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GuidelinesEML (Adult Hospital STG)

Gastrointestinal Conditions

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition

Anorexia and Cachexia

Constipation

Tumour-related bowel obstruction

Diarrhoea

Nausea and Vomiting

Management of close contacts of patients with HBV infected hepatocellular carcinoma

ANOREXIA AND CACHEXIA

R63.0/R63.4/R64 + (Z51.1)

DESCRIPTION

  • Anorexia/cachexia syndrome is a complex metabolic process found in many end-stage illnesses. 
  • It is characterised by loss of appetite, weight loss and muscle wasting, and cannot be fully reversed by conventional nutritional support.
  • It may impact significantly on the quality of life of patients, leading to increased anxiety and distress for both patients as well as family.

GENERAL MEASURES

  • Reduced food and fluid intake is expected at the end of life, and treatment of anorexia and weight loss may not be appropriate if these symptoms are not having a direct impact on quality of life. This should be explained to caregivers and family.
  • Management of anorexia and weight loss includes identification and, if appropriate, treatment of possible underlying cause(s).
  • It may include the use of pharmacological and non-pharmacological treatment approaches.
  • Identify reversible problems that may contribute to or exacerbate anorexia/cachexia including:
    • Pain, nausea, heartburn, dyspnoea, gastritis, depression, constipation, anxiety, dysphagia, medication and fatigue
    • Oral problems e.g. dry mouth, ulcers, candidiasis, etc.
    • Odours e.g. fungating lesions, cooking smells, incontinence, etc.
    • Delayed gastric emptying due to local disease, autonomic neuropathy with early satiety and vomiting of undigested foods
  • If appropriate, moderate exercise must be encouraged, along with pacing of activities and good sleep hygeine.
  • Nutritional advice includes eating small amounts of enjoyable food frequently.

MEDICINE TREATMENT

If the anorexia and/ cachexia contributes significantly to decreased quality of life and the patient has a short life expectancy.

  • Corticosteroids (intermediate-acting) e.g.:
    • Prednisone, oral, 0.5 mg/kg (e.g. 20-30 mg) daily.
      - The effect may be rapid but usually decreases after 3-4 weeks.
      - If there is no benefit after 1 week, stop the treatment.

LoE:IIbii

CONSTIPATION

K59.0 + (Z51.1)

DESCRIPTION

  • Constipation is the passage of small, hard faeces infrequently and with difficulty.
  • Individuals vary in the weight they give to the different components of this definition when assessing their own constipation and may introduce other factors, such as pain and discomfort when defecating, flatulence, bloating or a sensation of incomplete evacuation.
  • Constipation may also be secondary to other conditions e.g. dehydration, immobility, poor diet, anorexia, tumour compressing bowel wall or hypercalcaemia.

GENERAL MEASURES

  • Ensure privacy and comfort to allow a patient to defecate normally.
  • Increase fluid intake within the patient's limits.
  • Encourage activity and increased mobility within the patient's limits.
  • Anticipate the constipating effects of pharmacological agents such as opioids, anticholinergic agents (e.g. tricyclic antidepressants), antacids, iron, 5HT3 antagonists and provide laxatives prophylactically.

MEDICINE TREATMENT

The combination of a softener and stimulant laxative is generally recommended, and the choice of laxatives should be made on an individual basis.

  • Sennosides A and B, oral, 13.5 mg, 1 tablet at night.
    - In resistant cases increase to 2 tablets 
    LoE:IIbiii

AND/OR

  • Lactulose, oral, 15-30 mL 12-24 hourly. 
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Severe constipation in patients who are unable to swallow:

  • Bisacodyl, rectal, 10 mg suppository daily. 
    LoE:IVbv

OR

  • Glycerine (glycerol), rectal, 1.698 mL/2.4g suppository when necessary. 
    LoE:IVb

If these therapies are not effective, other options should be considered.

Note

Manual removal should only be undertaken if the patient has received adequate pain relief and sedation, if relevant.

