Malignant Bowel Obstructio

Question 1

Malignant Bowel Obstruction - Definition

Answer 1

Bowel obstructive symptoms due to the presence of an intra-abdominal malignancy.

Often occurs in context of advanced disease.

May be secondary to non-malignant (post-surgical adhesions, radiotherapy bowel damage) or malignant causes (more likely as cancer becomes more advanced, or if primary CA is ovarian)

Question 2

Most common cancers where malignant bowel obstruction is seen

Answer 2

• Gyne cancers (particularly ovarian - as many as 40% of patients with ovarian CA)
• GI cancers (esp colorectal)

Cancers metastasizing to the abdomen (esp lung, breast, malignant melanoma).

Question 3

Pathophysiology of MBO

Answer 3

Mechanical (more common, where the lumen is occluded) or functional (less common)

Mechanical:

• Extrinsic occlusion of the lumen (compression of the bowel due to progression of the tumour, mesenteric or omental masses, adhesions, etc.)
• Intraluminal occlusion of the lumen (primary or metastatic tumour)
• Intramural occlusion of the lumen (intestinal linitis plastica - proliferation of the cancer through the intestinal tissue resulting in thickening and rigidity)

Functional (dysmotility)

• Motility disorder without mechanical occlusion
• Carcinomatosis (infiltration of the mesentery, bowel muscle, or nerves)
• Paraneoplastic syndrome
• Celiac plexus involvement
• Cancer related neuropathy
• Decreased motility secondary to meds (e.g. opioids)
• Bowel motility problems secondary to other illnesses like DM

Contributory causes:

• inflammatory edema
• fecal impaction
• constipating meds
• dehydration

Question 4

Common symptoms of MBO

Answer 4

• Nausea and vomiting (due to fluid accumulation proximal to obstruction, leading to bowel distention and secretion of water/sodium into the lumen)
• Colicky pain (bowel contracts to overcome obstruction)
• Abdominal pain (Inflammatory response to bowel distention and damage to epithelium, with production of prostaglandins, vasoactive intestinal peptides and nociceptive mediators)
• Late stage - systemic hypotension, sepsisdue to ongoing inflammatory response and splanchnic vasodilation, as well as passage of bacteria through the intestinal wall. Ultimately, may result in perforation.

Question 5

Differential diagnosis of MBO

Answer 5

1. Severe constipation
   - Check for history consistent with preceding constipation, drug use associated with constipation, in activity, check for hypercalcemia, hypokalemia, hypothyroidism
   - On exam, look for palpable fecal masses
   - Rectal exam for hard feces, and if rectum is empty but distended, consider obstipation at a higher level
   - AXR flat plate to assess for MBO
2. Opioid bowel syndrome
   - Opioids alter GI motility
   - Up to 4% of patients with cancer may develop nausea, vomiting, mild abdo discomfort, constipation, gaseous abdo distention, and weight loss.

Question 6

Presentation of MBO

Answer 6

• More common in advanced stages and often slowly progressive with multiple episodes of partial obstruction
• Intestinal strangulation, ischemia, and perforation are uncommon
• Radiographic testing may not always confirm the diagnosis, or may changes may predate the onset of symptoms - maintain a high index of suspicion

Symptoms:

• N/V (intermittent or continuous). May be undigested stomach contents or feculant depending on level of obstruction
• Continuous pain (bowel distention, tumour mass, hepatomegaly)
• Colicky pain (occurs only in mechanical obstruction)
• Abdominal distention (variable)
• Constipation (intermittent or complete, with absence of flatus)
• Diarrhea (may occur initially as a result of bacterial liquefaction of fecal material blocked in the sigmoid or rectum)

Question 7

Common signs of MBO on exam

Answer 7

Inspection

• abdominal distention (varies - if extensive peritoneal tumour spread, likely to be less)
• visible loops of distended bowel or peristalsis

Palpation

• masses
• organomegaly
• ascites
• tenderness (including rebound tenderness)

Auscultation

• bowel sounds increased or decreased
• absent in late obstruction, peritonitis, and functional bowel obstruction
• succession splash when the stomach is filled with ++ fluid (e.g. in GOO)

