Bowel Obstruction in Advanced cancerBowel Obstruction

in Advanced cancerPractical management Practical management

Dr. Robin LoveMarch 2015

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ObjectivesObjectives

Understand the causes of obstruction in cancer Be able to discuss goals of care with

patients and family Plan various treatments depending on

the goals of care and clinical context

Understand the causes of obstruction in cancer Be able to discuss goals of care with

patients and family Plan various treatments depending on

the goals of care and clinical context

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OutlineOutline

Case Epidemiology Pathophysiology Clinical Diagnosis Treatment

Surgical Medical

Case Epidemiology Pathophysiology Clinical Diagnosis Treatment

Surgical Medical

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Case 1 Norman Case 1 Norman

78 year old man , lives on GabriolaIsland Cecal carcinoma resected 3 years later: recurrent obstructive Sx

several admissions Admitted via ER with mild nausea,

moderate abdominal pain, no flatus or stool for days

78 year old man , lives on GabriolaIsland Cecal carcinoma resected 3 years later: recurrent obstructive Sx

several admissions Admitted via ER with mild nausea,

moderate abdominal pain, no flatus or stool for days

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Epidemiology: Bowel ObstructionEpidemiology: Bowel Obstruction

Occurs in 3-10% of all cancer-related terminally ill Most common Ovary 25% (10-42%) Colorectal 15% (5-25%)

Less common Pancreas, gynecological, prostate, gastric,

bladder

Occurs in 3-10% of all cancer-related terminally ill Most common Ovary 25% (10-42%) Colorectal 15% (5-25%)

Less common Pancreas, gynecological, prostate, gastric,

bladder

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Typical Locations of Obstructions Esophageal Biliary

Gastro duodenal Small Bowel Colorectal

Typical Locations of Obstructions Esophageal Biliary

Gastro duodenal Small Bowel Colorectal

Gastro-intestinal Tract Anatomy

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Pathophysiology…Pathophysiology…

Small bowel (61%) or large bowel (33%) or both (20%) Single or multiple sites Partial or complete Malignant or benign causes

Final common path: occlusion of the lumen of the bowel

Small bowel (61%) or large bowel (33%) or both (20%) Single or multiple sites Partial or complete Malignant or benign causes

Final common path: occlusion of the lumen of the bowel

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Etiology: Related to the Cancer

Etiology: Related to the Cancer

Tumour Mass Single or multiple Intraluminal Intramural Extraluminal Separate from the

bowel Tumour invasion of

mesentery, muscle or nerve plexus

Tumour Mass Single or multiple Intraluminal Intramural Extraluminal Separate from the

bowel Tumour invasion of

mesentery, muscle or nerve plexus

Volvulus/torsion Around tumour Around adhesions Around fistula

Massive ascites Paraneoplastic

syndrome

Volvulus/torsion Around tumour Around adhesions Around fistula

Massive ascites Paraneoplastic

syndrome

Often Multifactorial

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Etiology: Related to the Cancer treatment

Etiology: Related to the Cancer treatment

Adhesions PostoperativeMalignant Post radiation

Radiation enteritis Chemotherapy (ileus)

Adhesions PostoperativeMalignant Post radiation

Radiation enteritis Chemotherapy (ileus)

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Etiology: unrelated or indirectly related to the cancer

Etiology: unrelated or indirectly related to the cancer

Constipation / Impaction

Ileus Infection Drugs Diabetes

Peritonitis Bowel infarction

Constipation / Impaction

Ileus Infection Drugs Diabetes

Peritonitis Bowel infarction

Other unrelated Hernia Diverticulitis Pancreatitis… Inflammatory bowel

disease Adhesions

a significant number are benign causes

Other unrelated Hernia Diverticulitis Pancreatitis… Inflammatory bowel

disease Adhesions

a significant number are benign causes

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Diagnosis of Bowel ObstructionDiagnosis of Bowel Obstruction History Physical

examination Imaging of the

abdomen Plain films CT Contrast studies

History Physical

examination Imaging of the

abdomen Plain films CT Contrast studies

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Clinical: History and symptoms…Clinical: History and symptoms…

Rarely an acute event- usually develops slowly and often is partial Cramps, nausea, vomiting, abdominal

distension Gradually become more severe and

continuous

Rarely an acute event- usually develops slowly and often is partial Cramps, nausea, vomiting, abdominal

distension Gradually become more severe and

continuous

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…symptoms and signs…symptoms and signs

Constant abdominal pain in 90% (related to the underlying tumor ?)

