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Bowel Obstruction in Palliative Care
Dr Andrew Binns





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Bowel Obstruction in Palliative Care

Complete bowel obstruction in the terminally ill patient

The scenario of persistent vomiting and colicky abdominal pain in a terminally ill patient with metastatic cancer causing bowel obstruction, is a major challenge for doctors involved in the palliative treatment of their patients. When all surgical options have been explored and considered futile, it is time to commence appropriate medical management to minimise the suffering for such a patient.

The traditional approach of IV fluids and nasogastric suction whilst awaiting surgery is quite inappropriate for the continuing medical management of irreversible complete bowel obstruction in a patient with terminal cancer. IV fluids increase the hydration and potential for more gastric and bowel secretion with resultant vomiting. Dehydration is a better tolerated option, so long as diligent mouth care is attended to.

NG tubes are very irritating if used for more than a few days and are disliked by both patients and their families. It is far more dignified to die without a drip and an NG tube.

However, there are a small number of cases, particularly in those with high obstruction and frequent high volume vomits where continued use of an NG tube is unavoidable.

Can the obstruction be relieved medically?

Sometimes obstruction, particularly if only partial, can be relieved by the use of steroids in an attempt to reduce peri-tumour oedema and open the stenosis.

The dose used is controversial, but at St. Vincent's PCU, we use dexamethasone 4mgm qid. initially and reducing to 4mgm mane after a few days. Because the patient is unlikely to absorb this medication given orally, it is recommended that it be given subcutaneously through a butterfly needle. Because dexamethasone is incompatible with other agents it should be an SC site separate from that used for other drugs. The effectiveness of this treatment is controversial and further research is being done to further define the role of steroids in bowel obstruction.

In addition faecal softeners are sometimes useful in partial bowel obstruction. Laxatives that stimulate peristalsis may cause colicky pain and are not recommended.

Reducing nausea and vomiting

Vomiting may be due to the obstruction or metabolic problems or both. The aim is to eliminate nausea and reduce vomiting to once or twice per day. This can be done by:-
  1. Restricting oral fluids to small frequent quantities of nutritious fluid (low residue) whilst continuing diligent mouth care. Ice can be helpful to keep the mouth moist.
  2. Removing IV therapy as mentioned above.
  3. If the obstruction is high, metoclopramide as a gastric emptying agent may make the situation worse and is contraindicated. If the obstruction is lower in the bowel and only partial, cisapride may have a role to play.
The centrally acting agents are usually what is needed to reduce the amount of vomiting. The ones used commonly are:-

Haloperidol

This is a powerful antiemetic and can easily be given by the SC route. The dose used is 5- 15mgm/day - parkinsonian side effects may occur in higher doses.

Cyclizine

Cyclizine is an antihistamine (HI blocker) that acts on the vomiting centre in the area postrema. The dose used is 100-150mgm/day and again it can be given by the SC route. It can be used in association with haloperidol.

NB. This drug requires special authority from Canberra - contact St. Vincent's PCU for further details. It is not an expensive drug and has been used extensively in the UK for many years.

Hyoscine butybromide (Buscopan)

This drug reduces the volume of gastric secretions leading to fewer and smaller vomits. The dose used is 60-200mgm/day and again can be given by the SC route and it mixes well with morphine.

It can be given either four hourly SC or via a syringe driver by continuous infusion.

Reducing abdominal pain

Abdominal pain can be either colicky or continuous and is to some degree opioid responsive. In addition to the use of SC morphine in carefully titrated doses, it is often necessary to add an antispasmodic for colicky pain.

Hyoscine butybromide (Buscopan) is best used in doses up to 200mgm/day and has the advantage over Hyoscine hydrobromide in having less CNS side effects (particularly drowsiness and confusion).

Side effects of Hyoscine butybromide are usually mild such as dry mouth from the anticholinergic effects. Tachycardia, accommodation disturbances, somnolence, urinary retention and low blood pressure are much less common side effects.

