Bowel Obstruction in Cancer Patients Dr Fathi Azribi Consultant Medical Oncologist The James Cook University Hospital 19/04/2013

Bowel Obstruction in Cancer Patients Ovarian cancer: 5%-51% Gastrointestinal cancer: 10%-28% Other cancers (breast, melanoma, sarcoma, lung…etc) Poor prognosis Median survival 30-90 days Mercadante S. Palliative Medicine, 2009 Pasanisi F, Nutrition, 2001 Pameijer CR, Int J Gastrointest. Cancer 2005 Bais JMJ, J Gynecol Oncol 2002

Types of obstruction Site: Mechanism: Onset: Bowel level Proximal BO: Upper GI &HBP Cancers Distal BO: Colon & Ovarian Cancers Obstruction level One site Multiple sites Mechanism: Mechanical: Tumour Non malignant (adhesions, strictures, desmoplastic reactions) Functional: Paraneoplastic Drugs Onset: Acute…complete Sub acute….partial Intermittent

Symptoms and signs Severity and order vary: Symptoms: Signs Nausea & vomiting Bloating & fullness Pain Constipation Signs Abdominal distension Bowel sounds: active & tinkling vs. silent Signs of dehydration Perforation, peritonitic & toxic

Approach to management History and clinical examination Initial treatment: hydration Imaging Direct discussion (with surgeons)… MDT Specialist Palliative Care Team

Investigations Imaging: useful but low accuracy hardly used Plain x ray useful but low accuracy Barium/gastrograffin studies hardly used CT scan specificity 100% sensitivity 94% Other investigation: FBC, U& Es, LFT, tumour markers….etc

Individualized approach PS Comorbidities Nutritional status Tumour type Tumour burden Diffuse carcinomatosis Extensive prior anticancer therapy Previous surgery Single vs. multilevel Expected survival Patient’s choice Surgery Medical therapy NG tubes Stenting Venting gastrostomy

Individualized approach 68 years old lady Stage IIIC ovarian carcinoma presented with bowel obstruction Defunctioning ileostomy…North Tees Hospital October 2009 4 cycles of Carboplatin and Paclitaxel chemotherapy Laparotomy BSO, omental biopsy, reversal of ileostomy Feb 2010 followed by 2 more cycles of chemotherapy Disease progression with several lines of chemotherapy 8/4/2013 reasonably well and will have some more chemotherapy for further progression

Individualized approach 47 years old lady Stage 4 primary peritoneal carcinoma July 2010 6 cycles of Carboplatin and Paclitaxel chemotherapy completed December 2010 with good response Disease progression April 2011, treated with 6 cycles of Caelyx completed October 2011 Small bowel obstruction Feb 12, laparotomy and loop ileostomy….good symptomatic improvement and reasonable quality of life for a few months Died August 2012

Individualized approach 35 year old lady Low grade ovarian carcinoma Diagnostic laparoscopy: extensive disease, drainage of ascites and intrabdominal biopsies November 2011 Received 1 cycle of carboplatin and paclitaxel chemotherapy on December 2011 High small bowel obstruction Jan 2012 due to disease progression Best supportive care Discharged home ( PPC) Died 2 weeks later

Surgery? Who is for surgery? Patients should be carefully selected Careful consideration of prognostic factors (e.g. PS, tumour burden) and the expected outcome (symptom control, quality of life. Survival) A thorough discussion among the health professionals Patient’s expectations and wishes should be explored

Surgery? What surgery Resection/debulking….primary anastomosis Bypass surgery Defunctioning colostomy/ileostomy

Chemotherapy? Unlikely to help as a sole modality It depends: Tumour type Extent of disease Type of obstruction Heavily pre-treated Previous PS Co-morbidities

Gastric & colonic stenting Advantages: Alternative option for patients unfit for surgery or do not want to have surgery A quick fix while waiting for surgery High success rate for gastric outlet and left sided colonic obstruction Quicker recovery & shorter hospital stay Less successful: Rapidly progressive cancers Multifocal bowel obstruction Diffuse carcinomatosis

NG tubes and PEG NG tube: PEG: Effective symptom relief Could be useful for a quick relief of gastric distension and improve nausea and vomiting Not recommended for long term use (nose and throat pain, sinusitis, abscess formation, erosion of nasal cartilage, aspiration oesophageal erosion.. etc.) PEG: Effective symptom relief Technically easy procedure Easily handling at home and at terminal stages However, not very popular!

Medical therapy Pain Nausea/vomiting Gastrointestinal secretions

Medical therapy Pain Continuous Colic Opiates: morphine, oxycodone, fentanyl Can aggravate colic Constipation Nausea/vomiting Other analgesics Colic Hyoscine butylbromide (Buscopan)

Medical therapy Nausea/vomiting Cyclizine: safe when complete obstruction Haloperidol: less sedation, good for nausea levomepromazine Metclopramide: antiemetic and gastroprokinteic Contraindicated: complete obstruction Caution: colic Useful: functional, partial obstruction Dexamethasone Ondansetron

Medical therapy Gastrointestinal secretions: Combination therapy Anticholinergic: Hyoscine butylbromide Somatostatin analogues: Octreotide Combination therapy Almost always needed typical combination: analgesic + antiemetic + corticosteroid + octreotide Syringe driver

Total parental nutrition (TPN) Not recommended for the majority of patients with malignant obstruction Advanced malignancy with poor prognosis High rate of complications (infection, electrolyte disturbance, thrombosis…etc) May be considered for a selected patients Neoadjuvant setting Low volume disease, high response rate to chemotherapy and expected long survival

Continued care Patients can eat - as long as it is tolerated Mouth care, ice chips, lubrication to the lips, and sips of fluid are all helpful to reduce mouth dryness and sense of thirst Intravenous fluids: usually difficult discussion Long-term and excessive use is not recommended Discontinue once symptoms controlled and no further intervention is planned Patients and family should be well informed and involved in decision-making

Summary Malignant bowel obstruction needs: individualised approach Team work (oncology, surgery, radiology, specialist palliative care team and other health care professionals) Communication: Treatment options, expectations & limitations, discharge plan and preferred place of care….the earlier you discuss with patient and family, the better coping and the less of unnecessary anxiety and fear of uncertainty