Malignant Bowel Obstruction Clinical Guideline V1.0 ... · PDF file 2.1. Malignant Bowel...

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Transcript of Malignant Bowel Obstruction Clinical Guideline V1.0 ... · PDF file 2.1. Malignant Bowel...

  • Malignant Bowel Obstruction Clinical Guideline

    V1.0

    November 2019

  • Malignant Bowel Obstruction Clinical Guideline V1.0 Page 2 of 13

    Summary

    Integrated Care Pathway for Clinical Diagnosis of Malignant Bowel Obstruction

    Suspected Malignant Bowel Obstruction

     Abdominal distension

     Abdominal pain

     Nausea and vomiting +/- diarrhoea

     Constipation or absence of PR flatus (patient may have diarrhoea in partial

    obstruction)

    Please e-mail patient details to Dr John Mcgrane, Consultant Clinical Oncologist (for registration purposes only)

    IV fluids, SC/IV analgesia, Anti-emetics

    PR exam

    CT Thorax Abdomen Pelvis (with contrast where possible)

    Abdominal distension

    Vomiting

    Not passing stool/flatus

    Abdominal pain

    Malignant Bowel Obstruction suspected

    -Symptomatic measures -Imaging

    Malignant

    Bowel

    Obstruction confirmed

    Inform

    -Relevant Surgical team

    -Palliative Care

    -Acute Oncology

    Start MBO protocol

    management plan

    Drain any significant

    ascites

  • Malignant Bowel Obstruction Clinical Guideline V1.0 Page 3 of 13

    1. Aim/Purpose of this Guideline

    1.1. This guideline applies to patients presenting to RCHT with potential malignant bowel obstruction (luminal narrowing of small or large bowel with clinical evidence of bowel obstruction in the setting of metastatic intra-abdominal cancer). 1.2. This version supersedes any previous versions of this document. 1.3. Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in.

    DPA18 is applicable to all staff; this includes those working as contractors and providers of services.

    For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team rch-tr.infogov@nhs.net

    2. The Guidance

    2.1. Malignant Bowel Obstruction (MBO) is the luminal narrowing of small or large bowel with clinical evidence of bowel obstruction in the setting of metastatic intra-abdominal cancer 2.2. MBO may be suspected if there is:

    2.2.1. Abdominal distension 2.2.2. Abdominal pain

    2.2.3. Nausea and vomiting +/- diarrhoea

    2.2.4. Constipation or absence of PR flatus (patient may have diarrhoea in partial obstruction)

    2.3. If Malignant Bowel Obstruction is suspected:

    2.3.1. IV fluids and electrolyte replacement 2.3.2. Analgesia: - SC Morphine

    2.3.2.1. If opioid naïve, start at 10 - 20mg Morphine over 24 hours, or 10mg-15mg over 24 hours if frail / low body weight (10mg SC Morphine = 20mg oral morphine). 2.3.2.2. If already on opioids, opioid conversion dose to be

    mailto:rch-tr.infogov@nhs.net

  • Malignant Bowel Obstruction Clinical Guideline V1.0 Page 4 of 13

    discussed with the Hospital Palliative Care Team: Monday – Friday 0900 – 1700 or Specialist Palliative Care Advice Line 01736 757707 (out of hours)

    2.3.2.3. If reduced renal function (eGFR < 30ml/min), use SC Oxycodone at 50% dose of morphine doses above

    2.3.2.4. If patient has a transdermal opioid (e.g. Fentanyl) on admission keep this going and ADD SC opioid until palliative care input

    2.3.2.5. Do not start transdermal opioids (e.g. Fentanyl) unless under palliative care supervision

    2.3.3. Anti-emetics: (Cyclizine SC or IV 150mg/24hrs first line - SC preferred). (NB: Cyclizine may precipitate with Hyoscine butylbromide, and with Oxycodone, when mixed in syringe driver) 2.3.4. Rectal examination: - consider suppositories / enema if faecally loaded rectum

    2.3.5. Consider NG / Ryle’s tube: if ongoing vomiting (and acceptable to patient) 2.3.6. Investigations

    2.3.6.1. Baseline blood tests including FBC, clotting, CRP, renal, lactate, liver and bone profiles, and Mg2+ 2.3.6.2. CT Thorax, Abdomen & Pelvis with contrast if renal function allows (unless extensive co-morbidities)

    2.4. If Malignant Bowel Obstruction is confirmed:

    2.4.1. Please e-mail patient details to: Dr John Mcgrane, Consultant Clinical Oncologist (registration only) 2.4.2. QDS Observations – Temperature, Pulse, BP, Resp Rate, Oxygen saturation