Again, it may be useful to give Hyoscine butybromide via a syringe driver particularly for home use. The device can be loaded also with morphine in the syringe for 24 hour use - a daily community nurse visit for reloading may be needed.

Results of medical management of terminal malignant bowel obstruction

Control of continuous abdominal pain is very good with 89 per cent of patients becoming pain free. Colic is harder to treat and 31 per cent of patients continue to have mild colic. The management of nausea and vomiting is more difficult and the majority of patients continue to vomit about once a day, but experience little nausea.1*

Some patients can live for weeks or even years with multiple level acute episodes of bowel obstruction using the above methods. Even if life is very limited, the above measures can make an important contribution to the quality of life in the last few days.

1* Baines MJ, Oliver DJ, Carter RL. Medical management of intestinal obstruction in patients with abdominal malignant disease: a clinical and pathological study. Lancet, 1985; ii.990-3.

Andrew Binns

Discussion
INTESTINE BLOCKAGE
Adhesions as the cause after surgery
vomit looks like bowel movement
Bowell obstruction re-occurence
Small bowel obstruction and research on most advanced therapy and whre
Bowel Obstruction in Palliative Care
non maligant intestinal obstruction in the cecum

Maggie, imm@qconline.com
Posted 27/8/01 9:24 PM


My father is 88 and has been treated for this obstruction over the last eight weeks with dilitation of the lower colon. Any other ideas. He is not a candiate for surgy because of a heart ejection problem.



Maggie, imm@qconline.com
Posted 27/8/01 9:24 PM


My father is 88 and has been treated for this obstruction over the last eight weeks with dilitation of the lower colon. Any other ideas. He is not a candiate for surgy because of a heart ejection problem.



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chanel miriegu e, rewhy@hotmail.com
Posted 7/4/2001 2:18 AM


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Adhesions causing strangulation of the bowell

Cori & Julie, cori.john@talk21.com
Posted 11/2/2001 3:49 AM


Help. My friend Julie is in hospital for the 5th time. She has had numerous operations to remove growths caused by adhesions and scar tissue from previous operations. Each time after the operation the adhesions cause growths which eventually grow so big, they strangle the bowell. Her doctor is now worried that another operation would kill her anyway and doesnt quite know what to do. Her stomach is so swollen she looks like she is 8 months pregnant. If they leave the growth, her bowell could end up bursting which would kill her anyway. Any suggestions Please???



Abdominal swelling & Dizziness

S. Choak, schoak@nortelnetworks.com
Posted 5/1/2001 4:51 AM


For the past two weeks my Father has been suffering from the following symptoms:
Abdominal swelling during eating meals accompanied by dizziness and feeling sick. He is also suffering from constipation. He has a good appetite however, half way through a meal he comes over strange and feels he's going to faint, hence he's started to loose weight. He said especially in the mornings he feels freezing cold and very shakey. He has suffered from IBS for several years. My father is 69 (6ft & ways approx 9.4 stones). He is very active and always eats sensibly (never smoke and has an occasional drink). He is currently taking 8 Buscopan a day (prescribed by his Doctor)and his blood pressures is low. Today the Doctor gave him some salt type tablets and told him to just drink water for the next 24hrs. I am conscerned with the quantity of Buscopan he's taking. The Doctor's said his blood test is clear but doesn't know what's wrong with him - he's still working on it. The Doctor also prescribed him Bevrin, he took one and was very poorly. I'd appreciate your opinion



INTESTINE BLOCKAGE

ESTER ROSSI, NIKEGIRL12@HOTMAIL.COM
Posted 16/11/2000 7:11 AM


MY FATHER IN LOW BEEN OPERATED FOR CNCER IN THE STOMACH, THE SURGEON REMOVE 75% OF HIS STOMACH,
5 DAYS AGO IS IN THE HOSPITAL FOR A BLOCKAGE OF HIS INTESTINE,
I APPRECIATE IF SOMEONE ANSWER ME BACK.