Intermittent colic in 75% Vomiting early and in large amounts in

proximal (gastric,duodenal and small bowel) and later in large bowel

Constant abdominal pain in 90% (related to the underlying tumor ?)

Intermittent colic in 75% Vomiting early and in large amounts in

proximal (gastric,duodenal and small bowel) and later in large bowel

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RadiologyRadiology

Plain radiographs useful (and easy) CT very useful to assess (new gold standard) Global extent of disease Staging including complications (ischemic bowel) Assist in choice of surgical treatment

*if appropriate and patient is well enough

Plain radiographs useful (and easy) CT very useful to assess (new gold standard) Global extent of disease Staging including complications (ischemic bowel) Assist in choice of surgical treatment

*if appropriate and patient is well enough

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General approach….General approach….

As with any problem in palliative care, we must consider whether our inquiries or investigations will change the management of the patient.

As with any problem in palliative care, we must consider whether our inquiries or investigations will change the management of the patient.

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…General approach…General approach

• This is rarely an emergency -take time to :

• Monitor• Investigate appropriately• Provide symptom control

• Remember the overall context…(stage of disease etc)

• This is rarely an emergency -take time to :

• Monitor• Investigate appropriately• Provide symptom control

• Remember the overall context…(stage of disease etc)

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Care…the right thing for this particular patientCare…the right thing for this particular patient

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Principles of Care…Principles of Care…

Primary areas of symptom control Pain Nausea Vomiting Thirst

Secondary areas of support Nutrition, including hydration Education Patient & family support

Primary areas of symptom control Pain Nausea Vomiting Thirst

Secondary areas of support Nutrition, including hydration Education Patient & family support

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…Principles of Care…Management is highly patient specific…Principles of Care…Management is highly patient specific

Stage of illness

Stage of illness

Type of obstruction

Type of obstruction

PrognosisPrognosisPerformance status

Performance status

Goals and choices of

patient

Goals and choices of

patient

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Active Treatment ApproachesActive Treatment Approaches

Active surgical ResectionBy-passVenting

Colostomy etc Gastrostomy

Active medical

Comfort Care only

Active surgical ResectionBy-passVenting

Colostomy etc Gastrostomy

Active medical

Comfort Care only

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NormanNorman

Surgery Day 2 Diffuse carcinomatosis Omental caking Not resectable , bypass not possible Moderate symptoms ( N, pain)

Surgery Day 2 Diffuse carcinomatosis Omental caking Not resectable , bypass not possible Moderate symptoms ( N, pain)

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Active Surgical Active Surgical

Not routine in our patient population, but should be considered in selected patients with mechanical obstruction single site of obstruction reasonable performance status and prognosis

Excellent clinical judgment is necessary. Is it technically feasible and will the patient benefit?

Not routine in our patient population, but should be considered in selected patients with mechanical obstruction single site of obstruction reasonable performance status and prognosis

Excellent clinical judgment is necessary. Is it technically feasible and will the patient benefit?

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…Surgical …Surgical

25-35% of obstructions due to benign factors or unrelated second primary

Some individuals symptom free for long period after palliative surgery

Operative mortality 10-20%, similar morbidity and complication rate

Median post-op. survival 2.5-11 months Surgical studies rarely look at Quality of Life

25-35% of obstructions due to benign factors or unrelated second primary

Some individuals symptom free for long period after palliative surgery

Operative mortality 10-20%, similar morbidity and complication rate

Median post-op. survival 2.5-11 months Surgical studies rarely look at Quality of Life

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Poor prognostic factorsPoor prognostic factors Prior failed surgery Widespread carcinomatosis Gross Ascites Multiple levels of obstruction Multiple liver metastases Cachexia Elderly Previous radiotherapy to abdomen