    2.4.3. Full Fluid Balance Chart, ESPECIALLY frequency, appearance and VOLUME of vomits and/or NG drainage

    2.4.4. Food Chart if eating and drinking

    2.4.5. Stool Chart – including estimated VOLUME if profuse liquid stool

    2.4.6. Catheterise if concerned re: dehydration / renal function

    2.4.7. Dependent upon bed availability, transfer patient to Eden (or designated Gynae surgery ward) or Lowen (Oncology Ward) if not for surgery

  • Malignant Bowel Obstruction Clinical Guideline V1.0 Page 5 of 13

    2.5. Daily Management (see Appendix 3 for Daily Checklist)

    2.5.1. Day 1 Management:

    Day 1 Management

    Treatment  Nil by mouth

     IV fluids & electrolyte replacement

     Anti-emetics o - avoid metoclopramide if any possibility of complete and/or

    mechanical obstruction o Vomiting / Nausea = Cyclizine 150 mg in 24 hours SC or IV (SC

    preferred) If not already on anti-emetic

     Paracentesis to drain any significant ascites

     Consider IV/SC Steroids. o If commencing steroids, recommend starting dose of IV 6.6mg daily

    (8mg equivalent) Dexamethasone or (6-16mg/24hrs), given parenterally (iv or SC), as a morning dose once daily (or morning /noon if BD).

    o Check BM for hyperglycaemia at 6pm – prn Novorapid 4 units if BM >20

    o Ensure has IV gastric protection – PPI / Ranitidine

     Ranitidine: If high bowel obstruction plus confirmed gastric dilatation consider IV ranitidine 150mg BD

     NG (Ryles) tube placement (IF ACCEPTABLE TO PATIENT)

     Pain Management o Colicky pain - Hyoscine butylbromide 60-80mg/24 hours +/-

    opiate o Non-colicky pain - Morphine (or Oxycodone if eGFR

  • Malignant Bowel Obstruction Clinical Guideline V1.0 Page 6 of 13

    o No previous extensive abdominal surgery

     If single site obstruction -consider a radiological / endoscopic stent if appropriate

     Early involvement of the Nutrition Support Team and Dietitians for Cancer and Palliative Care is advised, especially if surgery or chemotherapy is likely.

     Consider Treatment Escalation Plan (TEP) and record limits of activity of treatment if appropriate.

    o Consider appropriate place of care – discussion with patient and family if appropriate

    2.5.2. Day 2 Management

    Day 2 Management

    As per day 1 plus:

    Adjust opioid for symptom control as appropriate

    If NG tube in place :

    Consider removal of NG tube if • Nausea and vomiting controlled /significantly improved, and volume of NG drainage

  • Malignant Bowel Obstruction Clinical Guideline V1.0 Page 7 of 13

    If patient remains NBM in obstruction and considered for surgery or chemotherapy - consultant level decision regarding Total Parenteral Nutrition (TPN) (see 2.6). Please refer using Maxims to ‘Nutrition Team (TPN) Inpatient Service.

    Symptom Control

     Adjust opioid and anti-emetic for symptom control as appropriate

     If high volume vomiting /NG tube drainage greater than 1000 mls in 24 hours despite previous measures: Stop Hyoscine butylbromide.

     Consider addition of Octreotide 300mcg over 24 hours via syringe driver (Consultant level decision)

    Gastrograff in swallow

     100ml oral ‘Gastrograffin swallow’ may be tried therapeutically to reduce oedema and promote luminal flow in patients who do not have high NG output.

     Evidence for this is stronger in the non-malignant setting but it may be attempted if obstruction is ongoing.

    2.5.4. Day 4 Management

    Day 4 Management

    As per day 2 + 3 plus:

     If high volume vomiting/NG drainage tube drainage greater than 1000 mls in 24 hours despite previous measures

    o Increase Octreotide by a further 300 micrograms /24 hours in syringe driver

    2.5.5. Day 5 Management

    Day 5 Management

    As per day 2, 3 + 4 plus:

     If high volume vomiting/NG drainage tube drainage greater than 1000 mls in 24 hours despite previous measures :

    o Increase Octreotide by a further 300 micrograms /24 hours in syringe driver – dose increases can continue by 300 mcg increments up to a maximum dose of 1800 mcg per 24 hours according to response (after which dose point there is little likelihood of additional benefit)

    Gynae- Oncology Surgical,

    Oncology, and

    Specialist Palliative

    Care review

     Final decision regarding any surgical or interventional options of care

     Final decision re whether there is any role for further oncological intervention

     Definitive decision reg