THANKS

ESTER ROSSI



Diana, peeblesj@ccsdana.net
Posted 11/12/2000 2:22 PM


My mother has ovarian cancer and she has opted for no further treatment, she has an intestine blockage now from the tumor and has had no bowel movements for 2 weeks, she is not in pain with the use of 50mg of duragesic patch. She is constantly vomiting even with the use of compazine IM and nausea pills, the problem is nothng is really helping and the hospic group can not think of anything else to use I am going to print off the above article and maybe they will try some of the drugs listed for nausea at this point we will try anything to get some relief.
Also is she has a complete blockage and no relief from it how long might she be in such misery.



Diana , peeblesj@ccsdana.net
Posted 11/12/2000 2:16 PM


Diana , peeblesj@ccsdana.net
Posted 11/12/2000 2:16 PM




Adhesions as the cause after surgery

Marie Braden, Marbr2deco@aol.com
Posted 15/2/00 6:41 AM


What is the best treatment for bowel obstruction caused by adhesions after abdominal surgery?



melinda, mjasmine90@cs.com
Posted 10/8/2000 8:25 AM


well im a 27 yr old woman that has had 5 surgerys to romove bowel adhesion and working on the 6th one. i know im tired of having surgery if there is anyone with any imformation on this please email me at mjasmine90@cs.com.



vomit looks like bowel movement

Annie Billings, willbill@bellsouth.net
Posted 19/1/00 12:34 PM


My mother has been in the hospital for almost 4 weeks. She has diabetes, had her foot amputated 3 weeks ago because of gangrene and last thursday she had the leg ampuated from the knee down. For the past two weeks she has been nauseous constantly and throws up whenever she tries to eat. The vomit does not look normal because it is dark brown. I have reason to believe she is throwing up her bowel movements. Please advise as I am very concerned. Thank You, Annie



Bowell obstruction re-occurence

Paul Johnson, prj3230@aol.com
Posted 7/1/00 10:08 AM


I recently had surgery for a bowell obstruction and am concerned about a re-occurence? Can you give me any suggestion on how to prevent such an occurence?



Tawana Blanks, t_wana@harmonicvision.com
Posted 11/3/00 8:43 AM


My mother was diagnosed with colon cancer nd she has reoccuring bowel obstruction and her doctors are telling her that she will just have to wait unitl they clear. If someone can please give me information or suggest some kind of medicine she can take, because she is on chemo, I would very, very, very much appreciate it.
Thanks



Darlene Lowe, dllowe@gov.pe.ca
Posted 15/5/00 10:41 PM


My sister has had 5 surgeys for small bowell obstructions. She is in constant pain and is in and out of the hospital. The doctors say it is because of adhesions. Is there nothing they can do for this. Would removing the bowell help? She has no quality of life. She lives from the couch to bed. She can not go anywhere and is willing to try anything if it would help her.





JILL JOHNSON, jillybunk@sisna.com
Posted 16/7/2000 6:02 AM


I have had 14 small bowell obstructions last 12 years. Hospitalized treated with fluids & NG tube
bowell decompresses. Surgery laproscopic to remove adhesions from previous pelvic surgeries.
No help. Two hernia repairs with exploratory and bowell examined no adhesions around bowel discovered. The symptoms are cramping coming in waves and increasing in intensity and frequency like labor pains followed by intense vomiting and wretching. Otherwise I am a healthy 68 yr old physicaly active female. I feel fine and this just hits me out of the blue. The Drs. don't think diet or stress plays a part. I need help! I can't be comfortable traveling now we are retired because of this and worried about it not decompressing and strangulating sometime. Would any pain or other RX help when this is occurring or to prevent it? I do not have diarreah or constipation any time before or following a attach. I take metamucil daily and have a healthy diet. No weight loss. I have searched the internet and could see no articles on small bowel obstruction similiar to mine. I would appreciate any help I can get. Jill Johnson



