Background
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Malignant bowel obstruction (MBO) is a common complication of advanced gynaecological and gastrointestinal cancers, particularly ovarian cancer1. This life threatening complication sees a mean survival rate of approximately 3 months after obstruction has occurred. MBO occurs due to tumour growth or metastases in the abdominal region, which consequently cause obstruction of the bowel. Obstruction can be either partial or complete with the extent of the obstruction determining methods of treatment. This condition usually occurs progressively from an initial delay in bowel peristalsis to a complete and irreversible stoppage. Palliative care using a symptom-related approach is necessary for improved quality of life1.
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Purpose
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This guideline outlines the clinical features and appropriate management of inoperable MBO. Surgery may be considered, however contraindications to surgery include malnutrition, presence of re-obstruction, intra-abdominal metastasis or multiple palpable masses2. Medical management is a realistic alternative for patients with incurable progressive malignant disease.
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Incidence
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Twenty-five to forty percent (25-40%) of patients with ovarian cancer experience malignant bowel obstruction.
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Risk factors
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- advanced gynaecological malignancies
- gastrointestinal malignancies
- abdominal metastases.
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Assessment / investigations
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Effective management of bowel obstruction requires ongoing assessment, including a thorough history, physical assessment, review of current medicines, psychosocial assessment, and possibly surgical review. Physical examination may reveal a tender, distended abdomen secondary to accumulation of ascites and dilated bowel, along with hyper-resonant sounds on percussion. Auscultation may vary depending on location and severity of the obstruction3.
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Investigations that are recommended to assist in making a diagnosis include:
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 | - full blood examination (FBE), liver function tests (LFT), urea and electrolytes (U& E)
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| - plain abdominal and chest X-ray: demonstrates dilated loops of bowel, air and fluid levels, faecal impaction, perforation and/or the obstruction
- CT or MRI Scans: demonstrate disease progression, assisting with treatment plans
- Gastrograffin contrast: often used to determine the exact point of obstruction.
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Management
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Management (non-pharmacological)
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- Hydration is required to correct dehydration and any electrolyte abnormalities. Treatment options should be considered on an individual basis.
- Nil orally to reduce the incidence of vomiting. Mouth care needs to be maintained to ensure healthy oral mucosa.
- If nausea and vomiting are controlled, provide small low residue meals.
- Insertion of a naso-gastric tube (NGT) may be necessary for initial treatment and decompression or while waiting to make other treatment decisions4. Provide regular nasal care. Some patients prefer to endure vomiting rather than have an NGT inserted.
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- Psychosocial support should be offered to the patient and their family as they are confronted with the terminal nature of this diagnosis. These patients are considered to be at a higher risk of psychosocial distress due to:
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| - poor prognosis
- progression of disease
- greater functional impairment and disease burden
- symptoms such as nausea, vomiting, and pain.
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- In discussion with the patient concerning their disease and prognosis it is essential that:
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| - information is provided in a quiet, private environment in which interruptions can be avoided
- the patient is first asked what information they want to know about their disease/prognosis and that the information provided is accurate
- the patient’s understanding should be assessed and questions encouraged to assist in minimizing anxiety levels.
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- Psychosocial issues facing people with cancer, such as emotional, social, psychological, physical etc. should be assessed using the Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer10.
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Management (pharmacological)
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Pharmacological management should be given intravenously or subcutaneously due to inconsistent absorption rates when medication is given orally. All medications listed can also be administered via continuous infusion (Graseby pump) if appropriate.
Regime options include:
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- dexamethasone 4 to 16mg subcutaneous or intravenously, twice daily, is given for inflammation of the bowel/tumour. Discontinue if there is no response evident within 4 to 5 days5.
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- hyoscine butylbromide (Buscopan®) 120mg subcutaneously administered over 24 hours in syringe driver. This aims to reduce intestinal motility and muscle spasm7.
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- haloperidol 1mg subcutaneous or intravenously twice daily (BD) is indicated for nausea and vomiting for complete bowel obstruction.
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- octreotide 0.1mg subcutaneous or intravenously three times daily (TDS) with a maximum dose of 0.9mg in 24 hours. This will reduce vomiting and the amount of gastrointestinal secretions, potentially allowing for removal of nasogastric tube6.
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- metoclopromide 80mg continuous subcutaneous infusion is for nausea/vomiting if incomplete bowel obstruction and no significant colic. Metoclopromide is not to be used in cases of complete bowel obstruction due to its motility effect on the bowel4.
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References
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References
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Evidence table
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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