REFERRAL/CONSULTATION

  • If bowel obstruction is suspected, refer/consult for appropriate radiological investigations and, if appropriate, surgical interventions.

TUMOUR-RELATED BOWEL OBSTRUCTION

K56.6

DESCRIPTION

  • Malignant bowel obstruction is a well-recognised complication of advanced cancer and is defined as symptoms, signs, and radiographic evidence of obstruction to the transit of gastrointestinal contents caused by cancer, or the consequences of anticancer therapy including surgery, chemotherapy or radiation therapy.
  • It occurs most commonly with ovarian or colorectal cancer.

LoE:IVbvi

GENERAL MEASURES

  • Consult a surgeon to discuss potential surgical interventions before restricting management to medicine treatment.
  • Patients and families require in depth counselling around the cause, care, further nutrition, and nasogastric tubes.
  • Parenteral nutrition generally has no role in patients with advanced cancer.

MEDICINE TREATMENT

  • These patients may be difficult to manage. Consult with a palliative care provider for advice on management of patient.
  • To identify and contact a palliative care provider if necessary, visit: https://palprac.org/palliative-care/find-a-provider/. See: Nausea and Vomiting.

REFERRAL/CONSULTATION

  • All patients that might require surgical management must be discussed with a surgeon. All patients who require medical management of bowel obstruction must be discussed with a palliative care provider.

DIARRHOEA

A09.0

See Primary Health Care chapter: Medicines for palliative care: Diarrhoea.

NAUSEA AND VOMITING

R11 + (Z51.5)

GENERAL MEASURES

  • Treat the underlying cause and rehydrate the patient.
  • Identify and manage reversible causes, which include medication, hypercalcemia, constipation, uraemia, gastritis, gastroenteritis, coughing and infections.
  • Manage odours e.g. cooking smells and fungating wounds.

MEDICINE TREATMENT

  • Metoclopramide, oral/IM/IV, 10 mg 8 hourly, 30 minutes before a meal.
  • In renal impairment start with a dose of 5 mg, 8 hourly.
  • Increase according to clinical response using alternate 5 mg and 10 mg doses if required.

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If metoclopramide is ineffective or contraindicated (i.e. inoperable bowel obstruction):

  • Haloperidol, oral, 1.5–5 mg daily.

LoE:IIIbviii

OR

  • Olanzapine orodispersible tablet, oral or IM injection
    • Initiate 5 mg at night (2.5 mg in frail and elderly patients).
    • Titrate in increments of 2.5 mg to a maximum dose of 10 mg daily.

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Drug-induced parkinsonism: 

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ADD

  • Anticholinergic agent, e.g.:
    • Orphenadrine, oral, 50-150 mg daily according to individual response
      - Usual dose: 50 mg 8 hourly.
      - Maximum dose: 150 mg daily.
      - Use with caution in the elderly as it may cause confusion and urinary retention

Note

Anticholinergic medicines (e.g. orphenadrine) should not be added prophylactically to antipsychotics to prevent extrapyramidal side effects.

If haloperidol is ineffective/ inoperable bowel obstruction:

  • Promethazine, IM/IV, 12.5-25 mg, 4-6 hourly. 

LoE:IVbIxi

Corticosteroids can decrease cerebral oedema: See section Brain oedema due to tumours and inflammation.

REFERRAL

MANAGEMENT OF CLOSE CONTACTS OF PATIENTS WITH HBV INFECTED HEPATOCELLULAR CARCINOMA

For patients with hepatocellular carcinoma caused by hepatitis B who are not on hepatitis B antiviral therapy (tenofovir/lamivudine/emtricitabine): Screen caregivers, who are or will be in contact with bodily fluids, for hepatitis B including hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (HBsAb):

Consult the most recent Hepatitis Guidelines from the National Department of Health

Click here to access the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_07 November 2024

Chapter 24: Medicines used in Palliative Care_24.1 Gastrointestinal Conditions

Drugs mentioned

ICD-10 codes

NeoHealth® ID 19496 · updated 7/11/2025