1. Becky Owen 22/2/12

2. Overview Case Study Clinical Presentation Management Case Study Update Summary Questions

3. Mrs JL 55 yr Ovarian Carcinoma Diagnosed 2010 4 cycles palliative chemotherapy Stable disease until June 2011 Increased abdominal distension, nausea, vomiting, weight loss CT – disease progression, subacute small bowel obstruction What would you do next?

4. Bowel Obstruction in Palliative Care Due to functional or mechanical obstruction of bowel lumen and/or peristaltic failure Can be partial or complete Can occur at any level Oesophageal Gastric outlet & proximal small bowel Distal small bowel Large bowel

5. Causes The cancer itself Past treatment Adhesions, postradiation ischaemic fibrosis Drugs Opioids, antimuscarinics Debility Faecal impaction Unrelated benign condition Strangulated hernia

6. Clinical Picture Abdominal pain Abdominal distension Vomiting Nausea Intestinal colic Variable bowel habit

7. Bowel obstruction – Pathophysiology Partial or complete bowel obstruction Reduction or stop movement Increased bowel contractions Intestinal content Increased bowel distension Increased luminal content Increased gut epithelial surface area Increased bowel secretions (H2O, NaCl) Damage epithelium Oedema and hyperaemia Production noiceceptive mediators Continuous pain Colicky pain Nausea and vomiting

8. Management - Surgery Consider if; Single discrete organic obstruction i.e. adhesions, isolated neoplasm Good performance status Patient willing to undergo surgery Contra-indications; Previous laparotomy findings preclude prospect of successful intervention Diffuse intra-abdominal carcinomatosis Massive ascites (re-accumulates rapidly after paracentesis)

9. Management - Medical Focus on symptomatic relief Anti-emetics Opioids Review laxatives Corticosteroids Anti-secretory drugs Octreotide

10. Anti-emetics Patient without colic + passing flatus – Prokinetic first drug of choice Patient with colic – antisecretory + antispasmodic drug (Buscopan) To be aware of anti-cholinergic effect of some drugs – can inhibit gut motility

11. Octreotide Synthetic analogue of somatostatin with longer duration of action Inhibitory hormone – found throughout the body Inhibits release of Growth Hormone, TSH, Prolactin, ACTH in hypothalamus Inhibits peptides of Gastro-enteropancreatic system

12. Octreotide and bowel obstruction <50% patients – respond to typical starting dose of 300 micrograms/24hr 75-90% respond to 600-800 micrograms/24hr Comparisons with buscopan – Octreotide more effective and rapid relief of nausea, vomiting and reduced NG output NB after 4-6 days overall symptom comparison is similar Lanreotide – alternative sandostatin analogue available in depot formations

13. Octreotide and ascites Can suppress diuretic induced activation of renin- aldosterone-angiotensin system May interfere with ascitic fluid formation by reducing splanchnic blood flow or as a result of a direct tumour anti-secretory effect May also help improve efficacy of diuretics in cirrhosis

14. Undesirable effects from Octreotide Bolus SC injection painful Dry mouth Flatulence Nausea Abdominal pain Diarrhoea Impaired glucose tolerance Gallstones

15. Cautions Insulinoma Type 1 diabetes Cirrhosis Renal Failure Avoid abrupt withdrawal of short-acting octreotide after long-term treatment Monitor thyroid function

16. Octreotide Drug Interactions Octreotide markedly reduces plasma ciclosporin concentrations and inadequate immunosuppression may result.

17. Octreotide CSCI Compatability 2 drug compatibility data for octreotide and; Morphine sulphate, metoclopramide, hyoscine butylbromide, diamorphine, alfentanil (in WFI) Check PCF4 / palliativedrugs.com Conflicting observational reports with levomepromazine

18. Depot Formulation of Octreotide Sandotatin – 10-30mg every 4/52 Relative bio-availability of 60% compared to SC Deep IM injection Used in patients with symptoms already controlled with octreotide therapy Lanreotide – 60mg every 4/52 ‘Somatuline Autogel’ preparation can be given SC

19. Management - Interventions Dependant on level and extent of obstruction Stents Venting gastrostomy

20. Mrs JL Cont. Not suitable for surgery/intervention No colic – initially trialled metoclopramide CSCI Not effective – converted to levomepromazine CSCI (12.5mg over 24 hr) Ongoing large volume vomits – octreotide added to CSCI (1 mg over 24 hr) Helped stabilise symptoms and allow for period of 6/52 at home with family

21. In Summary One of the most challenging problems in palliative care To focus on improving quality of life If focal obstruction – consider possibility / suitability of intervention Rarely need IV fluids or NG tube to relieve symptoms

22. Any Questions?

23. References Palliative Care Formulary 4 th Edition; R Twycross, A Wilcock. Symptom Management in advanced cancer 3 rd Edition; R Twycross, A Wilcock.