Transcript Communication

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