recognising illness in the terminal stage mr aali sheen 10 th october 2015
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Recognising illness in the Recognising illness in the Terminal StageTerminal Stage
Mr Aali SheenMr Aali Sheen
1010thth October 2015 October 2015
Who am I?Who am I?
Consultant General SurgeonConsultant General Surgeon
Hepatopancreatobiliary specialistHepatopancreatobiliary specialist
Abdominal wall and HerniaAbdominal wall and Hernia
Medical school 1993Medical school 1993
Trained in London, Leeds and ManchesterTrained in London, Leeds and Manchester
Appointed Consultant in 2005Appointed Consultant in 2005
Undertaken 450 Liver/GB; 101 Pancreas Undertaken 450 Liver/GB; 101 Pancreas resections for cancerresections for cancer
IntroductionIntroduction
Diagnosis of cancer is not always easyDiagnosis of cancer is not always easy
Cardinal signsCardinal signs
Soft signsSoft signs
Can always be missedCan always be missed
Cased based scenariosCased based scenarios– StraightforwardStraightforward– More difficult in interpretationMore difficult in interpretation
Early symptomsEarly symptoms
Generally feeling unwellGenerally feeling unwell
‘‘Not Right”Not Right”
HavenHaven’’t been the samet been the same
Going on for a few monthsGoing on for a few months
Occasional tummy pain but nothing Occasional tummy pain but nothing seriousserious
But I was eating fine up until last weekBut I was eating fine up until last week
Cardinal symptomsCardinal symptoms
Weight lossWeight loss
Abdominal discomfortAbdominal discomfort
Poor appetitePoor appetite
Altered bowel habitAltered bowel habit
PR bleedingPR bleeding
DysphagiaDysphagia
OdynophagiaOdynophagia
HaemoptysisHaemoptysis
SignsSigns
Increasing ageIncreasing age
Recent change in lifestyleRecent change in lifestyle
Thin (not always)Thin (not always)
CachecticCachectic
JaundicedJaundiced
Abdominal distensionAbdominal distension
Lump – SJ noduleLump – SJ nodule
Case 1Case 1
69 year old man69 year old man
Likes his drinkLikes his drink
Noted tummy swellingNoted tummy swelling
Feels otherwise okFeels otherwise ok
Eating plentyEating plenty
Thought he should come and see you?Thought he should come and see you?
Tests??Tests??
Ultrasound?Ultrasound?
Routine serum investigationsRoutine serum investigations
Cancer pathwayCancer pathway
Immediate referral to Specialist and Immediate referral to Specialist and Cancer MDTCancer MDT
Tumour markers – can be undertaken in Tumour markers – can be undertaken in hospitalhospital
HepatomaHepatoma
History predicts problemHistory predicts problem
Diagnosis often lateDiagnosis often late
CirrhosisCirrhosis
Options for cure are limitedOptions for cure are limited– Surgery if Childs ASurgery if Childs A– TACETACE– AblationAblation– ChemotherapyChemotherapy
Case 2Case 2
35 year old patient mother of three35 year old patient mother of three
Feels awfulFeels awful
Jaundiced !Jaundiced !
Bilirubin – 275Bilirubin – 275
Admission to Hospital – donAdmission to Hospital – don’’t take no for t take no for an answer – Call the Consultantan answer – Call the Consultant
InvestigationsInvestigations
Relief of Jaundice failed with ERCPRelief of Jaundice failed with ERCP
Tight distal bile duct stricture ? StonesTight distal bile duct stricture ? Stones
Percutaneous drain inserted – could not Percutaneous drain inserted – could not bypass stricture – is this malignant?bypass stricture – is this malignant?
Patient deterioratingPatient deteriorating
Died 30 after admissionDied 30 after admission
DiagnosisDiagnosis
Malignant cholangiocarcinoma – on a Malignant cholangiocarcinoma – on a background of choledochal cystsbackground of choledochal cysts
Poor overall prognosisPoor overall prognosis
Take home messageTake home message
Very high Bilirubin!Very high Bilirubin!
It’s ok for a transient rise but not to a very high It’s ok for a transient rise but not to a very high levellevel
Case 3Case 3
55 year old lady with UC complained of a 55 year old lady with UC complained of a low Hblow Hb
Investigated with colonoscopy – no tumourInvestigated with colonoscopy – no tumour
Gastroscopy normalGastroscopy normal
Bloods show a mild anaemiaBloods show a mild anaemia
No obvious other abnormalitiesNo obvious other abnormalities
What next??What next??
Blood filmBlood film
Bone marrowBone marrow
Abdominal imagingAbdominal imaging
UltrasoundUltrasound– Dilated ducts on the left lobe onlyDilated ducts on the left lobe only– Normal LFTsNormal LFTs
CAT scan ?CAT scan ?
