MULTI DISCIPLINARY TEAM

Multi Disciplinary Team



Multi Disciplinary Team

Pancreatic cancer patients experience a variety of disease- and treatment-related respiratory complications that can significantly impair quality of life. Some of the most common of these complications encountered in clinical practice include cough, hemoptysis, dyspnea, airway obstruction, aspiration syndromes, thromboembolic disease, infection, and hiccups(Silvestri, Knittig, Zoller, Nietert, 2003, pp.1379-1382). This report analyses the management of the patient John who is 64 year old man and recently diagnosed with pancreatic cancer and Liver secondaries, awaiting oncological opinion.

Literature Review

Voogt, van, der, Rietjens, et al (2005, pp.2012-2019) have recently emphasized the occurrence of hiccups in cancer patients as a poorly recognized complication of chemotherapy. Hiccups is indeed a relatively frequent problem in these patients that usually occurs when there is continuous phrenic nerve or diaphragmatic irritation (for example, from mediastinal or abdominal tumors or abscesses, hepatomegaly, ascites, esophagitis, or gastric distension) or as a consequence of treatment with chemotherapy or related drugs, such as antiemetics or corticosteroids(Read, Tierney, Page, et, al, 2004, pp.3099-3103). Hiccups occur when an abrupt, involuntary spasm of the diaphragm and intercostal muscles is followed by sudden closure of the glottis, generating the characteristic onomatopoeic “hic” sound. The medical term for hiccups, singultus, is of Latin origin and means to gasp or sigh. Hiccups were first attributed to phrenic nerve irritation by Shortt in 1833(Say Thomson 2003 pp.542-545). Clinically, most hiccup episodes are benign, of acute onset, and self-limited, typically ceasing within minutes. 

When hiccups are severe, they become an incapacitating symptom that is difficult to treat. Besides vagal maneuvers, the preferred approach for treating hiccups is the systemic administration of different drugs(Silvestri Knittig Zoller Nietert 2003 pp.1379-1382): dopaminergic antagonists (chlorpromazine, haloperidol), antiarrhythmics (phenytoin, lidocaine, nifedipine, quinidine), or central nonopioid analgesic agents (baclofen, nefopam). All of these can produce considerable side effects and are not always successful.

It has been reported (Voogt van der Rietjens et al. 2005 pp.2012-2019)that phrenic nerve block can be useful in the therapy of intractable hiccups as well as in the palliation of supraclavicular referred pain secondary to diaphragmatic irritation, but this is a fairly unknown therapeutic technique in the oncology community and, consequently, rarely used for cancer patients. We evaluated the feasibility and efficacy of cervical phrenic nerve block in five consecutive metastatic cancer patients (pancreas, lung, stomach, Merkel's cell) with intractable hiccups resistant to standard therapy.

Treatment Options for patient with pancreatic cancer and Liver secondaries

Patients with persistent or intractable hiccups usually require pharmacologic intervention, especially if quality of life is impaired or medical complications are apparent. The only medication approved by the US Food and Drug Administration (FDA) for hiccups is the antipsychotic phenothiazine chlorpromazine, which may not be optimal for all patients due to adverse effects such as hypotension, urinary retention, glaucoma, or delirium. Treatments dating to the 1970s and 1980s include the anticonvulsants phenytoin, valproic acid, and carbamazepine(Zafirellis et al 2002 pp.1150-1155 ). These drugs may inhibit hiccups at the central level through blockade of neural sodium channels but possess a narrow therapeutic index and the tendency for multiple drug interactions, making them less than optimal in patients with advanced cancer who typically receive numerous ...