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Management of malignant bowel obstruction
Robert A. Milch1, Jaclyn Schneider2
1
Clinical Surgery, State University at Buffalo School of Medicine, Palliative Care Service, 9A, Veterans Administration Hospital, Buffalo, New York
14221, USA; 2Palliative Care and Hospice, State University at Buffalo School of Medicine, Palliative Care Service, 9A, Veterans Administration
Hospital, Buffalo, New York 14221, USA
Correspondence to: Robert A. Milch, MD, FACS. Professor, Clinical Surgery, State University at Buffalo School of Medicine, Palliative Care Service,
9A, Veterans Administration Hospital, 3495 Bailey Avenue, Buffalo, New York 14221, USA. Email: [email protected]; Jaclyn Schneider, MD.
Fellow, Palliative Care and Hospice, State University at Buffalo School of Medicine, Palliative Care Service, 9A, Veterans Administration Hospital,
3495 Bailey Avenue, Buffalo, New York 14221, USA. Email: [email protected].
Abstract: Malignant bowel obstruction (MBO) is a frequent and troubling complication in patients with
cancer. The frequency of MBO has been found to be approximately 5–51% in patients with gynecological
malignancies, and between 10% and 28% in primary intestinal cancers. The management of MBO challenges
clinicians, patients and their families. The management of MBO includes operative surgical interventions
and non-operative medical.
Keywords: Malignant bowel obstruction (MBO); management; pain; palliative Care
Received: 09 May 2016; Accepted: 05 August 2016; Published: 18 August 2016.
doi: 10.21037/xym.2016.08.07
View this article at: http://dx.doi.org/10.21037/xym.2016.08.07
Introduction
Malignant bowel obstruction (MBO) is a frequent and
troubling complication in patients with cancer, especially
those of digestive or gynecological origin, whether as a
primary presenting symptom or associated with advanced
or metastatic disease. MBO can be divided into mechanical
or functional etiologies, both of which result in the inability
for flatus and contents to flow through the gastrointestinal
tract. The obstruction may be at one or many sites along
the bowel from the esophagus to the ano-rectum, and may
partially or fully obstruct the bowel lumen. Even though
the patient population that develops MBO generally has
advanced cancer, the obstruction per se may be benign or
malignant (1).
Prevalence
Bowel obstruction involves the small intestine roughly
twice as frequently as it does the colon (2). The frequency
of MBO has been found to be approximately 5–51% in
patients with gynecological malignancies, and between
10% and 28% in primary intestinal cancers (3). It is also
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reported in patients with lymphoma, melanoma, lung, and
pancreaticobiliary neoplasms. MBO is the root cause of death
in patients with ovarian cancer, most of those patients dying
within a year of developing the obstruction (4). Patients with
MBO due to metastatic disease face a poor prognosis due to
risks of aspiration, pneumonia, and malnutrition, leading to
an estimated life expectancy after MBO of 1–9 months (5,6).
Because its occurrence is of such prognostic significance,
discussions regarding the realistic goals and the plan of
care, individualizing for each patient and their unique
circumstances, need to be had (7).
Pathophysiology
Gastric emptying and flow through the bowel is impeded
either mechanically or functionally in a MBO. Several
mechanisms have been described, though the end result
is the same. Patients with previous abdominal or pelvic
surgeries for malignancy are predisposed to mechanical
obstructions due to the development of adhesions,
both “benign” (i.e., fibrotic) and of malignant origin.
Tumors themselves can cause intraluminal or intramural
occlusion and directly block bowel transit. Primary tumors
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or recurrence of omental and mesenteric masses can
extrinsically cause occlusion by kinking the bowel. Radiation
fibrosis and intraperitoneal chemotherapy can also cause
extrinsic occlusion (8).
Functional obstruction should be thought of as a
disorder of motility. Infiltration of the myenteric or celiac
plexuses can disrupt nervous system signaling resulting in
decreased or disordered peristalsis and obstruction. Tumors
may also infiltrate the intestinal muscularis, rendering it
unable to contract and relax properly. A subset of patients
with Autoimmune Paraneoplastic Autonomic Neuropathy,
which is a paraneoplastic syndrome, may develop autonomic
disturbances which can cause pseudo-obstruction (9).
