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Malignant bowel obstruction: A palliative thread
Possibly one of the most complex and challenging presentations in palliative care.
Eating, drinking and going to the toilet are habits of a lifetime.
Obstruction can lead to sudden medicalisation of what comes naturally.
Possibly one of the most complex and challenging presentations in palliative care.
Eating, drinking and going to the toilet are habits of a lifetime.
Obstruction can lead to sudden medicalisation of what comes naturally.
Causes (malignant)
1) Intraluminal obstructing bowel cancer
2) Extraluminal compression from primary or metastatic disease affecting the bowel, peritoneum or omentum.
3) Peristaltic failure due to damage of bowel wall, nerves and myenteric plexus
1) Intraluminal obstructing bowel cancer
2) Extraluminal compression from primary or metastatic disease affecting the bowel, peritoneum or omentum.
3) Peristaltic failure due to damage of bowel wall, nerves and myenteric plexus
Colon and Ovarian cancer tend to cause distal obstruction
Pancreatic and Cholangiocarcinoma tend to cause proximal obstruction
Melanoma and Breast cancer are the most common extra-abdominal causes and may cause multilevel obstruction.
Pancreatic and Cholangiocarcinoma tend to cause proximal obstruction
Melanoma and Breast cancer are the most common extra-abdominal causes and may cause multilevel obstruction.
Proximal obstruction
Bilious vomiting (green-yellow)
Smaller volume vomits
Reflux symptoms
Post prandial vomiting and pain
Little or no abdominal distension
Often unable to eat at all due to symptoms
Dehydration and electrolyte upset common
Shorter time between vomiting
Bilious vomiting (green-yellow)
Smaller volume vomits
Reflux symptoms
Post prandial vomiting and pain
Little or no abdominal distension
Often unable to eat at all due to symptoms
Dehydration and electrolyte upset common
Shorter time between vomiting
Distal obstruction
Larger volume vomiting (often litres)
Vomiting often in evening
Malodorous or faeculant
Abdominal swelling often extensive
Typmanic abdomen
Dull, visceral pain often colicky
Longer interval between vomiting as more space to fill behind obstruction.
Larger volume vomiting (often litres)
Vomiting often in evening
Malodorous or faeculant
Abdominal swelling often extensive
Typmanic abdomen
Dull, visceral pain often colicky
Longer interval between vomiting as more space to fill behind obstruction.
Bedside tips
Succussion splash: gently rock the patient’s upper abdomen from side to side while listening closely over their stomach area.
A sloshing sound can point to duodenal/gastric outlet obstruction
Succussion splash: gently rock the patient’s upper abdomen from side to side while listening closely over their stomach area.
A sloshing sound can point to duodenal/gastric outlet obstruction
Bowel sounds
Loud borborygmi: heard often from the end of the bed more common in distal small bowel and large bowel obstruction.
Tinkling bowel sounds: like drips in a large cave are often found in small bowel obstruction as fluid hits the blockage
Loud borborygmi: heard often from the end of the bed more common in distal small bowel and large bowel obstruction.
Tinkling bowel sounds: like drips in a large cave are often found in small bowel obstruction as fluid hits the blockage
Diagnosis is usually confirmed by Abdominal X-Ray and CT scan but the clinical presentations outlined above in a patient with known cancer
can be very useful when imaging not available or the person is approaching end of life.
CT scanning can identify the cause in 94% of cases.
can be very useful when imaging not available or the person is approaching end of life.
CT scanning can identify the cause in 94% of cases.
A word on bowel motions
Constipation is usually present.
This can be intermittent or total associated with inability to pass flatus.
Over time bacterial overgrowth can occur in the bowel which liquefies stool allowing it to pass an obstruction causing overflow diarrhoea.
Constipation is usually present.
This can be intermittent or total associated with inability to pass flatus.
Over time bacterial overgrowth can occur in the bowel which liquefies stool allowing it to pass an obstruction causing overflow diarrhoea.
Definitive management is surgery.
Surgeons can cure or postpone complete obstruction.
That’s amazing and why it should always be considered as a treatment option, even in the palliative setting.
Stents, venting, lasering and stoma formation are some of the treatments.
Surgeons can cure or postpone complete obstruction.
That’s amazing and why it should always be considered as a treatment option, even in the palliative setting.
Stents, venting, lasering and stoma formation are some of the treatments.
Some people are not able to undergo surgery or a trial of chemotherapy:
- May be too frail
- Multilevel bowel obstruction
- Patient preference
- Severe malnutrition
Perioperative complications rise with advancing cancer stages.
What now?
- May be too frail
- Multilevel bowel obstruction
- Patient preference
- Severe malnutrition
Perioperative complications rise with advancing cancer stages.
What now?
General measures
Explain what is happening.
Use a diagram or drawing.
Talk over the pattern of symptoms
Plan day around good spells
Discuss fears: often about weight loss, not eating and dehydration.
Discuss place of care fully.
Can be difficult to manage symptoms at home.
Explain what is happening.
Use a diagram or drawing.
Talk over the pattern of symptoms
Plan day around good spells
Discuss fears: often about weight loss, not eating and dehydration.
Discuss place of care fully.
Can be difficult to manage symptoms at home.
Mouth care is essential
Dehydration, vomiting and medications can cause dry mouth and thrush.
Provide Ice chips/lollies
Cold drinks
Fruit slices to suck on
Daktarin gel can be useful but can still try fluconazole orally for thrush.
