malignant bowel obstruction - palliative care management · bowel obstruction occurs when there is...
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Malignant Bowel
Obstruction
Dr. Thiru Thirukkumaran
Palliative Care Physician
Palliative Care Services Northwest Tasmania
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What is Malignant Bowel Obstruction? Bowel Obstruction occurs when there is blockage of the forward flow gastric contents through GI tract.
Causes:
Tumour growth,
Adhesions,
Carcinomatosis,
Faecal impaction,
Pharmacotherapy
Neuropathy
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Pathophysiology
Functional Obstruction
Paralytic (adynamic) ileus or functional obstruction
Intestinal Motility Disorders: Infiltration of mesentery, bowel muscle or nerves or coeliac plexus
Para-neoplastic neuropathies and related conditions
Structural Obstruction
Intraluminal Obstruction
- Polypoid tumours or Annular spread
Intramural: Intestinal Linitis Plastica
External Obstruction
- Tumour or recurrence, Omental or Mesenteric masses,
- Adhesions or Fibrosis
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Statistics
4
Frequency in advanced disease Ovary: 5-42%
Colorectal: 4-24%
Location
Small Bowel: 61%
Large Bowel: 33%
Both sites: 20%
Benign causes: Adhesions, post RT fibrosis, herniae, etc.
Make up between 3-48%
MRI and CT Scans poor at distinguishing benign from malignant causes (Anthony 2007)
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Classification
5
1. Partial or complete
2. Single or multiple sites
3. Location in the GI tract
This will affect Presentation,
Symptoms &
Clinical management
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Clinical Features
Gradual onset….. So symptoms may not be typical.
Often……a partial obstruction
Symptoms: 90% (Continuous) tumour pain
75% (Intermittent) abdominal colic
‘Emptying vomiting’ & abdominal distension depends on location and extent of tumour
Signs: from examination Tympanic percussion,
Tinkling bowel sounds, rarely visible peristalsis.
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Investigations
1. AXR
2. Barium can worsen the condition
3. Most important to exclude constipation as the sole cause
4. CT Scan
7
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A small bowel obstruction
CT Scan AXR
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Consider the followings options:
1. Surgery Resection
Bypass
2. Stent
3. Venting gastrostomy
4. Chemotherapy
5. Medical management
6. Nutrition and hydration
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Surgery
9
No consensus on the indications for conservative versus surgical management
Bowel primary more amenable than ovarian Large bowel more amenable than small bowel Mortality 9-40% Complications 9-90% Survival 1-12 months (mean from reported studies) Non-randomised study showed no difference in
survival between conservative and surgical management
Type of obstruction and procedure performed don’t appear to affect survival
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Benefits from Surgery
Not just about survival
Time in hospital
Symptom control
Complications
Need to weigh up all the benefits and burdens
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Suggested Contraindications
Absolute CI 1. Recent laparotomy demonstrating corrective surgery not possible
2. Diffuse metastatic cancer
3. Involvement of proximal stomach
4. Severe motility problems
5. Diffuse palpable intra-abdominal masses
6. Massive ascites, re-occurring after drainage
Relative CI 1. Extra-abdominal metastasis
2. Poor general performance status
3. Poor nutritional status (e.g. wt loss, low albumin)
4. Advanced age associated with cachexia
5. RT to abdomen or pelvis
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Upper GI Stents
Systematic review suggests stents for patients with shorter prognosis gastrojejunostomy (GJJ) for those with longer. (Jeurnink 2007)
Upper GI stent outcomes Success rate 96% Early complications 7% Late complications 18% Persisting symptoms 8% Recurrent obstructive symptoms 18% (compared with 1% from GJJ) Hospital stay 7days
Complications Ulceration Perforation Stent migration Pain Blockage Reflux Bleeding
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Lower GI Stents
Only left sided tumours are accessible
Complications:
Incontinence in addition to the above
Systematic review of colorectal stents to relieve MBO
(Watt A. Annals of Surgery 2007)
Little high level evidence
Shorter hospital stays and adverse outcomes than surgery
Appears safe and effective
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Pharmacological Management
Focus on
Nausea
Vomiting
Pain
First described 1985 (Baines, Oliver et al, Lancet)
In-patient and out-patient management
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Vomiting
What is acceptable? 1-2 per day
Every few days
No vomiting at all
Management options Steroids
Pro-kinetic
Anti-emetics
Anti-secretory
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Anti-cholinergic medications
Hyoscine butylbromide / Hyoscine hydrobromide
/ Glycopyrronium
Actions – Decrease bowel tone and peristalsis
– Decrease secretions
Side-effects – Central S/Es (limited by using HB and Glycopyrronium) (Hyoscine Hydrobromide & Glycopyrronium are less likely to cross the blood-brain barrier as they are not as lipid-soluble, thereby causing less central side-effects).