Once the bowel transit is disrupted, regardless of the
mechanism, there is an accumulation of luminal contents
and an accumulation of secretions which are not absorbed.
This leads to an increased secretion of water and sodium
into the lumen and a decrease of water and sodium
reabsorption from the bowel. The secretions collect in
the lumen, increasing bowel and abdominal distension,
damaging the intestinal epithelium, releasing cytokines and
other noxious compounds, and resulting in a widespread
inflammatory response. The intraluminal pressure rises
and may obstruct venous drainage in the area affected,
which may eventually lead to intestinal mucosal slough or
even perforation, though more extensive, frank gangrene is
uncommon in the absence of a “closed loop” obstruction (1).
Clinical presentation
The patient’s history and the clinical presentation of
MBO can often lead the clinician to the location of the
bowel obstruction. Though colorectal cancer patients
usually present, at least initially, with single-site large
bowel obstructions, gynecologic cancer patients or others
with peritoneal carcinomatosis often suffer from multiple
jejunal and ileal occlusions, and thus with different
symptomatology (10).
The obstruction that results as a consequence from
narrowing of the bowel lumen is often chronic, developing
over weeks and months, and incomplete, which may lead
to vague symptoms until the lumen becomes near- or
completely obstructed (11). Common symptoms of MBO
include nausea, vomiting, colicky abdominal pain vs.
continuous pain, xerostomia, constipation, and overflow
diarrhea (12). Functionally, the bowel attempts to overcome
the evolving obstruction by increasing frequency and
intensity of contractions, which results in colicky abdominal
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pain. As described previously, due to the obstruction the
bowel becomes edematous and luminal contents increase
due to excess secretions, leading to nausea and vomiting.
With the inflammatory response then comes abdominal
distension. Overflow diarrhea may result as the resistance
to flow of fecal material increases, gut flora acts to liquefy
contents, and these are finally forcefully expelled (12).
Obstruction in the proximal gastrointestinal tract
usually results in emesis of recently ingested material. The
presence or absence of bile in the emesis indicates a level of
obstruction above or below the pylorus and proximal small
bowel. In small bowel obstructions, vomiting is usually
watery or bilious and occurs within 45 minutes to 1 hour
of ingestion, whereas it takes several hours or a time later
in the day for a patient with distal small intestinal or large
bowel obstruction to report worsening nausea and vomiting
(13,14). If patients report intense crampy pain in brief
intervals, it is often as indication of a jejunoileal obstruction
or “high” SBO (14). Pain, cramps or emesis occurring later
in the day, often described with fecaloid content, indicates a
more distal location of the obstruction.
The pain related to a small bowel obstruction is generally
periumbilical and colickly, as compared to the steadier,
localized pain in a large bowel obstruction which may or
may not be episodic or colicky. This acute phase pain often
presents as an exacerbation of more chronic pain from
extensive intra-abdominal disease; each requires directed
therapy, which will be described. When the abdomen
becomes distended, which occurs more frequently in distal
small or large bowel obstructions, continuous pain with
variable intensity is often reported (13). Constipation or
obstipation may also occur intermittently with a partial
obstruction, whereas the patient may report scant flatus or
bowel movements initially with a complete obstruction,
followed by complete obstipation (15).
Diagnosis
“Listen to the patient, doctor. He is trying to help you.”
—William Osler, Aphorisms
The key to patient care is in obtaining a thorough history
and physical. Though the diagnosis of an MBO is often
made clinically, it is usually confirmed through the use
of radiographic modalities. Furthermore, given the
emphasis on cost effective medicine, it seems prudent to
discuss which test(s) should be ordered within the first 24
hours of presentation to investigate a MBO. In addition
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to radiographic evaluation, blood work should also be
obtained, as these patients frequently have both acute and
chronic metabolic abnormalities.
