Bowel Obstruction

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

Conservative 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, ranitidine, and octreotide), 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 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. [1,3] A systematic review comparing ranitidine with proton pump inhibitors suggests that ranitidine is a more effective agent for reducing the volume of secretions and may therefore be valuable as antisecretory agent in malignant bowel obstruction. [4]

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. [5] 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. [6]

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, including the ability to continue oral intake. [7-9] Stenting is more appropriate than surgery in patients whose prognosis is relatively short (a few months). [4,10]

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, [5] 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.
  

PubMed Searches

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Review Collection
  1. Mercadante S, Casuccio A, Mangione S. Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review. J Pain Symptom Manage. 2007 Feb;33(2):217-23.
  2. Feuer DJ, Broadley KE. Corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Cochrane Database Syst Rev. 2000;(2):CD001219.
  3. Clark K, Lam L, Currow D. Reducing secretions -- a role for histamine 2 antagonists or proton pump inhibitors in malignant bowel obstruction? Support Care Cancer. 2009 Dec;17(12):1463-8. Epub 2009 Mar 17.
  4. Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol. 2007 Jun 8;7:18.
  5. 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. Support Care Cancer. 2001 Jun;9(4):223-33.
  6. 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 Syst Rev. 2000;(4):CD002764.
  7. Khot U, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg. 2002 Sep;89(9):1096-102.
  8. Watt AM, Faragher IG, Griffin TT, Rieger NA, Maddern GJ. Self-expanding metal stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg. 2007 Jul;246(1):24-30.
  9. Hosono S, Ohtani H, Arimoto Y, Kanamiya Y. Endoscopic stenting versus surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis. J Gastroenterol. 2007 Apr;42(4):283-90. Epub 2007 Apr 26.
  10. Dormann A, Meisner S, Verin N, Wenk Lang A. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness. Endoscopy. 2004 Jun;36(6):543-50.

Guidelines

Links to prescribing information

Overview article

Last updated 18 January 2017