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Case Two

Case Two. MALIGNANT BOWEL OBSTRUCTION. Malignant bowel obstruction. can occur at any level in the GI tract presenting symptom in 16% colorectal tumours 42% of ovarian cancers obstruct at some stage 3-15% patients with terminal illness obstruct obstruction may be mechanical or functional.

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Case Two

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  1. Case Two

  2. MALIGNANT BOWEL OBSTRUCTION

  3. Malignant bowel obstruction • can occur at any level in the GI tract • presenting symptom in 16% colorectal tumours • 42% of ovarian cancers obstruct at some stage • 3-15% patients with terminal illness obstruct • obstruction may be mechanical or functional

  4. Causes • tumour • adhesions • faeces • drugs, eg opioids • unrelated benign condition • eg strangulated hernia

  5. Clinical features • abdominal pain • vomiting • distension • bowels – variable • bowel sounds – absent to hyperactive • obstruction may be intermittent • multiple sites of obstruction are common

  6. Management • to admit or not to admit? • consider the patient’s circumstances • are they fit enough for hospital intervention? • will hospital intervention improve/extend quality of life? • are they near the end of life? • what are the patient's and family’s wishes?

  7. Conventional management • drip (IVI) • suck (NG tube) • starve (NBM) • operate

  8. When might surgery be appropriate? • first episode of obstruction • single site of obstruction, potentially simple to reverse or bypass • patient is fit enough for anaesthetic and surgery • patient is expected to live long enough to benefit • patient is fully informed, mentally competent and gives their consent

  9. Don’t go there if….. • patient is cachectic, elderly and/or in poor general medical condition • previous laparotomy shows diffuse intra-abdominal disease • obvious palpable multiple tumour masses • recurrent ascites • multiple sites of obstruction • small bowel obstruction

  10. Stenting as an alternative to surgery • specialised skill, not always available • lesion must be reachable by endoscope • patient must be fit enough for repeated stenting or lasering at regular intervals

  11. What if the patient is not suitable for surgery? • IVI, NG tube and NBM is perfectly OK in the short term, eg while waiting for the next available theatre list • it is a miserable way to spend the last few weeks of your life if surgery is not an option

  12. Pharmacological management • late 1960s – pioneered by Dr Mary Baines at St Christopher’s Hospice, London • case series of 40 patients (including post-mortem data), published 1985 • (Baines et al, Lancet 1985 2: 990-993)

  13. Aims of pharmacological management • reduce anxiety • resolve nausea and pain • reduce vomiting • allow for partial/complete resolution of obstruction if possible • maximise quality of life

  14. How to do it - 1 • explanation of treatment aims and what is happening • syringe driver (SD) • control pain • diamorphine for tumour pain • hyoscine butylbromide for colic 60mg sc/24h • control nausea • Levomepromazine 12.5-25mg sc/24h

  15. How to do it – 2 • stop stimulant laxatives, eg senna, codanthramer, codanthrasate • faecal softeners are ok, eg milk of magnesia if patient is able to open bowels • arachis oil enemas are also ok if there is an uncomfortable mass of hard faeces in the distal bowel/rectum

  16. What else might help? • dexamethasone • octreotide

  17. Why bother? • patients do not always die quickly • patients can eat and drink as they want and what they want • patient can be as mobile as they wish • the patient may be able to be nursed at home

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