A plain radiographic abdominal series (upright, flat,
decubitus views) of the abdomen is the easiest and least
expensive way to define the extent and estimated location of
the obstruction. However, plan X-rays have their limitations;
an ileus often looks similar to an obstruction, and multiple
sites may be involved, which is difficult to discern on a
plain film, and the physician may be limited by the lack of
sensitivity when trying to diagnosis a MBO, as studies have
shown that as many as 75% of plain X-rays may be nondiagnostic (16). Regardless of its limitations, the first step in
diagnosing a bowel obstruction radiographically should be
an abdominal X-ray in which the presence of dilated bowel
loops and air-fluid levels may suggest an MBO.
Contrast radiography may distinguish between mechanical
and functional causes as well as localize the site and extent
of the obstruction (17). The use of this study can be limited
if the patient is suffering from intractable nausea, is unable
to swallow the contrast, or contrast cannot be placed via an
enteric tube. Water-soluble contrast, such as gastrografin,
is preferable to barium as barium may be retained or cause
subsequent impaction or aspiration (12).
Computed tomography (CT) scans have become the
imaging tool used most frequently when a patient has
a suspected MBO, as it has a specificity of 100% and a
sensitivity of 94% (16). Abdominal/pelvic CT scans with
both oral and intravenous contrast agents can localize
an obstruction, reveal lymphadenopathy and bowel wall
irregularities, as well as delineate the extent of tumor
burden in the abdomen and pelvis (18). Because of their
specificity and sensitivity, other forms of radiography are
generally not used as CT scans with contrast are the most
valuable (19). Though MRI may provide more detailed
information regarding the extent of disease (e.g., peritoneal
implants), it is more cumbersome, restrictive, and expensive,
hence less frequently employed in clinical practice in favor
of the CT scan.
Operative surgical management
“First, he would have to know when or not to operate, then how
to operate, then when to stop operating.”
—Dr. Charles Mayo,
on the qualities in the surgeon chosen to operate on him
Consideration of operative intervention for MBO requires
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deliberation and judgment, with individualization of its
application to the case at hand. The penalties to be paid
for imprudent intervention, with the attendant rates of
complication, death, and failure to provide meaningful
symptom palliation, let alone life prolongation, are too
significant to be minimized. Discussion and concurrence
regarding the goals of care, realistic expectations for
outcomes both operative and beyond, framed substantively
and compassionately beyond the common rosary of
“potential risks and benefits” need be had with the patient,
if possible, and with surrogate decision-makers.
For the patient with unproven intra-abdominal
malignancy and fair-good performance and nutritional
status, it is generally agreed that laparotomy is indicated
to establish a definitive diagnosis, stage the disease intraabdominally, and relieve the obstruction by venting, lysis,
resection, bypass, or debulking.
Operative surgical intervention in other circumstances
needs be nuanced by known outcomes in patient
populations balanced against what constitutes “benefits”
for the individual patient consistent with their overall goals
for care. Reasonable candidates for exploration are those
with an estimated life expectancy of 2 or more months, an
ECOG performance status of two or better, a Palliative
Performance Scale (PPS) rating of 40 or more, and slowly
growing tumors. Ominous prognostic factors for surgical
intervention include those patients with palpable abdominal
masses, extensive ascites, multiple levels of obstruction,
distant metastases, a history of abdominal radiation, hepatic
or renal insufficiency, malnutrition/hypoproteinemia
<2.5 gm albumin, or previous laparotomy for obstruction.
Multiple series of patients with these co-morbidities reveal
morbidity/complication rates 7–90%, subsequent reobstruction in 10–50%, and mortality rates 15–30% with a
disconcerting number occurring in less than 30 days (20,21).
