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

Causes tumour adhesions faeces drugs, eg opioids unrelated benign condition -eg strangulated hernia

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

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?

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

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

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

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

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

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 : )

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

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 mg sc/24h

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

What else might help? dexamethasone octreotide

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