Biotene gel and mouthwash
Apply gently
Dehydration, vomiting and medications can cause dry mouth and thrush.
Provide Ice chips/lollies
Cold drinks
Fruit slices to suck on
Daktarin gel can be useful but can still try fluconazole orally for thrush.
Biotene gel and mouthwash
Apply gently
If proximal obstruction suspected, frequent vomiting or new onset symptoms then discuss a trial of a large bore nasgastric tube with patient.
These can be sited quickly and often provide significantly relief.
Remember tubes can be uncomfortable and visually upsetting.
These can be sited quickly and often provide significantly relief.
Remember tubes can be uncomfortable and visually upsetting.
Acute bowel obstruction often resolves after a few days and the NG tube can be removed.
Obstruction can come and go repeatedly over time with vomiting/constipation followed by decompression and symtpom resolution.
This is often termed sub-acute obstruction.
Obstruction can come and go repeatedly over time with vomiting/constipation followed by decompression and symtpom resolution.
This is often termed sub-acute obstruction.
Fluids
Encourage oral fluids when possible
The oral route helps with thirst more than IV/scut routes
IV fluid replacement may help with symptomatic dehydration and electrolyte imbalance.
Scut fluids can provide up to 1.5litres/day in hospice and community settings.
Encourage oral fluids when possible
The oral route helps with thirst more than IV/scut routes
IV fluid replacement may help with symptomatic dehydration and electrolyte imbalance.
Scut fluids can provide up to 1.5litres/day in hospice and community settings.
Steroids
There is evidence to support a trial of dexamethasone for 5 days at a dose of usually 8-16mg.
This may relieve partial obstruction by reducing peri tumour oedema
Usually should be given as subcutaneous injection to ensure absorption.
Usual side-effects of course
There is evidence to support a trial of dexamethasone for 5 days at a dose of usually 8-16mg.
This may relieve partial obstruction by reducing peri tumour oedema
Usually should be given as subcutaneous injection to ensure absorption.
Usual side-effects of course
Pain
Colicky pain: often indicates impending or complete obstruction.
Anticholinergics
Hyoscine butylbromide Glycopyrronium
Relax smooth muscle and have anti-secretory properties
Give as scut boluses or via a syrigne driver. Oral bioavailability is poor.
Dry mouth in 100%
Colicky pain: often indicates impending or complete obstruction.
Anticholinergics
Hyoscine butylbromide Glycopyrronium
Relax smooth muscle and have anti-secretory properties
Give as scut boluses or via a syrigne driver. Oral bioavailability is poor.
Dry mouth in 100%
Continuous pain is often due to tumour infiltration of nerves and peritoneal lining
Subcutanous opioids are often required either as bolus doses or via a syringe driver
Morphine is 1st line
If falling renal function eGFR<30 then consider Alfentanil as opioid of choice
Subcutanous opioids are often required either as bolus doses or via a syringe driver
Morphine is 1st line
If falling renal function eGFR<30 then consider Alfentanil as opioid of choice
Anti-emetics
Metoclopramide(prokinetic) consider a trial of this via scut route if partial obstruction/dysmotility is suspected. Stop if it causes colicky pain. Often given with steroid
Levomepromazine or Cyclizine are often used when colic occurs. Both can cause drowsiness.
Metoclopramide(prokinetic) consider a trial of this via scut route if partial obstruction/dysmotility is suspected. Stop if it causes colicky pain. Often given with steroid
Levomepromazine or Cyclizine are often used when colic occurs. Both can cause drowsiness.
Octreotide
Somatostatin analogue that reduces secretions throughout the GI tract.
Some debate if more effective anti-secretory than hyoscine.
Often require to use both in complete obstruction.
Scut infusion usually. Start slowly and titrate over days.
Expensive drug
Somatostatin analogue that reduces secretions throughout the GI tract.
Some debate if more effective anti-secretory than hyoscine.
Often require to use both in complete obstruction.
Scut infusion usually. Start slowly and titrate over days.
Expensive drug
Extras
A fentanyl patch may be a suitable analgesic option. Less constipating opioid but seek specialist advice from palliative care team.
Dyspepsia is common: consider omeprazole or ranitidine(if available) via scut route. Oxetacaine in antacid may help if tolerated
A fentanyl patch may be a suitable analgesic option. Less constipating opioid but seek specialist advice from palliative care team.
Dyspepsia is common: consider omeprazole or ranitidine(if available) via scut route. Oxetacaine in antacid may help if tolerated
Preserving dignity
Refresh sick bowls promptly
Provide loose fitting clothes if abdomen swollen
NG drainage bags can be placed in a clothes peg bag or similar to shield them.
Remove pressure of “meal times”
Provide well ventilated room
Don’t overtalk symptoms esp nausea
Refresh sick bowls promptly
Provide loose fitting clothes if abdomen swollen
NG drainage bags can be placed in a clothes peg bag or similar to shield them.
Remove pressure of “meal times”
Provide well ventilated room
Don’t overtalk symptoms esp nausea
This thread maybe has seemed more serious and that’s ok
Inoperable malignant bowel obstruction is one of the conditions in palliative care that defines “specialist palliative care” in my view.
It can get quite medical but never forget the basics.
Dignity Compassion Quality
Inoperable malignant bowel obstruction is one of the conditions in palliative care that defines “specialist palliative care” in my view.
It can get quite medical but never forget the basics.
Dignity Compassion Quality
