Difference between revisions of "Malignant bowel obstruction"

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==Introduction==
 
==Introduction==
 
+
*[[Bowel obstruction]] in malignancy is complex in etiology
Bowel obstruction in malignancy is complex in aetiology
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*Underlying pathophysiology often involves combination of physical mechanical obstruction plus ileus / motility related issues, usually in patients with disseminated peritoneal metastases
 
+
*Common causes
Underlying pathophysiology often involves combination of physical mechanical obstruction plus ileus / motility related issues, usually in patients with disseminated peritoneal metastases
+
**Pelvic malignancies, especially ovarian cancer
 
+
**GI malignancies such as colorectal pancreatic cancer
==Common causes==
 
 
 
Pelvic malignancies, especially ovarian cancer
 
 
 
Gastrointestinal malignancies such as colorectal cancer or pancreas cancer
 
  
 
==Clinical features==
 
==Clinical features==
 +
*Often a preceding waxing and waning course of [[nausea and vomiting]] with [[constipation|reducing frequency of bowel movements]] and abdominal distension for a few weeks.
 +
*As the illness progresses an obvious mechanical bowel obstruction may develop. See [[Small bowel obstruction#Clinnical Features]]
  
Often a preceding waxing and waning course of nausea and vomiting with reducing frequency of bowel movements and abdominal distension for a few weeks.
+
==Differential Diagnosis==
 +
{{Constipation DDX}}
  
As the illness progresses an obvious mechanical bowel obstruction may develop. See [[Small bowel obstruction#Clinnical Features]]
+
==Evaluation==
 
+
*The appropriate extent of investigations and treatment varies based on how advanced the patients malignancy is as well as his or her wishes.
==Investigations==
+
*CT scan
 
+
**May be appropriate if stenting or surgery would be considered
The appropriate extent of investigations and treatment varies based on how advanced the patients malignancy is as well as his or her wishes.
+
**Will often distinguish between unifocal (which may be amenable to endoscopic stenting or surgery) versus multi-focal obstructions (which portends a poor prognosis)
 
 
CT scan
 
*May be appropriate if stenting or surgery would be considered
 
*Will often distiguish between unifocal (which may be amenable to endoscopic stenting or surgery) versus multi-focal obstructions (which portends a poor prognosis)
 
  
 
==Management==
 
==Management==
 
 
==="Pre-Bowel Obstruction"===
 
==="Pre-Bowel Obstruction"===
 
+
*In patients at high risk of a full blown malignant bowel obstruction who have no abdominal pain but increasing distension, nausea, vomiting and reducing bowel movements:
In patients at high risk of a full blown malignant bowel obstruction who have no abdominal pain but increasing distension, nausea, vomiting and reducing bowel movements:
+
*[[Metoclopramide]] 30mg via CSCI over 24 hours
 
+
*Sodium [[docusate]] 200mg twice daily (or an alternative stool softener)
Metoclopramide 30mg via CSCI over 24 hours
+
*+/- [[Dexamethasone]] 8mg daily SC
Sodium docusate 200mg twice daily (or an alternative stool softener)
 
+/- Dexamethasone 8mg daily SC
 
  
 
===Clear Malignant Bowel Obstruction===
 
===Clear Malignant Bowel Obstruction===
 +
*In many patients surgery or stenting is unlikely to be helpful, although for very proximal unifocal lesions or for patients otherwise very fit and healthy it may be worth considering
 +
*Usually malignant bowel obstruction is indicative that a patient is coming into the last few weeks or month of life. A kind but frank discussion about this is usually helpful.
 +
*If vomiting and abdominal pain are very severe, consider drainage NG tube. If severe vomiting and discomfort are not major issues then it may be best to avoid an NG tube, especially if a more comfort-based approach to treatment is being considered
 +
*Treat vomiting and distension with anti-secretorary agents:
 +
**[[Ranitidine]] 150mg via [[CSCI]] over 24 hours
 +
**[[Octreotide]] 600mg via CSCI over 24 hours
 +
*Treat nausea with an anti-emetic, e.g.
 +
**[[Haloperidol]] 2.5mg via CSCI over 24 hours
 +
**+ Haloperidol 1mg SC 2-hourly PRN for nausea
 +
*Treat abdominal pain with an anti-spasmodic + an opioid, e.g.
 +
**Hyoscine butylbromide 60mg via CSCI over 24 hours
 +
**A low dose opioid via CSCI over 24 hours and SC PRN
 +
*Also consider [[dexamethasone]] 8mg daily SC
 +
*If intractable vomiting persists, consider a venting PEG.
 +
*In patients where comfort and quality of life are the key concerns, IV fluids may not be helpful unless thirst is an issue.
 +
*In patients where life-prolongation is very important, IV hydration and TPN in hospital or in the home setting may be appropriate.
  