– Dry mouth
– Retention
– Etc.
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Somatostatin and Octreotide • Decrease
– GI hormone release and activity
– Acid secretion
– Motility
– Bile production
– Mucus production
– Splanchnic blood flow
• Increase absorption of water and electrolytes
• Can inhibit acetylcholine activity.
• Half life 1.5 hours
• Cost
• Can be given by monthly depot following 2 weeks of infusion (Matulonis 2007)
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Octreotide: Suggested Benefits From Two Randomized Controlled Trials (RCTs)
More effective than Hyoscine butylbromide in terms of:
1. Reducing • GI secretions
• Intensity of nausea
• Frequency of vomiting
2. Suggested may work synergistically with anti-cholinergic
3. May prevent development of irreversible bowel obstruction
• Ripamonti C et al. J Pain Symptom Management 2000.
• Mercadante S et al. Supportive care in cancer. 2000.
• Mercadante S et al. J Pain Symptom Management 1997
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Anti-emetics
• Pro-kinetic – Metoclopramide
– If there is no colic
• Haloperidol
• Cyclizine
• Levomepromazine
• All have been used
• No comparative data
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Steroids
1. Systematic review suggests benefit though
didn’t reach statistical significance
2. Anti-emetic effect
3. Reduce peri-tumour and peri-neural oedema
4. Risk of stimulating appetite when a patient
can’t eat
5. Use high dose for a one week trial and
gradually reduce if effective
Feuer DJ, Broadley KE (1999)
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Feeds and Fluids 1. TPN
– Only beneficial in very select cases – Risks and potential prolonged hospital stay – Most patients anorexic and cachexic from the
malignant process already
2. Hydration – No direct correlation between hydration and dry
mouth / thirst – May improve nausea if given > 1litre / day – Risk of increasing bowel secretions if too much
3. Local measures: mouth care, pineapple, ice cubes, regular sips, etc. are effective for dry mouth
Ripamonti C et al. J Pain Symptom Management 2000. Mercadante S et al. Supportive care in cancer. 2000
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Pain
Why?
1. Tumour Pain
Opioids for tumour pain
2. Colic from smooth muscle contraction
Anti-cholinergic for colic
Constipation Avoid stimulant laxatives (Senna or Coloxyl with senna!)
Docusate
Movicol – especially if constipation
exacerbating partial obstruction
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Outcome
1. Colic – Almost always reduced to mild or none
2. Pain – Should achieve complete control in majority
3. Nausea and vomiting – Should be able to reduce 1/day or less
4. Prognosis – 3.7 months with 7/38 patients living > 7/12
5. Eating and drinking – Hydration can be maintained if vomiting controlled
Baines et al 1985
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Naso-Gastric Tubes
Aim is to be without them because
uncomfortable and risk of complications
May be useful
– In early stages
– Whilst establishing pharmacological
management
– In poorly patients with persistent vomiting
especially where there is a high obstruction
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Gastrostomy
Indications
– If pharmacological management unsuccessful
At surgery where complete bowel
obstruction appears
PEG can avoid need for surgery
Reported control of nausea and vomiting in
90% of cases
likely to be permanent or prolonged
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Conclusions
Palliative care approach 1. Dexamethasone 16mg / day for 7 day trial
2. If no colic
– Metoclopramide 40 – 120mg via syringe driver
3. If colic
– Levomepromazine 5mg – 6.25mg (One vial is 25mg)
– Buscopan 40 – 120mg
+/- Octreotide 500 – 1000 micrograms
4. Pain
– Morphine at appropriate dose
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