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The
EPEC-O
TM
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
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EPEC – Oncology
Education in Palliative and End-of-life Care – Oncology
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Module 3e
Symptoms –
Bowel Obstruction
Bowel obstruction . . .

Definition: mechanical or functional
obstruction of the progress of food
and fluids through the GI tract
. . . Bowel obstruction

Impact: misery from nausea,
vomiting and abdominal pain
. . . Bowel obstruction
Epidemiology

Prevalence
3 % of all advanced malignancies
11 – 42 % ovarian cancer
5 – 24 % colorectal cancer

Prognosis – poor if inoperable
64 days
Krebs HR, Goplerud DR. Am J Obstet Gynecol, 1987.
Ripamonti S, et al. J Pain Symptom Manage, 2000.
Key points
1. Pathophysiology
2. Assessment
3. Management
Pathophysiology . . .

Intraluminal mass

Direct infiltration

External compression

Carcinomatosis

Adhesions

Other
. . . Pathophysiology

2 liters / day orally

8 liters / day gastric & intestinal
secretions

Obstruction causes accumulation

Peristalsis causes distention, pain,
nausea, and vomiting
Assessment

Symptoms
Continuous distension pain 92 %
Intestinal colic 72 – 76 %
Nausea/vomiting 68 – 100 %

Abdominal radiograph
Dilated loops, air-fluid levels

CT scan
Staging, treatment planning
Differentiating small vs.
large bowel obstruction
S/Sx
Small-high
Small-low
Large
Acute, severe
Acute, severe
Progressive
Variable
Variable
Mild, steady
Bowel sounds
Diminished
Hyperactive;
diminished
Hyperactive;
diminished
Bowel
movement
Short-term
Short-term
Constipation
Severe
Mild/moderate
None; severe
Onset
Abdominal
pain
Vomiting
Management . . .
Medical

Opioids
Morphine – 89 % control

Antiemetics
Prochlorperazine – 13 % control

Steroids
Dexamethasone
. . . Management
Surgical

Surgical evaluation

Standard
Intravenous fluids
Nasogastric tube – intermittent suction

Inoperable
Stent placement
Venting gastrostomy
Antisecretory agents
Drug
Dose
Notes
10 mcg / h SQ / IV
cont. infusion or
100 mcg SQ q 8 h
Minimal adverse
effects; titrate
daily
Scopolamine
(hyoscine
hydrobromide)
10 mcg / h SQ / IV
cont. infusion or
0.1 mg SQ q 6 h
Anticholinergic
effects may be
dose - limiting;
titrate daily
Glycopyrrolate
0.2 to 0.4 mg SQ
q 2 to 4 h; titrate
Anticholinergic
effects possible
Octreotide
Anticholinergics

Antispasmodic and antisecretory

Scopolamine
10 – 100 mcg / hr SC / IV
0.1 mg SC q 6 h and titrate

Glycopyrrolate
0.2 - 0.4 mg SC q 2 – 4 h and titrate
Baines M, et al. Lancet, 1985.
Davis MP, Furste A. J Pain Symptom Manage, 1999.
Somatostatin

14 amino acid polypeptide
Serum half-life = 3 minutes

Central action
Inhibits release of GH and thyrotropin

Peripheral action
Inhibits glandular secretion
Pancreas, GI tract
Octreotide . . .

Polypeptide analog of somatostatin
Serum half-life = 2 hr

Relieves symptoms of obstruction
Ripamonti, et al. J Pain Symptom Manage, 2000.
Mercadante, et al. Supportive Care Cancer, 2000.
Fainsinger RL, et al. J Pain Symptom Manage, 1994.
. . . Octreotide

Octreotide 10 mcg/h continuous
infusion

Titrate to complete control of N / V

If NG tube in place, clamp when
volume diminishes to 100 cc and
remove if no N / V

Try convert to intermittent SC

Continue until death
. . . Octreotide

Side effects
Mostly none
Dry mouth
Biliary sludge / stones

Studies in other palliative care
settings

Subcutaneous administration
Conclusions

Considerable symptom control
challenge

Surgery for selected cases

Pharmacological management
relieves symptoms in many patients

Antisecretory agents represent a
significant advance
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Summary
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Use comprehensive
assessment and
pathophysiology-based therapy
to treat the cause and improve
the cancer experience