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

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

3. 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

4. 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

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

6. 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

7. Individualized approachPS
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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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!

16. Medical therapy
Pain
Nausea/vomiting
Gastrointestinal secretions

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

18. 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

19. 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

20. 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

21. 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

22. 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