Download Bowel Obstruction - Yorkshire and the Humber Deanery

Becky Owen
22/2/12
Overview
 Case Study
 Clinical Presentation
 Management
 Case Study Update
 Summary
 Questions
Mrs JL
 55 yr Ovarian Carcinoma
 Diagnosed 2010
 4 cycles palliative chemotherapy
 Stable disease until June 2011
 Increased abdominal distension, nausea, vomiting,
weight loss
 CT – disease progression, subacute small bowel
obstruction
 What would you do next?
Bowel Obstruction in Palliative
Care
 Due to functional or mechanical obstruction of bowel
lumen and/or peristaltic failure
 Can be partial or complete
 Can occur at any level
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Oesophageal
Gastric outlet & proximal small bowel
Distal small bowel
Large bowel
Causes
 The cancer itself
 Past treatment

Adhesions, postradiation ischaemic fibrosis
 Drugs

Opioids, antimuscarinics
 Debility

Faecal impaction
 Unrelated benign condition

Strangulated hernia
Clinical Picture
 Abdominal pain
 Abdominal distension
 Vomiting
 Nausea
 Intestinal colic
 Variable bowel habit
Bowel obstruction – Pathophysiology

Partial or complete bowel obstruction
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Reduction or stop movement
Intestinal content
Increased bowel contractions
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Increased bowel distension
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Increased luminal content
Increased gut epithelial surface area
Increased bowel secretions (H2O, NaCl)
Damage epithelium
Oedema and hyperaemia
Production noiceceptive mediators

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Continuous pain
Colicky pain
Nausea and vomiting
Management - Surgery
 Consider if;


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Single discrete organic obstruction i.e. adhesions, isolated
neoplasm
Good performance status
Patient willing to undergo surgery
 Contra-indications;
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
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Previous laparotomy findings preclude prospect of successful
intervention
Diffuse intra-abdominal carcinomatosis
Massive ascites (re-accumulates rapidly after paracentesis)
Management - Medical
 Focus on symptomatic relief
 Anti-emetics
 Opioids
 Review laxatives
 Corticosteroids
 Anti-secretory drugs
 Octreotide
Anti-emetics
 Patient without colic + passing flatus – Prokinetic first
drug of choice
 Patient with colic – antisecretory + antispasmodic
drug (Buscopan)
 To be aware of anti-cholinergic effect of some drugs –
can inhibit gut motility
Octreotide
 Synthetic analogue of somatostatin with longer
duration of action
 Inhibitory hormone – found throughout the body
 Inhibits release of Growth Hormone, TSH, Prolactin,
ACTH in hypothalamus
 Inhibits peptides of Gastro-enteropancreatic system
Octreotide and bowel obstruction
 <50% patients – respond to typical starting dose of 300
micrograms/24hr
 75-90% respond to 600-800 micrograms/24hr
 Comparisons with buscopan – Octreotide more
effective and rapid relief of nausea, vomiting and
reduced NG output

NB after 4-6 days overall symptom comparison is similar
 Lanreotide – alternative sandostatin analogue
available in depot formations
Octreotide and ascites
 Can suppress diuretic induced activation of renin-
aldosterone-angiotensin system
 May interfere with ascitic fluid formation by reducing
splanchnic blood flow or as a result of a direct tumour
anti-secretory effect
 May also help improve efficacy of diuretics in cirrhosis
Undesirable effects from
Octreotide
 Bolus SC injection painful
 Dry mouth
 Flatulence
 Nausea
 Abdominal pain
 Diarrhoea
 Impaired glucose tolerance
 Gallstones
Cautions
 Insulinoma
 Type 1 diabetes
 Cirrhosis
 Renal Failure
 Avoid abrupt withdrawal of short-acting octreotide
after long-term treatment
 Monitor thyroid function
Octreotide Drug Interactions
 Octreotide markedly reduces plasma ciclosporin
concentrations and inadequate immunosuppression
may result.
Octreotide CSCI Compatability
 2 drug compatibility data for octreotide and;

Morphine sulphate, metoclopramide, hyoscine butylbromide,
diamorphine, alfentanil (in WFI)
 Check PCF4 / palliativedrugs.com
 Conflicting observational reports with
levomepromazine
Depot Formulation of Octreotide
 Sandotatin – 10-30mg every 4/52

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Relative bio-availability of 60% compared to SC
Deep IM injection
 Used in patients with symptoms already controlled
with octreotide therapy
 Lanreotide – 60mg every 4/52
 ‘Somatuline Autogel’ preparation can be given SC
Management - Interventions
 Dependant on level and extent of obstruction
 Stents
 Venting gastrostomy
Mrs JL Cont.
 Not suitable for surgery/intervention
 No colic – initially trialled metoclopramide CSCI
 Not effective – converted to levomepromazine CSCI
(12.5mg over 24 hr)
 Ongoing large volume vomits – octreotide added to
CSCI (1 mg over 24 hr)
 Helped stabilise symptoms and allow for period of
6/52 at home with family
In Summary
 One of the most challenging problems in palliative
care
 To focus on improving quality of life
 If focal obstruction – consider possibility / suitability
of intervention
 Rarely need IV fluids or NG tube to relieve symptoms
Any Questions?
References
 Palliative Care Formulary 4th Edition; R Twycross, A Wilcock.
 Symptom Management in advanced cancer 3rd Edition; R Twycross, A
Wilcock.