Treating the cause

  • Targeted antitumour therapy (surgery, radiotherapy, or chemotherapy) should be employed only if there is a reasonable chance of response and a low risk of (severe) side effects
  • Dose modification or, if necessary, discontinuation; in the case of opioids as cause: consider opioid rotation if complaints persist or try an alternative route of administration 
  • In the case of obstruction of the gastric outlet or duodenum and a life expectancy of several weeks or longer, stent placement may be considered. In >80% of cases, this results in a temporary or permanent reduction of the symptoms or the symptoms disappear completely. Possible complications are obstruction of the stent (18%), migration (5%) and bleeding and/or perforation (1%). A bypass operation (gastrojejunostomy) is rarely indicated 
  • Treatment of constipation, pain or cough 
  • Treatment of reflux, peptic ulcer, gastritis, gastroenteritis, pancreatitis, cholelithiasis, nephrolithiasis or cystitis 
  • Treatment of electrolyte disorders: 
    • hypercalcaemia: zoledronic acid 4 mg i.v. or APD 90 mg i.v. + 3 - 4 litres of 0.9% NaCl/24 hours; this often implies hospital admission for fluid administration and frequent blood samples 
    • hyponatraemia: water restriction (for SIADH) or broth/0.9% NaCl i.v. or s.c. (if there is concurrent dehydration) 
  • With ascites: consider ascites puncture or (in the case of transudate) diuretics 
  • With ileus: 
    • discuss the feasibility and desirability of surgery with the surgeon 
    • if surgery is not an option, use conservative therapy: 
      • drainage of gastric contents (nasogastric tube) as needed during the acute phase (particularly for severe vomiting) 
      • somatostatin analogues: octreotide 100 - 300 microgram s.c. three times daily or 300 - 900 microgram/24 hours continuous s.c. or i.v. infusion (particularly for severe vomiting); or, during the stable phase after the efficacy of octreotide has been confirmed, octreotide LAR 30 mg i.m. once every 4 weeks/lanreotide PR 30 mg i.m. once every 2 weeks 
      • hyoscine butylbromide 40 - 120 mg/24 hours s.c. or i.v. 
      • in the case of persistent nausea and vomiting despite pharmacological treatment: continuous gastric drainage with the use of a nasogastric tube or via existing percutaneous endoscopic gastrostomy (PEG) tube 
  • With brain metastasis: corticosteroids (dexamethasone 4 mg/day orally, s.c., or i.v.; if necessary higher doses can be given) and possibly radiotherapy or resection
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