9.1 Gastrointestinal Symptoms

9.1 Gastrointestinal Symptoms

Symptom Management is Domain 3 of the Certified Hospice and Palliative Nurse (CHPN) exam from the Hospice and Palliative Credentialing Center (HPCC). It accounts for 28 of 135 scored items (20.7%). The live exam is 150 four-option items in 3 hours (135 scored plus 15 unidentified pretest items). HPCC uses generic drug names and reports a scaled score of 200–800; the passing scaled score is 500, not a raw 75% and not a “75 scaled” leftover from stale local copy.

This section is Domain 3 letter D: Gastrointestinal. Chapter 8 covered neurologic, cardiovascular, and respiratory symptoms. Anorexia-cachexia and hydration sit in Chapter 10. Here the scored skills are nausea and vomiting, constipation, malignant bowel obstruction, diarrhea, ascites, and the related traps of overflow stool and gastrointestinal bleeding.

Match the antiemetic to the pathway, not to a favorite drug

Nausea is not one receptor. CHPN stems name a cause (new opioid, chemotherapy, motion, anxiety, constipation) and expect a pathway-matched generic. Giving ondansetron for every nauseated hospice patient is a classic miss. Ondansetron is a 5-hydroxytryptamine-3 (5HT3) antagonist that shines in chemotherapy- and radiation-related nausea. It is also constipating, so it can worsen the most common opioid problem.

The chemoreceptor trigger zone (CTZ) in the area postrema sits outside the blood–brain barrier. Uremia, hypercalcemia, opioids, and many circulating emetogens hit dopamine D2 receptors there. First-line CTZ drugs are haloperidol, prochlorperazine, and metoclopramide. Metoclopramide is also a 5HT4 prokinetic useful for gastroparesis—and is contraindicated in complete bowel obstruction, where pushing against a closed loop causes colic and theoretical perforation risk.

Vestibular nausea (motion, inner-ear disease, some opioid-related dizziness) uses histamine H1 and muscarinic receptors. Choose meclizine or scopolamine, not a 5HT3 antagonist as monotherapy.

Cortical, anxiety, and anticipatory nausea responds to a benzodiazepine, typically lorazepam. It is an add-on for conditioned chemotherapy nausea and for panic-linked retching. It is not a substitute for treating constipation or obstruction.

When the gut itself is the generator—constipation, obstruction, peritoneal carcinomatosis—treat the cause. Antiemetics without a bowel plan fail.

Receptor and drug table

Multifactorial nausea is allowed: a patient on morphine with pancreatic cancer may need a dopamine antagonist and a bowel regimen and a steroid if there is peri-tumoral edema. Stack by mechanism. Do not stack three 5HT3 drugs.

Bowel regimen with every opioid

Opioids bind mu receptors in the gut, slow transit, increase sphincter tone, and dry stool. Tolerance to analgesia may develop; tolerance to constipation does not. Every patient started on an opioid needs a proactive bowel regimen, usually a stimulant such as senna plus an osmotic such as polyethylene glycol. Docusate alone (a stool softener without a stimulant) is a weak plan for opioid-induced constipation. Document last bowel movement every visit. “PRN senna if needed” is how CHPN patients present with a three-day gap.

Rescue options after a failed standing regimen, once obstruction is off the table, include bisacodyl (oral or rectal), enemas if the vault is full and the abdomen is not surgical, and a peripheral mu antagonist such as methylnaltrexone for true opioid-induced constipation. Methylnaltrexone is contraindicated when bowel obstruction is known or suspected—it can precipitate perforation in a closed loop.

Worked scenario: opioid, no bowel movement in 3 days

A 64-year-old with metastatic ovarian cancer started morphine 15 mg oral every 4 hours around the clock three days ago. She has had no bowel movement in 3 days. She is nauseated. The exam wants a sequence, not a single magic drug.

