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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. E P E C EPEC – Oncology Education in Palliative and End-of-life Care – Oncology O 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 E P E C Summary O Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience