1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

2. EPEC  – Oncology Education in Palliative and End-of-life Care – Oncology Module 3e: Symptoms – Bowel Obstruction Module 3e: Symptoms – Bowel Obstruction

3. Bowel obstruction... l Definition: mechanical or functional obstruction of the progress of food and fluids through the GI tract

4. ... Bowel obstruction l Impact: misery from nausea, vomiting, and abdominal pain

5. Epidemiology l Prevalence 3% of all advanced malignancies 11-42% ovarian cancer 5-24% colorectal cancer l Prognosis – poor if inoperable 64 days Krebs HR, Goplerud DR. Am J Obstet Gynecol. 1987. Ripamonti S, et al. J Pain Symptom Manage. 2000.Epidemiology l Prevalence 3% of all advanced malignancies 11-42% ovarian cancer 5-24% colorectal cancer l Prognosis – poor if inoperable 64 days Krebs HR, Goplerud DR. Am J Obstet Gynecol. 1987. Ripamonti S, et al. J Pain Symptom Manage. 2000.... Bowel obstruction

6. Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

7. Pathophysiology... l Intraluminal mass l Direct infiltration l External compression l Carcinomatosis l Adhesions l Other l Intraluminal mass l Direct infiltration l External compression l Carcinomatosis l Adhesions l Other

8. ... Pathophysiology l 2 liters/day orally l 8 liters/day gastric/intestinal secretion l Obstruction causes accumulation l Peristalsis causes distention, pain, nausea, and vomiting l 2 liters/day orally l 8 liters/day gastric/intestinal secretion l Obstruction causes accumulation l Peristalsis causes distention, pain, nausea, and vomiting

9. Assessment l Symptoms  Continuous distension pain 92%  Intestinal colic 72-76%  Nausea/vomiting 68-100% l Abdominal radiograph  Dilated loops, air-fluid levels l CT scan  Staging, treatment planning l Symptoms  Continuous distension pain 92%  Intestinal colic 72-76%  Nausea/vomiting 68-100% l Abdominal radiograph  Dilated loops, air-fluid levels l CT scan  Staging, treatment planning

10. Differentiating small vs. large bowel obstruction Signs/Symptoms Small (proximal) Small (distal) Large Onset Acute, severe Progressive Abdominal pain VariableVariable Mild, steady Bowel sounds Diminished Hyperactive; diminished Bowel movement Short-termShort-termConstipation VomitingSevereMild/moderate None; severe

11. Management... Medical l Opioids  Morphine - 89% control l Antiemetics  Prochlorperazine - 13% control l Steroids  Dexamethasone l Opioids  Morphine - 89% control l Antiemetics  Prochlorperazine - 13% control l Steroids  Dexamethasone

12. ... Management Surgical l Surgical evaluation l Standard  Intravenous fluids  Nasogastric tube - intermittent suction l Inoperable  Stent placement  Venting gastrostomy l Surgical evaluation l Standard  Intravenous fluids  Nasogastric tube - intermittent suction l Inoperable  Stent placement  Venting gastrostomy

13. Antisecretory agents DrugDoseNotes Octreotide 10 mcg/h SQ/IV cont. infusion or 100 mcg SQ q 8 h Minimal adverse effects; titrate daily Scopolamine (hyoscine hydrobromide) 10 mcg/h SQ/IV cont. infusion or 0.1 mg SQ q 6 h Anticholinergic effects may be dose-limiting; titrate daily Glycopyrrolate 0.2 to 0.4 mg SQ q 2 to 4 h; titrate Anticholinergic effects possible

14. Anticholinergics l Antispasmodic and antisecretory l Scopolamine 10 to100 micrograms per hour SC/IV 0.1 mg SC every 6 hours and titrate l Glycopyrrolate 0.2-0.4 mg SC every 2 to 4 hours and titrate Baines M, et al. Lancet. 1985. Davis MP, Furste A. J Pain Symptom Manage. 1999. l Antispasmodic and antisecretory l Scopolamine 10 to100 micrograms per hour SC/IV 0.1 mg SC every 6 hours and titrate l Glycopyrrolate 0.2-0.4 mg SC every 2 to 4 hours and titrate Baines M, et al. Lancet. 1985. Davis MP, Furste A. J Pain Symptom Manage. 1999.

15. Somatostatin l 14 amino acid polypeptide  Serum half-life = 3 minutes l Central action  Inhibits release of growth hormone and thyrotropin l Peripheral action  Inhibits glandular secretion in Pancreas, GI tract l 14 amino acid polypeptide  Serum half-life = 3 minutes l Central action  Inhibits release of growth hormone and thyrotropin l Peripheral action  Inhibits glandular secretion in Pancreas, GI tract

16. Octreotide... l Polypeptide analog of somatostatin Serum half-life = 2 hours l Relieves symptoms of obstruction Ripamonti, et al. J Pain Symptom Manage. 2000. Mercadante, et al. Support Care Cancer. 2000. Fainsinger RL, et al. J Pain Symptom Manage. 1994. l Polypeptide analog of somatostatin Serum half-life = 2 hours l Relieves symptoms of obstruction Ripamonti, et al. J Pain Symptom Manage. 2000. Mercadante, et al. Support Care Cancer. 2000. Fainsinger RL, et al. J Pain Symptom Manage. 1994.

17. ... Octreotide treatment l Octreotide 10 micrograms per hour via continuous infusion l Titrate to complete control of nausea and vomiting l If NG tube in place, clamp when volume diminishes to 100 cc and remove if no nausea and vomiting l Try converting to intermittent SC injection l Continue until death l Octreotide 10 micrograms per hour via continuous infusion l Titrate to complete control of nausea and vomiting l If NG tube in place, clamp when volume diminishes to 100 cc and remove if no nausea and vomiting l Try converting to intermittent SC injection l Continue until death

18. ... Octreotide l Side effects o Mostly none o Dry mouth o Biliary sludge/stones l Studies in other palliative care settings show promise l Subcutaneous administration is possible l Side effects o Mostly none o Dry mouth o Biliary sludge/stones l Studies in other palliative care settings show promise l Subcutaneous administration is possible

19. Conclusions Bowel obstruction management: l Considerable symptom control challenge l Surgery for selected cases l Pharmacologic management relieves symptoms in many patients l Antisecretory agents represent a significant advance Bowel obstruction management: l Considerable symptom control challenge l Surgery for selected cases l Pharmacologic management relieves symptoms in many patients l Antisecretory agents represent a significant advance

20. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.