use of loperamide is not recommended.

Although three pediatric trials (n = 95) did not show a significant lorapamide effect,7274 four other trials were able to demonstrate a decrease in stool frequency and duration of diarrhea.7578 A case series of 15 children with chronic diarrhea following resection of advanced abdominal neuroblastoma, possibly resulting from disruption of the autonomic nerve supply to the gut during clearance of tumor from the major vessels of the retroperitoneum, demonstrated that loperamide reduces but did not abolish symptoms.79

Adverse effects, such as constipation or bloating, were uncommon in these trials and case reports. However children, especially infants, occasionally demonstrated central nervous side effects such as opioid over-sedation. Of note, inhibitors of P-glycoprotein such as ketoconazole, omeprazole, quinidine, and verapamil allow loperamide to cross the blood-brain barrier and as a result manifest central opioid effects.80 An overdose of loperamide in 216 cases has not resulted in life-threatening adverse effects or deaths with doses up to 0.94mg/kg.81

Bismuth subsalicylate

The mechanism of bismuth subsalicylate (Pepto-Bismol) is not well understood. A decrease in length of acute diarrhea symptoms could be shown in children with acute82,83 and chronic70,84 diarrhea. To prevent Reye’s syndrome, this medication and other salicylates should not be administered in children with viral infections.85 The administration of bismuth subsalicylate may result in black stools.

Colestyramine

Colestyramine (Questran) is a bile acid sequestrant, which binds bile in the gastrointestinal tract to prevent its reabsorption. Cholestyramine is primarily administered in the management of hypercholesterolemia, but also in the treatment of pruritus induced by liver failure and chronic diarrhea. Three pediatric trials74,86,87 (n = 78) resulted in a reduction in the duration of diarrhea. Case reports in the successful management of chronic pediatric diarrhea have been published.8891 One study (n = 39 infants and children) showed treatments with cholestyramine and bismuth sub-salicylate were equally effective in decreasing stool frequency in patients with green diarrhea, such as following partial illeocolectomy or Candida albicans overgrowth, however children with brown stools had an insignificant response to therapy.70 Because cholestyramine is not absorbed systemically, there are no severe systemic side effects. Possible adverse effects, such as abdominal pain, flatulence, and constipation, were not reported in the pediatric literature.

Anorexia and Cachexia

At its simplest, anorexia is a loss of appetite, while the definition of cachexia has been disputed until recently. In 2008 a consensus definition for cachexia emerged as “a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass.”96 Anorexia and cachexia are two interrelated symptoms that are often acknowledged together as the anorexia-cachexia syndrome.

The symptoms of anorexia and cachexia, assuming weight loss is a marker of cachexia, appear to be highly prevalent in children with life-limiting conditions of both malignant3,6,97 and non-malignant origin.3 In a study97 of 164 children and young people who died of progressive malignant disease, 48% had anorexia and 41% had weight loss on entering the study and these symptoms increased to just more than 67% in the last month of life, indicating anorexia and weight loss were not responsive to any treatments used. They were significantly more evident in children with CNS tumors when compared with leukemia and/or lymphoma or solid tumors. Similarly, a study6 reported a high prevalence of anorexia in children dying from cancer. However, this did not seem to result in a high level of suffering, but neither was it successfully treated.

A lower prevalence in the last week and day of life for anorexia, 33% and 24%, respectively, and weight loss, 20% and 21%, respectively, was found in 30 children dying in the hospital environment; 12 children had non-malignant conditions.6 They were not believed to cause undue distress to the child, but in more than half the children with the symptom were of moderate to severe intensity.

Anorexia-cachexia syndrome characterized by anorexia, involuntary weight loss, tissue wasting, weakness and poor physical function is a condition of advanced protein calorie malnutrition that inevitably leads to death98 if the underlying condition cannot be treated. In contrast to adults, children may manifest this problem as growth failure rather than weight loss.

For many parents the sight of their child visibly losing weight may intensify feelings of impotence and failure as parents, and lead to misunderstanding and blame within the extended family.

Pathogenesis

The process of anorexia-cachexia syndrome is complex, but what is clear is anorexia, alone, is inadequate for the syndrome to develop. In normal circumstances the reduced caloric intake from anorexia results in a loss of fat stores, which stimulates an adaptive response to maintain the fat stores. This response is driven by declining levels of leptin, a hormone secreted by adipose tissue. The consequence of low levels of leptin in the brain is for the hypothalamus to increase orexigenic signals such as neuropeptide-Y (NPY) to stimulate appetite and repress energy expenditure and decrease anorexigenic signals, corticotrophin-releasing factor and melanocortin, to achieve the same effect.98

There is increasing evidence that the cachectic process is established by an acute phase response mediated by several cytokines of which tumor necrosis factor-α, interleukin-1, interleukin-6 and interferon-γ have been implicated. The evidence to date would suggest these cytokines stimulate the expression and release of leptin and/or mimic the hypothalamic negative feedback signaling from leptin and, in so doing, prevent the normal compensatory mechanisms in the face of reduced food intake and decreasing weight.

This abnormal response has been suggested in a study99 that reported on the possible role of leptin and NPY levels as prognostic indicators in children with cancer. The study revealed a mean NPY level of 82.32 pmol/L and mean leptin level of 6.60 ng/mL at diagnosis in children who achieved complete remission, vs. a mean NPY and leptin level of 430.16 pmol/L and 0.192 ng/mL, respectively in those children who died with disease during the follow-up period. Furthermore, the mean NPY level declined and mean leptin level increased during the course of chemotherapy in the 23 children studied.

Other factors indicated in this syndrome include hypermetabolism or an elevation in resting energy expenditure and changes in carbohydrate, protein, and fat metabolism.

Integrative and supportive therapies

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