Bowel Obstruction

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Becky Owen 22/2/12

description

Bowel Obstruction. Becky Owen 22/2/12. Overview. Case Study Clinical Presentation Management Case Study Update Summary Questions. Mrs JL. 55 yr Ovarian Carcinoma Diagnosed 2010 4 cycles palliative chemotherapy Stable disease until June 2011 - PowerPoint PPT Presentation

Transcript of Bowel Obstruction

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Becky Owen22/2/12

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OverviewCase StudyClinical PresentationManagementCase Study UpdateSummaryQuestions

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Mrs JL55 yr Ovarian CarcinomaDiagnosed 20104 cycles palliative chemotherapyStable disease until June 2011Increased abdominal distension, nausea,

vomiting, weight lossCT – disease progression, subacute small

bowel obstructionWhat would you do next?

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Bowel Obstruction in Palliative CareDue to functional or mechanical obstruction

of bowel lumen and/or peristaltic failureCan be partial or completeCan occur at any level

Oesophageal Gastric outlet & proximal small bowel Distal small bowel Large bowel

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CausesThe cancer itselfPast treatment

Adhesions, postradiation ischaemic fibrosis

Drugs Opioids, antimuscarinics

Debility Faecal impaction

Unrelated benign condition Strangulated hernia

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Clinical PictureAbdominal painAbdominal distensionVomitingNauseaIntestinal colicVariable bowel habit

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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

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Management - SurgeryConsider 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)

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Management - MedicalFocus on symptomatic reliefAnti-emeticsOpioidsReview laxativesCorticosteroidsAnti-secretory drugsOctreotide

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Anti-emeticsPatient without colic + passing flatus –

Prokinetic first drug of choicePatient with colic – antisecretory +

antispasmodic drug (Buscopan)

To be aware of anti-cholinergic effect of some drugs – can inhibit gut motility

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OctreotideSynthetic analogue of somatostatin with

longer duration of actionInhibitory hormone – found throughout the

bodyInhibits release of Growth Hormone, TSH,

Prolactin, ACTH in hypothalamusInhibits peptides of Gastro-enteropancreatic

system

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Octreotide and bowel obstruction<50% patients – respond to typical starting

dose of 300 micrograms/24hr75-90% respond to 600-800 micrograms/24hrComparisons 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

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Octreotide and ascitesCan suppress diuretic induced activation of

renin-aldosterone-angiotensin systemMay 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

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Undesirable effects from OctreotideBolus SC injection painfulDry mouthFlatulenceNauseaAbdominal painDiarrhoeaImpaired glucose toleranceGallstones

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CautionsInsulinomaType 1 diabetesCirrhosisRenal FailureAvoid abrupt withdrawal of short-acting

octreotide after long-term treatmentMonitor thyroid function

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Octreotide Drug Interactions Octreotide markedly reduces plasma

ciclosporin concentrations and inadequate immunosuppression may result.

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Octreotide CSCI Compatability2 drug compatibility data for octreotide and;

Morphine sulphate, metoclopramide, hyoscine butylbromide, diamorphine, alfentanil (in WFI)

Check PCF4 / palliativedrugs.comConflicting observational reports with

levomepromazine

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Depot Formulation of OctreotideSandotatin – 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

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Management - InterventionsDependant on level and extent of obstructionStentsVenting gastrostomy

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Mrs JL Cont.Not suitable for surgery/interventionNo colic – initially trialled metoclopramide

CSCINot 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

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In SummaryOne of the most challenging problems in

palliative careTo focus on improving quality of lifeIf focal obstruction – consider possibility /

suitability of interventionRarely need IV fluids or NG tube to relieve

symptoms

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Any Questions?

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ReferencesPalliative Care Formulary 4th Edition; R Twycross, A

Wilcock.Symptom Management in advanced cancer 3rd Edition; R

Twycross, A Wilcock.