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1、恶心和呕吐的姑息性处理目的 简要地回顾晚期癌症恶心和呕吐的原因 描述常用止吐药物的作用部位和机制 研究晚期癌症不同类型的恶心和呕吐的识别和处理Management of Nausea and Vomitingin Palliative Care Dr.Charlie Bond, Sir michael Sobell House, Oxford Aims To briefly review the causes of nausea and vomiting in advanced cancer To describe the site and mechanism of action of the
2、 common anti- emetics To consider the recognition and management of the different patterns of nausea and vomiting in advanced cancerCauses of Nausea and Vomiting in Advanced Cancer 晚期癌症患者恶心和呕吐的原因Cancer 癌症Visceral neuropathy 内脏神经病 Bowel obstruction 肠梗阻 Brain Metastases 脑转移 Raised Calcium 血钙升高 Renal F
3、ailure 肾功衰 Anxiety 焦虑 Cough 咳嗽General Debility 全身衰竭 Constipation 便秘 Oral/Oesophageal candida 口/食管念珠菌病 Infections 感染Treatment/Drugs 治疗/药物 Chemotherapy 化疗 Radiotherapy 放疗 Opioids 阿片类药物 NSAIDS/Aspirin T NSAIDS/阿司匹林 Anti-biotics 抗生素 Iron tablets 铁剂 Concurrent Conditions 合并症 Dyspepsia/peptic ulcer 消化不良/消
4、化性溃疡 Alcoholic gastritis 酒精性胃炎 Renal failure 肾功衰 Diabetic Ketoacidosis 糖尿病性酮症酸中毒 Gastric stasis 胃停滞Intestinal Obstruction 肠梗阻Other 其他Biochemical 生物化学因素Drugs 药物Common causes of nausea and vomiting in advanced cancer 晚期癌症患者恶心和呕吐的常见原因Vomiting CentreGut MucosaArea Postrema CTZCerebral CortexVestibular N
5、ucleiAnti-emetic Receptor ProfilesMetoclopromide D2, 5HT4 agonist 5HT3100mg Haloperidol D2+ Prochlorperazine D2, H1 Domperidone D2 (No central action) Cyclizine ACH, HI Levomepromazine D2, 5HT2, Alpha1, ACh Granisetron 5HT3H15HT2AChmD2-opioid5HT3H1AChmD2GABA25HT35HT2Morphine Digoxin Hypercalcaemia U
6、raemia ChemotherapyRaised Intra-cranial pressure Fear/AnxietyMovement/VertigoGastric irritants Morphine Radiotherapy Cytotoxic chemotherapy呕吐中枢胃粘膜 丘脑后部 CTZ大脑皮层前庭细胞核 止吐药受体类型 灭吐灵 D2, 5HT4 激动剂 5HT3100毫克氟哌啶醇 D2+ 丙氯拉嗪 D2, H1 多潘立酮 D2 (无中枢作用) 赛克利嗪 ACH, HI 左美丙嗪 D2, 5HT2, Alpha1, ACh 格拉司琼 5HT3H15HT2AChmD2-阿片
7、类受体5HT3H1AChmD2GABA25HT35HT2吗啡 地高辛 高钙血症 尿毒症 化疗颅内压升高 恐惧/焦虑运动/眩晕胃刺激物 吗啡 放射疗法 细胞毒素化疗恶心和呕吐 - 7 种临床原因 化学性/代谢性 胃停滞/胃排空梗阻 反流 肠梗阻 颅脑疾病/治疗性原因 与运动相关的因素 原因不明/多种原因Nausea and vomiting - 7 clinical pictures Chemical/metabolic Gastric stasis/gastric outlet obstruction Regurgitation Bowel obstruction Cranial diseas
8、e/treatment Movement related Cause unclear/multiple causes恶心和呕吐的处理 纠正可逆转的因素 非药物治疗 药物治疗 处理焦虑Management of Nausea and Vomiting Correct the correctable Non - drug treatment Drug treatment Manage anxiety化学性/代谢性因素 原因 药物 (包括阿片类药物) 尿毒症 高钙血症 癌病 临床表现 难治性/ 持续性恶心 呕吐常常不会缓解恶心症状Chemical/Metabolic Causes Drugs (in
9、cluding opioids) Uraemia Hypercalcaemia Carcinomatosis Clinical Picture Persistent/ continuous nausea Vomiting often does not relieve nausea化学性/代谢性 处理 处理 治疗高钙血症 治疗肾衰 ( 如果可能) 停止使用引起恶心的药物 (如果可能) 避免闻到刺激性食物的味道 氟哌啶醇 (作用于丘脑后部的多巴胺2拮抗剂) 二线药物:左美丙嗪 (广谱止吐药)Chemical/metabolic -management Management Treat Hyperc
10、alcaemia Treat renal failure ( if possible) Stop drugs causing nausea ( if possible) Keep away from smell of food Haloperidol (D2 Antagonist acting at area postrema) 2nd line: Levomepromazine (broad spectrum)胃停滞/胃排空梗阻 原因 药物 阿片类药物 抗胆碱能药物 自主神经系统障碍 肝肿大 消化性溃疡/胃炎Gastric stasis/gastric outlet obstruction
11、Causes Drugs Opioids Anti-Cholinergics Autonomic failure Hepatomegaly Peptic ulceration/gastritis胃停滞/胃排出梗阻 临床特征 间歇性恶心 恶心症状常由呕吐缓解 进食便感到过早饱胀 进食后感到腹胀 可能有呃逆现象Gastric stasis/gastric outlet obstruction Clinical picture Intermittent nausea Nausea often relieved by vomiting Feel full quickly when eating Fee
12、l bloated after eating May have Hiccups胃停滞/胃排空梗阻 治疗胃炎/消化性溃疡 停止使用刺激胃的药物(非甾体类抗炎药) 避免大量进食 动力性止吐药物: 灭吐灵(5HT4 激动剂, D2拮抗剂) 多潘立酮(D2 拮抗剂)Gastric stasis/gastric outlet obstruction Treat gastritis/peptic ulceration Stop drugs that irritate stomach (NSAIDS) Avoid large meals Pro-kinetic anti-emetic: Metoclopro
13、mide (5HT4 Agonist, D2 Antagonist) Domperidone (D2 Antagonist）反流 原因 食道癌/狭窄 纵膈肿瘤/淋巴腺病 临床特征 吞咽困难 偶尔消化不良 轻微或无恶心 食物反流 Regurgitation Causes Oesophageal tumour/stricture Mediastinal tumour/lymphadenopathy Clinical Picture Dysphagia Dyspepsia sometimes Little or no nausea Regurgitation of food反流的处理 放射诊疗 支架
14、/ 扩张/ 激光 地塞米松 软食/流质食物 质子泵抑制剂 - 奥美拉唑Regurgitation Management Radiotherapy Stents/ dilatation/ laser Dexamethasone Soft/liquid diet Proton pump inhibitor - Omeprazole颅脑疾病/治疗 原因 颅内压升高 放射治疗 脑干/脑膜疾病 临床表现 恶心在上午加重 头痛 神经病变体征 Cranial disease/treatment Causes Raised intracranial pressure Radiotherapy Brainstem/meningeal disease Clinical picture Nausea worse am Headache Neurological signs颅脑疾病/治疗 处理 地塞米松 8-16mg/每天 睡觉时盖薄被子 赛克利嗪 二线药物: 左美丙嗪 (甲氧异丁嗪)Cranial disease/treatment Management Dexamethasone 8-16mg/day Sleep with bed tilt Cyclizine 2nd Line: Levomep
