Malignant Bowel Obstruction
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Malignant Bowel Obstruction
Malignant Bowel ObstructionKara BischoffPalliative Care ServiceDivision of Hospital MedicineUniversity of California, San Francisco1A CaseA 57-year-old woman with a 1-year history of stage IV ovarian cancer (s/p debulking surgery, carbo + paclitaxel)Was doing generally well, still able to work part-time but with progressive fatigue and gradually increasing abd distention. Eating fairly well. Called her outpt pall care MD with 2 days of nausea and bilious emesis (~5 episodes/day). Unable to tolerate any POs. Last BM was 3 days prior and normal. No hx constipation. Initial concerns about what could be going on?2DefinitionBowel obstruction beyond the ligament of Treitz, in the setting of a diagnosis of intraabdominal cancer with incurable disease, or a diagnosis of non-intraabdominal primary cancer with clear intraperitoneal disease.Anthony T, Baron T, Mercadante S, et al. Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction. J Pain Symptom Manage, 2007.
3The ProblemCommon in ovarian and GI cancers20-50% of pts with ovarian cancer will develop MBO 10-28% of pts with CRC will develop MBO Also occurs when cancers metastasize to the abdomen (i.e. breast, melanoma, lung, bladder)Accounts for 15% of admits to pall care unitsLife expectancy is 80 days at presentation
Ripamonti C, Bruera E. Palliative management of malignant bowel obstruction. Int J Gynecol Cancer 2002.Krouse RS. The international conference on malignant bowel obstruction: a meeting of the minds to advance palliative careResearch. JPSM. 2007.GI cancers: intestinal>gastric>pancreatic
The diagnosis often coincides with a transition into the terminal phase of a patients illness and a rapid deterioration of medical and functional status4Survival
Chakraborty A, Selby D, Gardiner K, et al. Malignant Bowel Obstruction: Natural History of a Heterogeneous Patient Population Followed Prospectively Over Two Year. JPSM. 2011.Although diagnosis of MBO is generally an indicator of poor prognosis, there is great variability. 17% survived longer than 1 year, suggesting that aggressive interventions may be appropriate in a carefully selected subpopulation of patients with MBO.
26 of 35 (74%) patients were discharged home, six of 35 (17%) died in the acute care setting, and three of 35 (9%) were transferred to a palliative care unit for end-of-life care. (Chakraborty)
Median LOS for the incident admission was 16 days (range 2e105). Readmission was common, with 15 of 26 (58%) patients having a total of 23 readmissions to hospital subsequent to the incident admission. Readmission diagnoses included MBO recurrence (11 of 23), postoperative complications (2 of 23), and other diagnoses unrelated to MBO or its treatment (10 of 23), including renal insufficiency, sepsis, and failure to cope at home. Median number of days from discharge to the first readmission was 49 days (range 12-188 (Chakbornathy)
5Predictors of SurvivalMost significant factor affecting survival is ECOG performance status preceding obstruction. Median survival:ECOG 0-1: 222 daysECOG 2: 63 daysECOG 3-4: 27 daysOther predictors of poor prognosis: low albumin, ascites, heavy tumor burden, aggressive disease, extensive previous treatment.Wright FC, Chakraborty A, Helyer L, Moravan V, Selby D. Predictors of survival in patients with non-curative stage IV cancer and malignant bowel obstruction. J Surg Oncol. 2010.Jatoi A, Podratz K, Gill P, Hartmann LC. Pathophysiology and palliation of inoperable bowel obstruction in patients with ovarian cancer. J Support Oncol 2004.Dolan EA. Malignant Bowel Obstruction: A Review of Current Treatment Strategies. AJHPM. 2011.
Note, though, that this data is based on all observational data as there have not been ANY controlled trials about MBO. It may be that patients are treated differently based on their different ECOG coming in the door, for instance people with better ECOG status get more aggressive treatment and then do better so that its not possible to say whether their ECOG status or the aggressive treatments are what made the difference 6PathogenesisMechanical obstructionIntra-luminal occlusionExtrinsic occlusion from extra-luminal primary tumor or met, mesenteric and/or omental mets, adhesions, post-radiation fibrosisIntramural disease including intestinal linitis plastica
Functional obstructionMotility disorders from tumor infiltration of the enteric nervous system, malignant involvement of the celiac plexus, paraneoplastic neuropathy (particularly in lung ca)RipamontiCI, Easson AM, Gerdes H. Managementofmalignantbowel obstruction. Eur J Cancer. 2008.
Goldstein NE and Morrison RS. Evidence-Based Practice of Palliative Medicine. Philadelphia: Saunders, 2013. Print.8PresentationNausea: Mechanoreceptors are triggered by local distention vagus and splanchnic nerves to CTZVomiting: Following nausea or without preceding sxsAbd pain: Periumbilical, colicky. Localized pain worse with movement or palpation suggests peritonitis.Obstipation: Lack of flatus or stool suggests complete obstruction. Can also have overflow incontinence with liquefaction of stool by intestinal bacteria. Abdominal distension: From bowel distension +/- ascites.Goldstein NE and Morrison RS. Evidence-Based Practice of Palliative Medicine. Philadelphia: Saunders, 2013. Print.9A CaseA 57yo W with stage IV ovarian cancer and suspected MBOWhat would you advise our patient? What work-up would you suggest?10Work-UpVery context dependent
CT scan is the gold standard for diagnosisCan identify presence and degree of obstruction Can determining the pathological process(es)93% Se, 100% Sp, 94% accuracy in determining cause Carcinomatosis may be missed. Accuracy for implants