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Guide to Managing Persistent Upper Gastrointestinal Symptoms During and After Treatment for Cancer

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Guide to Managing Persistent Upper Gastrointestinal Symptoms During and After Treatment for Cancer OESOPHAGUS AND STOMACH Frontline Gastroenterol: first published as 10.1136/flgastro-2016-100714 on 14 October 2016. Downloaded from SYSTEMATIC REVIEW Guide to managing persistent upper gastrointestinal symptoms during and after treatment for cancer H Jervoise N Andreyev,1 Ann C Muls,1 Clare Shaw,1 Richard R Jackson,1 Caroline Gee,1 Susan Vyoral,1 Andrew R Davies2 ▸ Additional material is ABSTRACT INTRODUCTION published online only. To view Background Guidance: the practical This guide is designed for all clinicians please visit the journal online (http://dx.doi.org/10.1136/ management of the gastrointestinal symptoms of who look after people who have been flgastro-2016-100714). pelvic radiation disease was published in 2014 treated for upper gastrointestinal (GI) for a multidisciplinary audience. Following this, a cancer. It is also designed for patients 1The GI and Nutrition Team, The Royal Marsden NHS Foundation companion guide to managing upper who are experiencing upper GI symp- Trust, London and Surrey, UK gastrointestinal (GI) consequences was toms following any cancer treatment. 2 Guy’s and St Thomas’ NHS developed. Some of these will be doctors, others Foundation Trust, London, UK Aims The development and peer review of an may be senior nurses and increasingly, Correspondence to algorithm which could be accessible to all types other allied health professionals. Dr H J N Andreyev, The GI Unit, of clinicians working with patients experiencing Some lower GI symptoms are also The Royal Marsden NHS upper GI symptoms following cancer treatment. included because these are common after Foundation Trust, Fulham Rd, London SW3 6JJ, UK; j@ Methods Experts who manage patients with treatment for upper GI cancers. andreyev.demon.co.uk upper GI symptoms were asked to review the However, for more detailed advice about guide, rating each section for agreement with managing lower GI symptoms please Received 20 April 2016 the recommended measures and suggesting refer to Guidance: The practical manage- Revised 30 June 2016 Accepted 18 July 2016 amendments if necessary. Specific comments ment of the gastrointestinal symptoms of were discussed and incorporated as appropriate, pelvic radiation disease.1 and this process was repeated for a second The GI consequences of chemotherapy, round of review. radiotherapy and resectional surgery are http://fg.bmj.com/ Results 21 gastroenterologists, 11 upper GI not that different. Historically, clinicians surgeons, 9 specialist dietitians, 8 clinical nurse have associated specific clusters of symp- specialists, 5 clinical oncologists, 3 medical toms with typical diagnoses especially in oncologists and 4 others participated in the patients who have been treated for upper review. Consensus (defined prospectively as 60% GI and hepatopancreatobiliary cancer. ‘ ’ or more panellists selecting strongly agree or Research increasingly suggests that spe- on September 27, 2021 by guest. Protected copyright. ‘agree’) was reached for all of the original 31 cific symptoms are not reliable indicators sections in the guide, with a median of 90%. of the underlying cause, hence, this algo- 85% of panellists agreed that the guide was rithmic approach. acceptable for publication or acceptable with This guide defines best practice although minor revisions. 56 of the original 61 panellists not every investigation modality or treat- participated in round 2. 93% agreed it was ment may be available in every hospital. acceptable for publication after the first revision. Those using the guide, especially if Further minor amendments were made in non-medically qualified, should identify a response to round 2. senior gastroenterologist or other appro- To cite: Andreyev HJN, Conclusions Feedback from the panel of priately qualified and experienced profes- Muls AC, Shaw C, et al. experts developed the guide with improvement sionals whom they can approach easily Frontline Gastroenterology of occasional algorithmic steps, a more user- for advice if they are practicing in an Published Online First: [please friendly layout, clearer time frames for referral to unsupervised clinic. include Day Month Year] doi:10.1136/flgastro-2016- other teams and addition of procedures to the Practitioners should not use this guide 100714 appendix. outside the scope of their competency Andreyev HJN, et al. Frontline Gastroenterology 2016;0:1–29. doi:10.1136/flgastro-2016-100714 1 OESOPHAGUS AND STOMACH Frontline Gastroenterol: first published as 10.1136/flgastro-2016-100714 on 14 October 2016. Downloaded from and must identify from whom they will seek advice 3. Appendices with brief descriptions of the diagnosis, about