X-sectional imaging showed possible PSCX-sectional imaging showed possible PSC
Segmental cholangiocarcinoma is a worrySegmental cholangiocarcinoma is a worry
Needs surgeryNeeds surgery
Chemotherapy not ideal for this cancerChemotherapy not ideal for this cancer
Surgery undertaken – patient wellSurgery undertaken – patient well
What to look out for?What to look out for?
Unexplained weight lossUnexplained weight loss
Bleeding – Vomit/PR/PVBleeding – Vomit/PR/PV
Persistent heartburn or indigestionPersistent heartburn or indigestion
Altered bowel habitAltered bowel habit
JaundiceJaundice
HaempotysisHaempotysis
Breast LumpBreast Lump
Abnormal persistent lump Abnormal persistent lump
Terminal CancerTerminal Cancer
Review care needs and goals of care with resident (if Review care needs and goals of care with resident (if able), family and GPable), family and GP
Implement palliative care plan or pathwayImplement palliative care plan or pathway
Ensure care given is in line with previous direction Ensure care given is in line with previous direction from the resident, if they are now unable to give from the resident, if they are now unable to give directiondirection
Manage symptoms appropriatelyManage symptoms appropriately
Withdraw treatments, activities, medication that are no Withdraw treatments, activities, medication that are no longer appropriate or benefiting the residentlonger appropriate or benefiting the resident
Provide counselling and support, to the resident, Provide counselling and support, to the resident, family and staff.family and staff.
Three triggers !Three triggers !
The Surprise Question "Would you be The Surprise Question "Would you be surprised if this patient were to die in the surprised if this patient were to die in the next few months, weeks, days'?"next few months, weeks, days'?"
General indicators of decline - General indicators of decline - deterioration, increasing need or choice for deterioration, increasing need or choice for no further active careno further active care
Specific clinical indicators related to Specific clinical indicators related to certain conditions (unresolving jaundice).certain conditions (unresolving jaundice).
GuidanceGuidance
Three case scenariosThree case scenarios
69 year old woman with terminal cancer69 year old woman with terminal cancer
84 year old with deteriorating medical 84 year old with deteriorating medical conditioncondition
91 year old lady with chronic condition91 year old lady with chronic condition
GSF guidanceGSF guidance
A – BlueA – Blue– Diagnosis – Stable with a year + prognosisDiagnosis – Stable with a year + prognosis
B – GreenB – Green– Unstable, Advanced diseaseUnstable, Advanced disease
C – YellowC – Yellow– Deteriorating, weeks prognosisDeteriorating, weeks prognosis
D – RedD – Red– Terminal care, final daysTerminal care, final days
NAVY After careNAVY After care
Change in Patient’s statusChange in Patient’s status
Weight loss (more than 10% of body Weight loss (more than 10% of body weight in last 6 months); BMI below 18weight in last 6 months); BMI below 18
Serum albumin less than 25g/lSerum albumin less than 25g/l
General physical decline; dependent in General physical decline; dependent in ADL’s, bed / chair fastADL’s, bed / chair fast
Multiple diseases impacting on wellbeingMultiple diseases impacting on wellbeing
Increased frequency of admissions to Increased frequency of admissions to acute care.acute care.
End of lifeEnd of life
Prepare family for passing awayPrepare family for passing away
Unexpected when it finally happensUnexpected when it finally happens
Painful for all involvedPainful for all involved
Try not to expect them to know to much Try not to expect them to know to much information – as all the information they information – as all the information they have received may not have ‘got through’have received may not have ‘got through’
Best to let them ask any questions ?Best to let them ask any questions ?
SummarySummary
High index of suspicionHigh index of suspicion
Severe abnormality in blood tests should Severe abnormality in blood tests should raise alarm bellsraise alarm bells
Increasing age is important but younger Increasing age is important but younger patients usually present late with advanced patients usually present late with advanced disease - If in doubt please refer ondisease - If in doubt please refer on
Triggers Triggers
Preparation for death is never easyPreparation for death is never easy
Useful LinksUseful Links
NICENICE– http://www.nice.org.uk/guidance/cg27/chapter/http://www.nice.org.uk/guidance/cg27/chapter/
guidanceguidance
MacmillanMacmillan– http://www.macmillan.org.uk/information-and-http://www.macmillan.org.uk/information-and-
support/diagnosing/how-cancers-are-diagnosed/support/diagnosing/how-cancers-are-diagnosed/signs-and-symptoms/signs-and-symptoms.htmlsigns-and-symptoms/signs-and-symptoms.html
Cancer research UKCancer research UK– http://www.cancerresearchuk.org/about-cancer/http://www.cancerresearchuk.org/about-cancer/
cancer-symptomscancer-symptoms
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