Small bowel obstruction and research on most advanced therapy and whre

MD S Islam, Islam_md@hotmail.com
Posted Sunday,July 04, 1999 03:02 PM


From: MD Islam (islam_md@hotmail.com)
Date: Sunday,July 04, 1999 03:02 PM

I have a brother who is been suffering from small bowel obstruction (Partial obstruction in the small intestine) and currently in a hospital here in Atlanta, Georgia, USA. The doctor's, after dealing with the symptoms and doing all kind of procedure (A surgery in 04/98 for small bowel obstruction, hospitalized on 05/98 for partial blockage after the surgery and again on 06/98 for partial blockage and doing procedures such as Bronchoscopy ( in 09/98 and again in June 1999, colonoscopy (June 1999, small bowel enteroscopy (June 1999), upper gi endoscopy (June 1999)has been hospitalized for partial blockage in the small intestine in June 1999), still don't know what is the problem that causing him the partial obstruction in his small intestine. My brother after having very mild symptoms for almost 6 months or so back in the hospital again in June 24th 1999 for the partial obstruction in his small intestine. He is a young good guy and he needs right therapy to get well.So far the d!
octor's here are not helping much, I know they are trying. University of Chicago suppose to have the best place for these kind of treatment. His present doctor supposedly keeping in touch with the most famous doctor in the Gastroentrology dept in Chicago but all we know now is its not Cancer (Thanks to the almighty)and the pathologist in Atlanta including the doctor's in Atlanta told us it was Sarcoidosis (I asked all three doctos and all of them told us they are about 94-98% sure but after the partial obstruction, in a way ,they are changing their suggestion, although the Chcago pathologist after looking at the specimens believe it is tubercolisis. So, there is nothing concrete. He is given Steroid and these doctors want to go with another surgery where they again will take out 8-10' of his small intestine (I hope not, never). We strongly believe surgery didn't help him, it made his symptoms worse. I will really appreciate if any body from anywhere have any information on th!
ese kind of symptoms, research, recommendation, it will be a big.big help and I will be grateful.
Thanks
Shahid
My E-mail address is
Md_islam@bis.inrg.com (Office)
or,
Islam_md@hotmail.com

-




Carmen Martinez, Camijon@msn.com
Posted 11/8/99 2:49 PM


I have been suffering from partial obstruction for 2 years. The cause of this I'm told from my doctors is due to scar adhesions. I had 11 abdoninal surgeries. now until today I'm still being medicated. all the medication does is drug me up and does'nt cure the problem. now my problem is my civilian doctors say I need surgery.I also went for a second opinion which civialian also agrees with the first doctor. I even brought this letter to the Navy doctors.
my Husband being military and us having Champus The Navy doctors say no surgery until I'm fully obstructed. navy thinks if they do surgery the scar adhesions will just come back.I have been suffering for quite a while. my symtoms are nasseau, vomiting, abdoninal distension, constipation,spasms, dirreaha which is very painful and everytime I get this it seems to get worse. my question is can I be helped or do I have to wait until I'm fully obstructed.also how and when is it time to be hospitlized.



paula y, paulabug@aol.com
Posted 16/8/99 3:47 AM


i had a desmoid tumor that was attached to the terminal ileum of my small bowel which was removed. the result of the tumor caused dense adhesions which caused 4 bowel obstructions. all these obstructions had to result in surgey. the results were 18 inches of terminal ileum was removed,ileocecal valve was removed,cecum was removed,appendix removed,and ascending colon was removed. now 14 years later i have many bowel problems. i recently was admitted with a bowel obstruction. they were able to decompress it by using a canter tube. i was hoping there was some new information on treatment of abdominal adhesions without having to have surgery every time. they tell me to just wait and see what happens.



James Heinz, jjheinz@bfs.uwm.edu
Posted 11/11/99 3:26 PM


I was diagnosed with a desmoid tumor in March 1999. It apparently was the result of a small bowell resection to clear a total intestinal blockage in Mar 1997. Three weeks ago I began to get blockage symptoms (stomach cramps and vomiting). Barium xrays shows desmoid scar tissue partially blocking my small intestine at two spots 18 inches apart in the middle of my small intestine. I do not want to do surgery due to having already lost 3 feet of bowel and due to the high rate of recurrence. We are trying interferon and tamoxifen. Cox 2 antigen and radiation therapy are contraindicated due to dangers of causing crohn's disease to recurr. Any suggestions as to other drugs/procedures we could try? Thanks for any help.