Rectal exam

• palpable masses
• rectal shelf
• rock hard stool (significant constipation)
• ballooned empty rectum (colonic obstruction higher up)

Signs of dehydration

Question 8

Syndrome of gastric outlet and proximal SBO

Answer 8

• Severe n/v, early in the course, large amounts of undigested food
• emesis may be bile stained if upper SBO
• Vomiting of saliva and gastric juices may be almost odourless
• Epigastric distention, no colicky pain
• BMs may occur with the fecal matter consisting of intestinal cellular debris and bacteria

Question 9

Syndrome of distal small bowel MBO

Answer 9

• N/V moderate to severe
• Moderate generalised abdominal distention
• If mechanical, upper or central abdominal colic
• Constipation to varying degrees, occasionally diarrhea

Question 10

Syndrome of large bowel MBO

Answer 10

• N/V late, smaller amounts, feculent emesis eventually
• Significant abdominal distention
• Central to lower abdominal colic
• Colicky pain not as severe as in higher obstructions
• Often preceding history of alternating diarrhea and constipation before complete obstruction occurs

Question 11

Investigation of MBO

Answer 11

1. Basic labs (CBC, lytes, cr) - other causes of symptoms
2. AXR
   - Dilated loops of bowel, air fluid levels on an upright film proximal to the obstruction, decreased or absent intra luminal gas distal to the obstruction
   - In functional obstruction, will show uniform gaseous distention through the GI tract
   - Limited in showing the cause/location of obstruction, when there is tumour encasement of the bowel (as bowel cannot distend in this circumstance), and if there are multiple levels of obstruction.
3. XR with gastrograffin or barium contrast
   - Shows the site and extent of the obstruction and the presence of multiple sites of obstruction
   - NEVER use barium if a partial bowel obs is suspected, as the barium can worsen the obstruction
   - May be more useful in more proximal obstruction
4. CT
   - useful for identifying case of the obstruction, staging, and for assisting in the choice of invasive tx (e.g. surgery or stenting)
   - superior results in assessment of abdominal symptoms

Question 12

Indications for surgery in MBO

Answer 12

• Surgery is controversial in MBO, but may be required for patients with non-malignant obstruction related to previous surgery or radiation
• No prospective randomized trials
• Potential pitfalls include re-obstruction, inadequacy of symptom relief, and post-op morbidity and mortality
• Surgery would be a better option than stenting for palliation in patients who have a longer prognosis (>60 days), few comorbidities, and single site of obstruction near the gastric outlet.

Options:

• Complete resection (most useful with GI primary where negative margins are possible)
• Operative bypass
• Lysis of adhesions
• Diverting stoma (minimum of 100cm of small bowel before a stoma in order to maintain nutrition, risk of fluid balance problem)

Question 13

Intraluminal stents for Upper MBO - indications and risks

Answer 13

• Surgery would be a better option for palliation in patients who have a longer prognosis (>60 days), few comorbidities, and single site of obstruction near the gastric outlet.
• Stenting better for those with short length of tumour, single site of obstruction near the pylorus or proximal 2/3 of the duodenum, with intermediate to high performance status and life expectancy > 30 days
• May be placed in upper and lower bowel with good relief of symptoms
• Cannot be done for long obstructions or beyond the length of the endoscope
• Lasers may be used to canalize through tumours to allow stent placement

Risks:

• Aspiration during procedure (risk can be mitigated with GA and intubation)
• Perforation (7-14%)
• Migration
• Reobstruction (long term failure rate of 25-30%)

Question 14

Medical management of MBO

Answer 14

1. Bowel decompression
2. Chemo (poorly studied)
3. Rads (may be effective in some cases)
4. Pain relief (opioids)
5. Anti-emetics
6. Anti-secretory agents (ocreotide, buscopan, glycopyrrolate)
7. Corticosteroids
8. IV hydration and bowel rest