Prior failed surgery Widespread carcinomatosis Gross Ascites Multiple levels of obstruction Multiple liver metastases Cachexia Elderly Previous radiotherapy to abdomen

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Other Surgical / Interventional Options: decompression techniques

Other Surgical / Interventional Options: decompression techniques

Cecostomy etc Percutaneous Gastrostomy “PEG”

“Venting Gastrostomy” Endoscopic Radiologic

Very effective for persistent nausea and vomiting (up to 92%)

Cecostomy etc Percutaneous Gastrostomy “PEG”

“Venting Gastrostomy” Endoscopic Radiologic

Very effective for persistent nausea and vomiting (up to 92%)

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Other Surgical / Interventional OptionsOther Surgical / Interventional Options

Metal stents placed under endoscopic or fluoroscopic guidance Flexible and self expanding Expensive, not always available in Canada Overall cost effective Technical success rate 90% ( ??) Esophageal, gastro-duodenal, biliary,

colorectal

Metal stents placed under endoscopic or fluoroscopic guidance Flexible and self expanding Expensive, not always available in Canada Overall cost effective Technical success rate 90% ( ??) Esophageal, gastro-duodenal, biliary,

colorectal

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Stent partially deployedStent partially deployed

NormanNorman

Recurrence of distension, vomiting Still on dexamethasone and haldol Increase steroids, move to PCU Temporary NG tube (his choice)

Recurrence of distension, vomiting Still on dexamethasone and haldol Increase steroids, move to PCU Temporary NG tube (his choice)

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Medical Treatment of Obstruction:symptom relief and possible reversalMedical Treatment of Obstruction:symptom relief and possible reversal

NG tube and rehydration: 30-50% will reverse (but usually takes several days) Temporary – patients choice

Medications: Analgesics Motility agents Antiemetics Antisecretory

NG tube and rehydration: 30-50% will reverse (but usually takes several days) Temporary – patients choice

Medications: Analgesics Motility agents Antiemetics Antisecretory

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Medical Treatment of Obstruction:AnalgesicsMedical Treatment of Obstruction:Analgesics

Usual opioids by parenteral route (s.c., transdermal etc) anticholinergics for colicky pain Scopolamine hydrobromide 0.4-0.8 mg sc q2-4h

Usual opioids by parenteral route (s.c., transdermal etc) anticholinergics for colicky pain Scopolamine hydrobromide 0.4-0.8 mg sc q2-4h

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Medical Treatment of Obstruction:Motility agentsMedical Treatment of Obstruction:Motility agents Metoclopramide: 10-40mg sc qid

(Domperidone po only) The classic approach is not to use it in

complete obstruction because it might cause increased cramps. No evidence for this How do you really know complete vs. partial vs.

ileus?

My approach: try it for all and see if increased cramps

Metoclopramide: 10-40mg sc qid(Domperidone po only)

The classic approach is not to use it in complete obstruction because it might cause increased cramps. No evidence for this How do you really know complete vs. partial vs.

ileus?

My approach: try it for all and see if increased cramps

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Medical Treatment of Obstruction:antinauseantsMedical Treatment of Obstruction:antinauseants Metoclopramide 10-40 sc qid Haloperidol 0.5-2 mg sc/po/iv q12h and prn Metoclopramide 10-40 sc qid Haloperidol 0.5-2 mg sc/po/iv q12h and prn

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Medical treatment of obstruction: corticosteroidsMedical treatment of obstruction: corticosteroids Dexamethasone 10-20mg daily for trial of five

days (mechanism unknown- helps the nausea, may relieve obstruction by reducing bowel wall edema)

Reduce peritumoral edema Antisecretory : reduce water and salt

secretion

Dexamethasone 10-20mg daily for trial of five days (mechanism unknown- helps the nausea, may relieve obstruction by reducing bowel wall edema)

Reduce peritumoral edema Antisecretory : reduce water and salt

secretion

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Medical Treatment of Obstruction:Antisecretory…Medical Treatment of Obstruction:Antisecretory…