For certain lesions, endoscopic stenting may offer an
alternative to formal surgical intervention, offering either
temporizing palliation of obstruction or a “bridge” to
subsequent formal laparotomy. This approach may be
considered for patients with lesions of the esophagus,
gastric outlet and duodenum, or distal colon/proximal
rectum who have a single point of obstruction or extensive
regional disease, or who are otherwise too high a risk for
more extensive surgery. For proximal lesions, stenting offers
relief of nausea and vomiting and shorter hospitalizations
and fewer complications than “open” surgical approaches,
as well as avoidance of intestinal stomas. In experienced
hands, even some distal duodenal and proximal colonic
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lesions are amenable to stenting. Initial success rates, both
technical and clinical, are reported >85%, with immediate
(perforation, bleeding) complication rates <10%, and
subsequent stent migration or occlusion 10–15% (22).
Non-operative management
General considerations
For many patients with MBO, placement of a nasogastric
tube is a prudent initial or temporizing intervention
allowing for decompression of the often painful, distended
proximal gastrointestinal track as fluid and electrolyte
abnormalities are corrected and subsequent care
deliberations made. However, long term use of NG tubes
is uncomfortable and not without its own complications
such as sinusitis, aspiration, xerostomia, and even social
isolation. Fortunately, clinical experience has demonstrated
that the majority of patients with MBO can be satisfactorily
managed as described below without prolonged nasogastric
intubation. For those patients not considered operative
surgical candidates or those whose symptoms do not
respond to medical therapy, a venting gastrostomy should
be considered as it may provide significant relief of nausea,
vomiting and distension.
Similarly, intravenous hydration is usually an
appropriate initial step in restoring depleted intravascular
volume, correcting electrolyte abnormalities, and
clearing accumulated metabolites. However, prolonged
use of crystalloid fluids, particularly in malnourished or
hypoproteinemic patients, leads to increased extravascular
fluid, uncomfortable edema, increased lung water with
pulmonary complications, and does not prevent the
sensation of thirst. Much of the perception of thirst derives
from dry oral mucosa, and all patients with restricted PO
intake should have meticulous attention to mouth care and
oral hygiene, including scheduled routine moisture every 2
hours and artificial saliva applied to tongue, lips, and palate
every 4–6 hours.
Like surgical intervention, the use of total parenteral
nutrition (TPN) needs be a studied decision. The majority
of patients with MBO or extensive cancers, particularly
those with cancer cachexia, do not benefit from TPN, as
manifested by lack of significant improvement in qualityof-life measures, performance status, or overall survival (7).
Moreover, as a technical intervention requiring close
monitoring and frequent manipulations, it can be a
distraction or impediment to social interactions. In
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addition, it is not without its own risks and complications
such as local infection, line sepsis, vascular thrombosis, and
hyperglycemia. While it may benefit in select patients who
are likely to die of starvation rather than the malignancy, or
in time-limited goal-specific circumstances such as family
milestones, its utilization should be accompanied by clearly
articulated goals and agreed upon parameters for assessing
its benefits and continuation (2).
Medical management
Medical management seeks minimization of pain, nausea and
vomiting. As orally administered drugs are inconsistently
absorbed in the presence of nausea, distension, and
stasis, and certainly with emesis, medications should be
provided initially by parenteral routes, either intravenous,
subcutaneous, or (rarely) intramuscular. Once nausea
and emesis are controlled and gastrointestinal motility
restored—a not uncommon outcome often lasting
many weeks—consideration can then be given to
sublingual, oral or transdermal administration of some
of the pharmacologic. However, it is almost always
necessary to use a combination of analgesics, antiemetics,
anticholinergics, corticosteroids, and octreotide to achieve
symptom resolution. Once achieved, many of the drugs
used—such as morphine, metoclopramide, haloperidol,
and glycopyrrolate—are compatible in solution and can be
combined for a consolidated infusion.
Pain
Two types of pain are typical in patients with MBO. The
first is the “background” pain of extensive malignancy,
usually constant or continuous. This is dealt with by
titration to effect of potent opioids such as morphine,
hydromorphone, fentanyl, or methadone. Co-analgesics
such as ketorolac may have an opioid-sparing result,
particularly if used short-term as other components of the
regimen take effect.