1. Assess before you escalate. Ask about stool character from the last movement, flatus, vomiting (feculent versus bilious), abdominal pain quality (colicky versus constant), and whether she is passing gas. Examine for distention, tenderness, and bowel sounds. A digital rectal exam looks for impaction. A full vault with liquid seepage is overflow, not “diarrhea that needs loperamide.”
2. Rule out obstruction and peritonitis. If the picture is complete malignant bowel obstruction (no flatus, feculent vomiting, high-pitched or silent abdomen, known peritoneal disease), stop stimulant laxatives and metoclopramide. Move to the obstruction pathway below. Do not give methylnaltrexone.
3. If the abdomen is soft, she is passing flatus, and the vault is empty or only mildly full, this is delayed opioid constipation. Confirm she actually received a standing stimulant plus osmotic. If she did not, start that now. If she did, escalate: add or increase polyethylene glycol, give rectal bisacodyl if the rectum is the hold-up, and consider an enema if lower stool is present and there is no surgical abdomen.
4. Treat the nausea with a CTZ drug (low-dose haloperidol is the hospice prototype) while the bowel regimen works. Ondansetron here adds constipation.
5. Do not stop the opioid as the only intervention if pain is still moderate to severe. Treat the constipation. If the opioid is the wrong molecule for another reason (renal failure, myoclonus), rotation is a later Domain 2 move—not a substitute for a bowel plan today.

Malignant bowel obstruction: comfort is the outcome

Malignant bowel obstruction (MBO) in peritoneal carcinomatosis, ovarian, colorectal, or gastric cancer is often multi-level and not a clean surgical lesion. Surgery is for the rare patient with a single transition point, adequate performance status, and goals that include life-prolongation. Most hospice stems are medical.

Comfort-directed medical management:

• Nil per os (NPO) to rest the gut; sips for pleasure if the patient wants them and vomiting is controlled.
• IV fluids only as they serve comfort. Flooding a dying patient increases bowel secretions and edema; dry mouth is treated with oral care, not an automatic liter bolus.
• Nasogastric suction is a short-term decompressing tool; it is uncomfortable. If survival is measured in weeks and vomiting persists, a venting gastrostomy can drain without a nasal tube.
• Octreotide, a somatostatin analog, reduces gastrointestinal secretions and can lessen vomiting volume.
• Dexamethasone may reduce peri-tumoral edema, has antiemetic effect, and is a reasonable time-limited trial.
• An anticholinergic such as glycopyrrolate or hyoscyamine reduces cramping and secretions (watch delirium and tachycardia). Scopolamine is more central and more deliriogenic.
• Haloperidol (or another dopamine antagonist) for nausea. Opioids for colic and peritoneal pain.
• Metoclopramide stays off in complete obstruction.

The goal is not a daily bowel movement. The goal is less vomiting, less colic, and a mouth the patient can use for ice or a taste of food if that is their wish.

Diarrhea, ascites, and two gastrointestinal traps

Diarrhea in hospice is often overflow around an impaction, laxative overshoot, Clostridioides difficile after antibiotics, radiation enteritis, pancreatic insufficiency, or a fistula. Loperamide is wrong for overflow and wrong for untreated C. difficile. Skin protection and odor control are nursing interventions the exam will credit.

Ascites from peritoneal carcinomatosis is often poorly diuretic-responsive; spironolactone plus furosemide help portal-hypertension ascites more than malignant fluid. Palliative paracentesis treats tense distention, dyspnea, and early satiety. Recurrent taps may lead to a tunneled peritoneal catheter when prognosis and goals support it. Do not chase albumin numbers in an imminently dying patient.

Hiccups (gastric distention, reflux, corticosteroids, uremia, diaphragmatic irritation) are treated by cause first; metoclopramide, baclofen, or gabapentin appear as pharmacologic options when the abdomen is not obstructed. Gastrointestinal bleeding at end of life is managed for comfort: dark linens, anxiolysis, a proton-pump inhibitor or octreotide in selected tumor or variceal pictures, palliative radiation for a bleeding mass, and a goals conversation about transfusion. Endless units in the last hours are not the default.