Octreotide 100-200 mcg sc q 8h Reduce GI secretions Slow intestinal motility Increase absorption of water and electrolytes

Good clinical evidence to support use in malignant bowel obstruction (RCT’s – total vomiting control in 92%)

Use it early in obstruction Rapid and effective

Octreotide 100-200 mcg sc q 8h Reduce GI secretions Slow intestinal motility Increase absorption of water and electrolytes

Good clinical evidence to support use in malignant bowel obstruction (RCT’s – total vomiting control in 92%)

Use it early in obstruction Rapid and effective

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Grenoble Study JPSM June 2006Grenoble Study JPSM June 2006

Stage 1: NG, hydrate, haldol, scopolamine, steroids, analgesics Stage 2 (after 5 days): still obstructed?

Stop steroids and scopol. , and start octreotide Stage 3 : gastrostomy

Sx control in 90% without ng tube

Stage 1: NG, hydrate, haldol, scopolamine, steroids, analgesics Stage 2 (after 5 days): still obstructed?

Stop steroids and scopol. , and start octreotide Stage 3 : gastrostomy

Sx control in 90% without ng tube

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Comfort : for all patients Comfort : for all patients

Pain Colic Continuous pain

Nausea & vomiting Mouth Care and Thirst Nutrition Emotional support

Pain Colic Continuous pain

Nausea & vomiting Mouth Care and Thirst Nutrition Emotional support

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Comfort Care OnlyComfort Care Only

Very advanced stage of disease Multiple medical problems Desire to stay at home In complete obstruction the average

survival is 10-20 days **(often misinformed about a quick

demise)

Very advanced stage of disease Multiple medical problems Desire to stay at home In complete obstruction the average

survival is 10-20 days **(often misinformed about a quick

demise)

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Norman Norman

Start octreotide 200 tid sc Metoclopramide 20 sc qid Dexamethasone 8 mg sc daily

Settled well, bowels remained open Discharged home day 14 Managed well at home (Gabriola Island) with

sc meds, low residue diet. Died 1 month later at home

Start octreotide 200 tid sc Metoclopramide 20 sc qid Dexamethasone 8 mg sc daily

Settled well, bowels remained open Discharged home day 14 Managed well at home (Gabriola Island) with

sc meds, low residue diet. Died 1 month later at home

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Overall approachOverall approach1. If urgent (severe Sx) – ng suction2. Start optimal medical management in almost all

patients unless really end stage3. Metoclopramide plus octreotide plus

dexamethasone (+/- haldol) (can combine in one CSCI) is easy and very effective

4. Consider hydration options (may reduce nausea)5. Consider other options/investigations6. Acceptable level of control may be vomiting 1-2

times/day ( as long as nausea is well controlled)

1. If urgent (severe Sx) – ng suction2. Start optimal medical management in almost all

patients unless really end stage3. Metoclopramide plus octreotide plus

dexamethasone (+/- haldol) (can combine in one CSCI) is easy and very effective

4. Consider hydration options (may reduce nausea)5. Consider other options/investigations6. Acceptable level of control may be vomiting 1-2

times/day ( as long as nausea is well controlled)

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References…References…1. Ripamonti et al, Clinical practice recommendations for the

management of bowel obstruction in patients with end-stage cancer. Support Care Cancer (2001) 9: 223-233

2. Ripamonti, C and E. Bruera Palliative Management of Malignant Bowel Obstruction Int J Gynecol Cancer 2002, 12: 135-143

3. Mercadante,S et al. Aggressive Pharmacalogical Treatment for Reversing Malignant Bowel Obstruction J of Pain and Symptom Mgt. 2004, 28: No.4, 412-416

4. Mercadante,S et al Comparison of octreotide and hyoscine butylbromide in controlling GI symptoms due to malignant inoperable bowel obstruction. Support Care Cancer (2000) 8:188-191