Colicky pain results from the increased or discoordinated
effort of peristalsis, particularly as distension progresses.
Paroxysms occur at more frequent intervals with jejunal
obstructions than with more distal or ileal obstructions.
These are treated with anticholinergics, which inhibit
motility while also decreasing intestinal secretions and emesis.
Glycopyrrolate in doses of 0.1–0.2 mg SQ/IV/1–2 mg
PO every 6–8 hours may be the drug of choice given
its pharmaceutical versatility. Moreover, it has fewer
cardiac side effects and a lower likelihood of triggering
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delirium than atropine (0.4 mg IV/SQ every 6–8 hours) or
scopolamine (0.4 mg IV/SQ every 6–8 hours; transdermal
1.5 mg every 3 days (2).
Nausea/vomiting
A variety of drugs are useful for treating nausea and
vomiting. Haloperidol, a selective D2 antagonist, can
be used SQ/IV or subsequently PO in doses from
0.5–2 mg every 4–6 hours, with the added advantage of
treating the delirium which often accompanies advanced
illness. Phenothiazines such as prochlorperazine and
chlorpromazine are also effective, though they cannot
be administered subcutaneously. Metoclopramide is
versatile, both a D2 antagonist and a 5HT4 agonist, thus
combining the central chemoreceptor trigger inhibition
of the phenothiazines with a pro-motility action (23).
Effective in doses of 5–10 mg SQ/IV every 6 hours, it is
helpful in incomplete obstructions and as other components
of therapy takes effect. It should be dose adjusted or
discontinued if colic worsens, and is contraindicated in
fixed, complete obstructions.
Olanzapine inhibits multiple neurotransmitters involved in
initiating emesis, and is seeing increasing use in problematic
cases of intractable nausea. An atypical antipsychotic, it is
used in doses of 2.5–10 mg/day for bowel obstruction, is
available as a sublingually dissolving tablet and, in restricted
use, as an intramuscular injection (24).
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Dosed as 100–200 micrograms SQ or IV q 6–8 h, it is
considered an essential component in non-operative
management of nausea, vomiting and colic (26).
Summary
“Same disease, different patient.”
—Old surgical adage
The management of MBO challenges clinicians, patients
and their families. Operative surgical interventions must be
judiciously employed given significant associated morbidity
and mortality, and less invasive procedures such as stenting
or venting may provide substantive benefit. Non-operative
medical management is often successful in relieving its
distressing symptoms, often for many weeks or several
months, but because MBO, particularly if inoperable, is a
harbinger of limited life expectancy, its occurrence calls for
comprehensive, compassionate discussions with patients
and families, and coordinated care tailored to each patient
and their caregivers, to identify and achieve mutually agreed
upon, realistic goals of care.
Acknowledgements
None.
Footnote
Corticosteroids
The presumed mechanism by which corticosteroids help
ameliorate MBO is by inhibiting the inflammatory response
and reducing peri-tumoral edema and associated pain. They
likely also act centrally to reduce nausea. Their net effect is
improvement of bowel function, often relieving incomplete
obstruction temporarily and helping restore bowel function.
Dexamethasone in doses 8–16 mg/day IV/SQ is most
frequently chosen, usually for a trial period of 5–7 days to
assess for efficacy and continued indefinitely if effective (25).
Antisecretories
An additive to the effect of anticholinergics in reducing
intestinal motility, octreotide inhibits release of many
intestinal secretions, including gastrin, vasoactive intestinal
polypeptide, pancreatic enzymes, and bile. It also reduces
splanchnic blood flow, thereby reducing the vascular
congestion of the bowel wall which accompanies MBO.
© Xiangya Medicine. All rights reserved.
Conflicts of Interest: This article has been originally published
in the book The Art and Science of Palliative Medicine.
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doi: 10.21037/xym.2016.08.07
Cite this article as: Milch RA, Schneider J. Management of
malignant bowel obstruction. Xiangya Med 2016;1:23.
© Xiangya Medicine. All rights reserved.
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