abnormal test results which they do not fully treatment and management techniques available. understand before using the guide. HOW TO USE THE ALGORITHM Specific therapies are usually not listed by name but 1. Up to 28 symptoms have been described in this patient ‘ ’ as a class of potential drugs as different clinicians group. may have local constraints or preferences as to the 2. Each symptom may have more than one contributing medications available. cause. Arranging all first line suggested investigations 3. Symptoms must be investigated systematically otherwise required by the symptom(s) at the first consultation causes will be missed. reduces follow-up and allows directed treatment of all 4. Identify the symptoms by systematic history taking. causes of symptoms at the earliest opportunity. Timely 5. Examine the patient appropriately. review of requested investigations is required so that 6. Use the algorithm to plan investigations. further investigations can be requested if required. If 7. Most patients have more than one symptom and inves- worrying symptoms are elicited or potentially abnor- tigations need to be requested for each symptom. mal findings are present on clinical examination, then 8. Usually all investigations are requested at the same time the order of investigations suggested in the algorithm and the patient reviewed with all the results. may no longer be appropriate. 9. When investigations should be ordered sequentially, the Practitioners seeing these patients are encouraged to algorithm indicates this by stating first line, second line, etc. consider providing patients with symptom question- 10. Treatment options are generally offered sequentially but naires including nutritional screening questions to clinical judgement should be used. complete before or during the consultation as this may help improve the choice of investigations and GUIDE TO USING BLOOD TESTS identify when referral is required. Routine blood tests include: full blood count, urea This guide has three parts: and electrolytes, liver function, glucose, calcium 1. An introduction, instructions how to use the algorithm, (table 1). guide to blood tests and taking a history. Additional blood tests are indicated depending on 2. An algorithm detailing the individual investigations and the presenting GI symptoms and differential diagnoses treatment of each of the 28 GI symptoms. as outlined in the algorithm (table 2). Table 1 Routine blood tests: responding to results Anaemic and symptomatic ▸ Consider blood transfusion (checking ferritin, transferrin saturation, RBC folate and vitamin B12 before transfusion). ▸ If iron deficient: consider iron supplements and coeliac screen (ie tissue transglutaminase and IgA levels), OGD, SI biopsy, colonoscopy and renal tract evaluation. Anaemic but not symptomatic ▸ Check ferritin, transferrin saturation, RBC folate and vitamin B12. Replace if necessary, monitor response. If unexplained consider coeliac screen, OGD, SI biopsy and colonoscopy and renal tract evaluation. ▸ If anaemia is unexplained, refer to haematology. http://fg.bmj.com/ Abnormal urea, electrolytes ▸ Urine dipstix. ▸ Discuss with supervising clinician within 24 hours. ▸ Consider appropriate intravenous fluid therapy/oral replacement. ▸ If K+ <3 mmol/L or >6 mmol/L, this is an emergency. ▸ If Na+ <120 or >150 mmol/L, this is an emergency. Abnormal liver function tests ▸ Discuss with supervising clinician within 24 hours. (new onset) ▸ Check thyroid function on September 27, 2021 by guest. Protected copyright. ▸ Patient will need a liver ultrasound and liver screen including hepatitis A, B, C and E serology, EBV and CMV, ferritin, α feta protein, α 1 antitrypsin, coeliac serology, liver autoantibodies, total Igs, cholesterol, triglycerides, caeruloplasmin (<50 years old only). Abnormal liver function tests ▸ Refer for further evaluation to a hepatologist. (long standing) Abnormal glucose level ▸ If no history of diabetes: Between 7–11 mmol/L: refer to GP. >11 mmol/L and ketones in urine: this is an emergency. >11–20 mmol and no ketones in urine: discuss with supervising clinician within 24 hours. >20 mmol/L and no ketones in urine: this is an emergency. ▸ If known diabetic: Do not check glucose levels. Consider checking glycosylated haemoglobin (HbAIC). Abnormal corrected calcium level ▸ If 2.6–2.9 mmol/L: discuss with supervising clinician within 24 hours. ▸ If <1.8 mmol/L or >3.0 mmol/L: this is an emergency. ▸ Check parathyroid hormone levels. CMV, cytomegalovirus; EBV, Epstein-Barr virus; GP, general practitioner; K, potassium; Na, sodium; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); RBC, red blood cell; SI, small intestine. 2 Andreyev HJN, et al. Frontline Gastroenterology 2016;0:1–29. doi:10.1136/flgastro-2016-100714 OESOPHAGUS AND STOMACH Frontline Gastroenterol: first published as 10.1136/flgastro-2016-100714 on 14 October 2016.
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