Question 15

Bowel decompression for MBO

Answer 15

• NG tube inserted to decompress gas and fluid in the bowel
• Generally a temporary measure for severe symptoms as a bridge to surgical or other medical tx
• May be unnecessary with adequate antisecretory therapy

Risks:

• Provides incomplete relief of symptoms
• Uncomfortable
• Long term morbidity (erosion of the nares, nutritional deficiency, aspiration pna)

Question 16

Venting gastrostomy or enterostomy

Answer 16

Indicated for patients in whom pharmacological management is not effective, or for very high gastric outlet or upper SBOs that cannot be bypassed

Allows patients to partake in the social experience of eating/drinking

Can do gastrostomy or jejunostomy depending on position of stomach (or if stomach has been removed)

Question 17

Pharmacologic approach to MBO

Answer 17

1. Provide clear written instructions. Typically, start antisecretory therapy, steroid, anti-emetic. Consider IVF if patient unable to tolerate PO fluids and NG tube for severe symptoms
2. If partial response to any pharmacologic therapy is not seen in 24 hrs, reassess
3. Reassess every 48 hrs as the clinical picture evolves

Question 18

Pain relief in MBO

Answer 18

Opioids

• Relief of pain
• Decrease in abnormal motility contributing to colic
• Administer parenterally (subcut) to ensure absorption

PO Loperamide
- May be useful as an antimotility agent, but no clear evidence

Antisecretory agents may also provide pain relief (may give buscopan 40 - 120mg/day) or glycopyrrolate in addition to opioids for colicky pain if opioids alone are ineffective)

Question 19

Anti-emetics in MBO

Answer 19

• No clear data to prefer one anti-emetic over another
• Antidopminergic drugs often used (e.g. haldol 5-15mg/day)
• No evidence for aprepitant or ondansetron
• Never use metoclopramide (useful in partial SBO) in complete bowel obs or if patient has colic as it will be worsened by the prokinetic effect

Complete relief of N/V due to MBO with anti-emetics alone is usually not possible due to hypermotility and then pooling of secretions and distention of the bowel.

Question 20

Anti-secretory agents in MBO (rationale, dosing, action, side effects)

Answer 20

• Much of the symptoms attributable to MBO are related to the abdominal distention, pain, and N/V due to a large volume of intestinal secretions.
• Anti-secretory therapy should be seen as first line even if the patient is being considered for surgery
• Give subcut, 300-600mcg/daily in divided doses or continuous infusion

Octreotide (somatostatin analogue)

• Give subcut, 300-600mcg/daily in divided doses or continuous infusion
• Inhibits release of gastrin, cholecystokinin, vasoactive intestinal peptide, and pancreatic enzymes, decrease bowel secretions overall
• Also decreases neurotransmission in the nerves of the GI tract, decreasing peristalsis, splanchnic blood flow, and increasing absorption of fluids

Side effects:

• dry mouth
• long term, can be associated with hyperglycemia and biliary sludging

May give buscopan or glycopyrrolate in addition to octreotide

Question 21

Corticosteroids in MBO (rational, mechanism, dosing)

Answer 21

MOA: likely anti-emetic, analgesic, anti-inflammatory effect that decreases peritumour edema

Dexamethasone 6 - 16mg PO daily

Poor evidence but widely used, does not appear to affect survival

Discontinue if no response within 4-5 days. If there is a response, wean down over time to a minimum effective level

Question 22

Hydration in MBO

Answer 22

IV or subcut hydration in case of severe fluid imbalance or severe electrolyte abnormalities. Rates should be lower if antisecretory agents are being used and patient is not severely dehydrated

Once secretions, nausea and pain are controlled, most patients can tolerate clear fluids PO until the obstruction resolves

Question 23

Nutrition - role of TPN or nutritional supplementation

Answer 23

Likely not to improve QOL for patients with survival of less than 3 months

For patients with slow growing tumours involving the GI tract, sparing other major organs, TPN trial in the case of weight loss from starvation may be considered.

For patients who are severely malnourished and in home a surgery is planned but cannot be enterally fed, may be appropriate to consider for 7-10 days preop to decrease rate post op infections, periop mortality, and LOS. Post op duration should be defined preop and generally should be < 10 days.

