Gastrointestinal Symptoms in Palliative Care

Dry mouth/lips

Manage with moisture replacement or saliva-inducing products (citrus), or sodium bicarbonate dissolved in warm water. Treat oral candidiasis with nystatin 100,000 units/mL 1 mL topically 4 times daily after food for 7–14 days, or miconazole 2% gel 2.5 mL topically 4 times daily after food for 7–14 days.

Aphthous ulcers

Respond to triamcinolone (Kenalog) 0.1% paste 3 times daily, or betamethasone 0.05% ointment topically twice daily.

Swallowing difficulty

Often caused by pain or strictures. Treat oesophagitis with lidocaine 2% viscous solution 10 mL orally 4-hourly, or sucralfate 1 g dispersed in 5 mL water orally 4 times daily.

Anorexia and weight loss

The most recognised and troubling symptoms for palliative patients and their carers. Reduced eating is commonly misconceived as the cause of approaching death, when in fact it’s usually the dying process causing reduced intake, not the reverse — this has strong social and emotional meaning for patients and families regardless.

Non-pharmacological:

• Avoid measuring weight in a patient with life-limiting disease.
• Explain the difference between thirst/dehydration and malnutrition/ anorexia.
• Small servings — finishing a small plate is kinder than leaving a large meal unfinished.
• Pureed food may help with swallowing difficulties; dietician input can help.

Pharmacological:

• If anorexia is due to impaired gastric emptying: metoclopramide or domperidone 10 mg every 8 hours.
• Dexamethasone 2–4 mg daily may improve appetite — be mindful of side effects; stop if no benefit within 5 days.

Nausea and vomiting

Due to poor gastric emptying, can also be treated with metoclopramide or domperidone 10 mg 3 times daily. Hyperacidity/mucosal erosion causing nausea or heartburn can be treated with a PPI or H2 antagonist once or twice daily as required.

Standard oral PPI doses: esomeprazole 20 mg daily; lansoprazole 30 mg daily; rabeprazole 20 mg daily; omeprazole 20 mg daily; pantoprazole 40 mg daily.

Severe constipation can itself cause nausea/vomiting and may respond to metoclopramide — but be cautious of mechanical bowel obstruction, since prokinetics risk perforation in that setting.

For central causes of nausea:

Drug	Regimen
Haloperidol	0.5–1 mg oral/SC twice daily, plus 0.5–1 mg 4-hourly PRN (max 5 mg/day)
Haloperidol (CSCI)	1–2.5 mg/24 hours
Metoclopramide	10 mg oral 8-hourly
Metoclopramide (CSCI)	30 mg/24 hours
Prochlorperazine	5–10 mg oral, 3–4 times daily

For vestibular causes:

Drug	Regimen
Prochlorperazine	5–10 mg oral, 3–4 times daily
Promethazine	25–50 mg oral 8–12-hourly PRN (max 100 mg/day)
Haloperidol	0.5–1 mg oral/SC twice daily, plus 0.5–1 mg 4-hourly PRN (max 5 mg/day), or 1–2.5 mg/24h CSCI

For intracranial causes: dexamethasone 4–8 mg oral/SC daily, plus (if required) haloperidol as above.

For chemotherapy/radiotherapy-induced nausea: a 5-HT3 antagonist (e.g. ondansetron 4–8 mg oral twice daily for up to 5 days then cease), plus dexamethasone 4 mg oral daily.

Constipation

Recommended first-line agents are osmotic laxatives (polyethylene glycol/Movicol, lactulose) and stimulant laxatives (bisacodyl, sodium picosulphate) ± a stool softener — a combination strategy, not monotherapy. Bulking agents (fibre) are not recommended in palliative care, since patients typically cannot maintain the fluid intake needed to make them safe and effective.

Prescribe a laxative prophylactically whenever starting a regular opioid — opioid-induced constipation affects 15–90% of patients and does not resolve with tolerance the way other opioid side effects do, so ongoing prevention is needed for as long as the opioid continues. Note that constipation in palliative care is increasingly defined by the patient’s own experience, not purely objective bowel-frequency criteria.

Drug	Regimen	Onset
Docusate + senna	50+8 mg, 1–2 tablets once daily at night or twice daily	—
Senna + dried fruit block	10 g orally daily	—
Polyethylene glycol (macrogol)	1–2 sachets twice daily	24–48 hours
Bisacodyl	5–10 mg nightly to twice daily	6–10 hours
Sodium picosulphate	10–20 drops daily to twice daily	6–12 hours

If very hard stools persist despite initial laxatives: docusate 240 mg at night, or macrogol 2 sachets daily until effect. If the patient has difficulty expelling an already-soft stool: bisacodyl 5 mg at night, increasing to 10 mg twice daily, plus either docusate+senna or senna+dried-fruit-block as above.

Diarrhoea

Drug	Regimen
Loperamide	2 mg orally after each loose motion (max 16 mg/day), or 2–4 mg 6-hourly
Codeine (if not already on an opioid)	15–30 mg orally, 4–6-hourly

Ascites

Where hypoproteinaemia, liver cirrhosis, portal vein thrombosis, or end-stage heart failure is present: spironolactone 25–100 mg orally daily (1–2 divided doses), plus (as required) furosemide 40–80 mg orally daily (1–2 divided doses).

Bowel obstruction

• High obstruction — generally poor prognosis; focus on symptom control.
• Low obstruction — exclude severe constipation first. Manage symptoms/ pain with antispasmodics and H2 antagonists to reduce pressure/secretions. Dexamethasone may help if there’s a single site of obstruction.

From eTG and AJGP (August 2025 constipation issue; November 2024 nausea/ vomiting supplement).