Case Two

MALIGNANT BOWEL OBSTRUCTION

Malignant bowel obstruction

• can occur at any level in the GI tract

• presenting symptom in 16% colorectal tumours

• 42% of ovarian cancers obstruct at some stage

• 3-15% patients with terminal illness obstruct

• obstruction may be mechanical or functional

Causes

• tumour

• adhesions

• faeces

• drugs, eg opioids

• unrelated benign condition

- eg strangulated hernia

Clinical features

• abdominal pain

• vomiting

• distension

• bowels – variable

• bowel sounds – absent to hyperactive

• obstruction may be intermittent

• multiple sites of obstruction are common

Management

• to admit or not to admit?

• consider the patient’s circumstances

• are they fit enough for hospital intervention?

• will hospital intervention improve/extend quality of life?

• are they near the end of life?

• what are the patient's and family’s wishes?

Conventional management

• drip (IVI)

• suck (NG tube)

• starve (NBM)

• operate

When might surgery be appropriate?

• first episode of obstruction

• single site of obstruction, potentially simple to reverse or bypass

• patient is fit enough for anaesthetic and surgery

• patient is expected to live long enough to benefit

• patient is fully informed, mentally competent and gives their consent

Don’t go there if…..

• patient is cachectic, elderly and/or in poor general medical condition

• previous laparotomy shows diffuse intra-abdominal disease

• obvious palpable multiple tumour masses

• recurrent ascites

• multiple sites of obstruction

• small bowel obstruction

Stenting as an alternative to surgery

• specialised skill, not always available

• lesion must be reachable by endoscope

• patient must be fit enough for repeated stenting or lasering at regular intervals

What if the patient is not suitable for surgery?

• IVI, NG tube and NBM is perfectly OK in the short term, eg while waiting for the next available theatre list

• it is a miserable way to spend the last few weeks of your life if surgery is not an option

Pharmacological management

• late 1960s – pioneered by Dr Mary Baines at St Christopher’s Hospice, London

• case series of 40 patients (including post-mortem data), published 1985

(Baines et al, Lancet 1985 2: 990-993)

Aims of pharmacological management

• reduce anxiety

• resolve nausea and pain

• reduce vomiting

• allow for partial/complete resolution of obstruction if possible

• maximise quality of life

How to do it - 1

• explanation of treatment aims and what is happening

• syringe driver (SD)

• control pain

- diamorphine for tumour pain

- hyoscine butylbromide for colic 60mg sc/24h

• control nausea

- Levomepromazine 12.5-25mg sc/24h

How to do it – 2

• stop stimulant laxatives, eg senna, codanthramer, codanthrasate

• faecal softeners are ok, eg milk of magnesia if patient is able to open bowels

• arachis oil enemas are also ok if there is an uncomfortable mass of hard faeces in the distal bowel/rectum

What else might help?

• dexamethasone

• octreotide

Why bother?

• patients do not always die quickly

• patients can eat and drink as they want and what they want

• patient can be as mobile as they wish

• the patient may be able to be nursed at home