Question 24

How to manage patients between episodes of MBO at home

Answer 24

• Maintain adequate hydration
• Give regular metoclopramide to keep intestinal contents moving through areas of partial obstruction
• Maintain daily soft BMs
  - osmotic laxatives with PEG, or lactulose
  - use bisacodyl supps PRN
  - avoid high enemas
• Soft or liquid low residue diet (poor evidence)
• Meds in the home for future events (anti-emetics, antisecretory drugs, antimotility agents, opioids) for use as soon as cramps, distention, nausea or vomiting occur

As episodes become more frequent and close together, complete irreversible bowel obstruction is more likely imminent

Question 25

How to discuss management of unremitting MBO with pt and family

Answer 25

- Initiate meeting with patient, family, any other caregivers - Clarify medical information (including limited options for treatment), as well as prognosis and possible outcomes (e.g. sepsis, bowel perforation) - Assess functional status, resources for assistance around the home - Establish patient/family wishes around home care - Explain that patient will likely vomit occasionally/not have complete symptom control and address issues of hydration/nutrition Patient may opt for hospital care (NG decompression, venting gastrostomy, IV fluids, etc.) until death

Question 26

Home based care for unremitting MBO

Answer 26

1. Adequate, coordinated resources at home (access to physicians and nursing services 24 hrs/day) and backup plan in case home care becomes impossible 2. Goal of eliminating nausea, vomiting to less than twice per day with meds (antisecretory, antiemetic, antimotility and analgesic drugs) 3. Ensure drugs are available in the home 4. Sips of fluid or soft foods as tolerated which may be absorbed proximally. Some patients continue to eat and vomit after meals. 5. Meticulous mouth care 6. Hydration may be offered either IV or subcut (and may reduce risk of opioid toxicity). If hydration is not offered, consider dose reduction of opioids

Question 27

Signs of complete MBO

Answer 27

- No evacuation of feces or flatus - Eventually, may have paradoxical diarrhea due to leakage of fecal fluid from fecal impaction (especially in large bowel obstruction)

Question 28

Patient selection for surgery in MBO

Answer 28

- Median survival in MBO treated surgically is 2-11 months (may reflect surgical selection process, where healthier patients are more likely to get surgery) - No clear guidelines 1. Patient factors - Performance status (best predictor of lower complication rate and improved survival) - Prognosis - Other treatment options - Comorbidities - Ascites 2. Decision-making process for surgeon - No obligation to offer futile therapy - How likely the surgery is to enhance QOL - Ensure MBO is mechanical (not functional) - Consider technical factors and type of surgery offered 3. Decision making process with family - Ensure patient and family have realistic understanding - Determine whether surgery fits with goals of care and risks outweigh benefits for patients - Provide commitment to care for patient regardless o decision - Ensure family is aware that it is possible no surgical procedure may be possible Not good candidates: - Extreme tumour burden (e.g. bulky carcinomatosis, ++ liver mets, large ascites, impaired organs from distant mets) - Multiple sites of obstruction - MBO from generalised carcinomatosis (not surgical candidate)

Question 29

When to treat MBO non-surgically (e.g. NG, meds)

Answer 29

Patients with: - poor PS - rapidly progressive disease - Evidence of advanced carinomatosis with mod/severe ascites - Multiple levels of obstruction on imaging - Prognosis of less than 30 days

Question 30

Intraluminal stends for colorectal obstruction

Answer 30

- Can be performed using colonoscopy or IR techniques - If doing by colonoscopy, try to do bowel prep using enemas - May require use of guidewire to get through tumour Lower risk of complications than with upper stent. - Requires a location of obstruction more distally in the colon (and readily reached by scope) Avoid in patients with: - torturous tumours making traversing the tumour difficult - Tightly obstructing tumours that would be difficult to expand a stent in - Tumours that are very very low in the rectum (patients will have complete loss of continence and would be better managed with a diverting colostomy. Complications: - Migration - Re obstruction - Occlusion from hard fecal material