5. Dean,Andrew The Palliative effects of Octreotide in Cancer patients Chemotherapy 2001;47 Suppl 2: 54-61

1. Ripamonti et al, Clinical practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer (2001) 9: 223-233

2. Ripamonti, C and E. Bruera Palliative Management of Malignant Bowel Obstruction Int J Gynecol Cancer 2002, 12: 135-143

3. Mercadante,S et al. Aggressive Pharmacalogical Treatment for Reversing Malignant Bowel Obstruction J of Pain and Symptom Mgt. 2004, 28: No.4, 412-416

4. Mercadante,S et al Comparison of octreotide and hyoscine butylbromide in controlling GI symptoms due to malignant inoperable bowel obstruction. Support Care Cancer (2000) 8:188-191

5. Dean,Andrew The Palliative effects of Octreotide in Cancer patients Chemotherapy 2001;47 Suppl 2: 54-61

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…References…References

6.Mystakidou,K et al. Comparison of Octreotide Administration vs Conservative Treatment in the Management of Inoperable Bowel Obstruction in Patients with Far Advanced Cancer: a randomized, Double-blind, Controlled Clinical Trial. Anticancer Research 2002 22: 1187-1192

7. Brooksbank, MA et al. Palliative Venting Gastrostomy in Malignant Intestinal Obstruction. Palliative Medicine 2002; 16: 520-526

8. Krouse,RS et al. When the Sun can set on Unoperated Bowel Obstruction: Management of Malignant Bowel Obstruction J Am Coll Surg 2002, 195: No 1 117-128

9. Keymling,M Colorectal Stenting Endoscopy 2003; 35:234-23810. Baron, TH. Expandable Metal Stents for the Treatmentof

Cancerous Obstruction of the GI Tract. NEJM 2001,344:22;1681-1687

6.Mystakidou,K et al. Comparison of Octreotide Administration vs Conservative Treatment in the Management of Inoperable Bowel Obstruction in Patients with Far Advanced Cancer: a randomized, Double-blind, Controlled Clinical Trial. Anticancer Research 2002 22: 1187-1192

7. Brooksbank, MA et al. Palliative Venting Gastrostomy in Malignant Intestinal Obstruction. Palliative Medicine 2002; 16: 520-526

8. Krouse,RS et al. When the Sun can set on Unoperated Bowel Obstruction: Management of Malignant Bowel Obstruction J Am Coll Surg 2002, 195: No 1 117-128

9. Keymling,M Colorectal Stenting Endoscopy 2003; 35:234-23810. Baron, TH. Expandable Metal Stents for the Treatmentof

Cancerous Obstruction of the GI Tract. NEJM 2001,344:22;1681-1687

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…References…References11. Pothuri, b et al. PEG tube placement in patients with MBO due to

ovarian carcinoma. Gynecologic Oncology 96 (2005) 330-33412.Laval,G. et al. Protocol for the Treatment of Malignant Bowel

Obstruction: A prospective study of 80 cases at Grenoble University Hospital Center. JPSM Vol 31 NO 6. June 2006 p 502-512

13. Mangili, G. et al. Palliative Care for intestinal obstruction in recurrent ovarian cancer: a multivariate analysis. Int Journal of Gynecologic Cancer Vol 15 issue 5 p 830-835

14. Mercadante,S et al. Medical Treatment for Inoperable Malignant Bowel Obstruction: a Qualitative Systematic Review. JPSM Vol 33 No . Feb 2007 p217-223

11. Pothuri, b et al. PEG tube placement in patients with MBO due to ovarian carcinoma. Gynecologic Oncology 96 (2005) 330-334

12.Laval,G. et al. Protocol for the Treatment of Malignant Bowel Obstruction: A prospective study of 80 cases at Grenoble University Hospital Center. JPSM Vol 31 NO 6. June 2006 p 502-512

13. Mangili, G. et al. Palliative Care for intestinal obstruction in recurrent ovarian cancer: a multivariate analysis. Int Journal of Gynecologic Cancer Vol 15 issue 5 p 830-835

14. Mercadante,S et al. Medical Treatment for Inoperable Malignant Bowel Obstruction: a Qualitative Systematic Review. JPSM Vol 33 No . Feb 2007 p217-223