Cecile P. Walker, cecilew@home.com
Posted 22/11/99 2:29 PM


I think that it is quite shocking that surgeons, doctors etc., DO NOT warn/explain to patients who have had abdominal surgery, the possibility and symptoms of bowel obstruction due to adhesions. Itis, once again, an example of modern medicine treating problems only once they have become chronic or acute, rather than helping to prevent them. I suggest natural methods of healing wherever possible, even if they take a little longer time that the (usually drastic) methods employed by the 'normal' medical personnel.



BECKY HUGHEY, becky.hughey@mail.sprint.com
Posted 24/12/99 1:53 AM


we've just found out my mom has a bowel obstruction and wondered if certain foods bring on the pain. She can go several weeks and not have any problems and then suddenly her pain starts. Is there anything we can do to avoid this - special diets, etc.

Thanks!



Kelli Schulte, shorty_69_00_16@hotmail.com
Posted 23/1/2001 9:45 AM




Bowel Obstruction in Palliative Care

elva ali, 8bnugx
Posted Friday, July 24, 1998 2:54:2


URGENT,URGENT, URGENT, PLEASE I NEED MORE INFO.
ON BOWEL OBSTRUCITON MY HUSBAND BEEN SUFFERING
FOR MANY YEAR AND WE DON'T KNOW WHAT CAUSE IT AND
HE HAD 7 SUJERYS AND WE ARE TIRED TO SPENDING THE
MONEY AND WE ARE VERY CONFUSED I WOULD REALLY APRI
CIATE IF YOU SEND INF.





elva ali, 8bnugx
Posted Friday, July 24, 1998 2:55:0


URGENT,URGENT, URGENT, PLEASE I NEED MORE INFO.
ON BOWEL OBSTRUCITON MY HUSBAND BEEN SUFFERING
FOR MANY YEAR AND WE DON'T KNOW WHAT CAUSE IT AND
HE HAD 7 SUJERYS AND WE ARE TIRED TO SPENDING THE
MONEY AND WE ARE VERY CONFUSED I WOULD REALLY APRI
CIATE IF YOU SEND INF.





Herbert Kaiser, herbert.kaiser@owl-online.de
Posted 23/2/99 6:36 PM


In our palliative care unit we fond the treatment with octreotid very usefull. Vomiting and nausea can be controlled by reducing secretions of stomach and bowel without severe anticholinergic side-effects. Dosage 3 x 50-200yg/day.

Dr.med. Herbert Kaiser
palliative care unit
Reckenbergertstr. 19
D-33332 Guetersloh




Deborah Scarmazzo, deborah.scarmazzo@pharma.novartis.com
Posted 13/3/2001 11:00 AM


My mother is in Stage IV of Ovarian Cancer. In December 2000, she was operated on for bowel obstructions. Before surgery, her surgeon asked if she would accept a bag if there was no other means of correcting the blockage and she agreed. After surgery she was told her small bowel had been resectioned but that there was still a partial blockage remaining which the surgeon planned on treating with chemo, 3 weeks on/1 week off for six weeks.
It's now March and she has persistent vomiting and abdominal pain and is able to eliminate very little with the use of laxatives. She's afraid to eat/drink because she thinks it will make her vomit. She is currently on no medication. Her doctor has suggested she take Haloperidol but since she lives alone she won't take it because she feels spacey. Is there another drug she can take that is minimally invasive?



Q, QLeo7@aol.com.au
Posted 21/5/2001 12:11 PM


We use Octreotide SC as an infusion and occasionally as a bolus for bowel obstruction in Palliative care. We never used N/G tubes.
Also a venting gastrostomy is an excellent way of allowing a patient to drink fluids without the risk of vomiting and will give them their last few days in relative comfort.





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