Malignant bowel obstruction is a frequent complication of intraabdominal or pelvic cancers, occurring in up to 42% of patients with ovarian cancer and up to 24% in colorectal cancer [1].
What is known
Medical management of malignant bowel obstruction is well-established in palliative care practice, using a combination of medications including:
- analgesics
- anti-inflammatories (corticosteroids)
- antisecretory agents (including hyoscine butylbromide, glycopyrrolate, octreotide, and ranitidine), and
- antiemetics.
The evidence base to support these practices is not extensive, due to the methodological challenges involved in doing high quality studies in these patients. A systematic review of those studies which have been done suggests that corticosteroids may speed the resolution of malignant bowel obstruction [2], and that (at least in the short term) octreotide is more effective at relieving symptoms of bowel obstruction than hyoscine butylbromide [1].
The options for surgical management for malignant bowel obstruction (open procedures to bypass or resect the site of obstruction, with or without a stoma) are of very limited value in advanced cancer [3]. The associated mortality and morbidity are significant, there is variation in patient selection criteria and clinical practice, and it is therefore not possible to evaluate the role of surgery in the management of malignant bowel obstruction [4].
The less invasive option of stenting is also being studied. It appears to be safe in appropriate patients, and has the potential to offer good palliation [5-7].
Implications for practice
Clinical practice recommendations for managing bowel obstruction in patients with end-stage cancer have been developed by the European Association of Palliative Care [3], based on a systematic review of the available evidence and consensus of expert opinion where evidence was lacking. The recommendations are:
- Surgery should not be undertaken routinely in patients with poor prognostic criteria, such as intra-abdominal carcinomatosis, poor performance status, and massive ascites
- A nasogastric tube should be used only as a temporary measure
- Medical measures such as analgesics, anti-secretory drugs and antiemetics should be used alone or in combination to relieve symptoms
- A venting gastrostomy should be considered if drugs fail to reduce vomiting to an acceptable level
- TPN should be considered only for patients who may die of starvation rather than from tumour spread
- Parenteral hydration is sometimes indicated to correct nausea, whereas regular mouth care is the treatment of choice for a dry mouth
- A collaborative approach involving both surgeons and physicians can offer patients an individualised and appropriate symptom management plan.
Related CareSearch pages
Anti-emetics
Constipation
End of life care
Finding out more
Guidelines
Links to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence
Overview article
References
- Mercadante S, Casuccio A, Mangione S. Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review. Journal of Pain and Symptom Management. 2007 Feb;33(2):217-23.
- Feuer DJ, Broadley KE. Corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Cochrane Database of Systematic Reviews, 2000;2:CD001219.
- Ripamonti C, Twycross R, Baines M, Bozzetti F, Capris S, De Conno F, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Supportive Care in Cancer. 2001 Jun;9(4):223-33.
- Feuer DJ, Broadley KE, Shepherd JH, Barton DP. Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Cochrane Database of Systematic Reviews. 2000;(4):CD002764.
- Khot U, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. British Journal of Surgery. 2002 Sep;89(9):1096-102.
- Watt A, Faragher IG, Griffin TT, Rieger NA, Maddern GJ. Self-expanding metal stents for relieving malignant colorectal obstruction: a systematic review. Annals of Surgery. 2007 Jul;246(1):24-30.
- Hosono S, Ohtani H, Arimoto Y, Kanamiya Y. Endoscopic stenting versus surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis. Journal of Gastroenterology. 2007 Apr;42(4):283-90.
- Baines MJ. ABC of palliative care. Nausea, vomiting, and intestinal obstruction. BMJ. 1997 Nov 1;315(7116):1148-50. no abstract available
This page was created on 24 May 2008 and is due for review in May 2010.
Last updated 26 May 2008