In many patients surgery or stenting is unlikely to be helpful, although for very proximal unifocal lesions or for patients otherwise very fit and healthy it may be worth considereding
+
==Disposition==
 
 
Usually malignant bowel obstruction is indicative that a patient is coming into the last few weeks or month of life. A kind but frank discussion about this is usually helpful.
 
 
 
If vomiting and abdominal pain are very severe, consider drainage NG tube. If severe vomiting and discomfort are not major issues then it may be best to avoid an NG tube, especially if a more comfort-based approach to treatment is being considered
 
 
 
Treat vomiting and distension with anti-secretorary agents:
 
 
 
Ranitidine 150mg via [[CSCI]] over 24 hours
 
Octreotide 600mg via CSCI over 24 hours
 
 
 
Treat nausea with an anti-emetic, e.g.
 
 
 
  Haloperidol 2.5mg via CSCI over 24 hours
 
  + Haloperidol 1mg SC 2-hourly PRN for nausea
 
 
 
Treat abdominal pain with an anti-spasmodic + an opioid, e.g.
 
 
Hyoscine butylbromide 60mg via CSCI over 24 hours
 
A low dose opioid via CSCI over 24 hours and SC PRN
 
 
 
Also consider dexamethasone 8mg daily SC
 
 
 
If intractable vomiting persists, consider a venting PEG.
 
 
 
In patients where comfort and quality of life are the key concerns, IV fluids may not be helpful unless thirst is an issue.
 
  
In patients where life-prolongation is very important, IV hydration and TPN in hospital or in the home setting may be appropriate.
 
  
 
==See also==
 
==See also==
 +
*[[Bowel obstruction]]
  
[[Bowel obstruction]]
+
==References==
 +
<references/>
  
[[Category: Palliative Medicine]]
+
[[Category:GI]]

Latest revision as of 23:01, 29 September 2019

Introduction

  • Bowel obstruction in malignancy is complex in etiology
  • Underlying pathophysiology often involves combination of physical mechanical obstruction plus ileus / motility related issues, usually in patients with disseminated peritoneal metastases
  • Common causes
    • Pelvic malignancies, especially ovarian cancer
    • GI malignancies such as colorectal pancreatic cancer

Clinical features

Differential Diagnosis

Constipation

Evaluation

  • The appropriate extent of investigations and treatment varies based on how advanced the patients malignancy is as well as his or her wishes.
  • CT scan
    • May be appropriate if stenting or surgery would be considered
    • Will often distinguish between unifocal (which may be amenable to endoscopic stenting or surgery) versus multi-focal obstructions (which portends a poor prognosis)

Management

"Pre-Bowel Obstruction"

  • In patients at high risk of a full blown malignant bowel obstruction who have no abdominal pain but increasing distension, nausea, vomiting and reducing bowel movements:
  • Metoclopramide 30mg via CSCI over 24 hours
  • Sodium docusate 200mg twice daily (or an alternative stool softener)
  • +/- Dexamethasone 8mg daily SC

Clear Malignant Bowel Obstruction

  • In many patients surgery or stenting is unlikely to be helpful, although for very proximal unifocal lesions or for patients otherwise very fit and healthy it may be worth considering
  • Usually malignant bowel obstruction is indicative that a patient is coming into the last few weeks or month of life. A kind but frank discussion about this is usually helpful.
  • If vomiting and abdominal pain are very severe, consider drainage NG tube. If severe vomiting and discomfort are not major issues then it may be best to avoid an NG tube, especially if a more comfort-based approach to treatment is being considered
  • Treat vomiting and distension with anti-secretorary agents:
  • Treat nausea with an anti-emetic, e.g.
    • Haloperidol 2.5mg via CSCI over 24 hours
    • + Haloperidol 1mg SC 2-hourly PRN for nausea
  • Treat abdominal pain with an anti-spasmodic + an opioid, e.g.
    • Hyoscine butylbromide 60mg via CSCI over 24 hours
    • A low dose opioid via CSCI over 24 hours and SC PRN
  • Also consider dexamethasone 8mg daily SC
  • If intractable vomiting persists, consider a venting PEG.
  • In patients where comfort and quality of life are the key concerns, IV fluids may not be helpful unless thirst is an issue.
  • In patients where life-prolongation is very important, IV hydration and TPN in hospital or in the home setting may be appropriate.

Disposition

See also

References