July 2003

Dear Readers: Here's the Article for this Month:

Name of article:

Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer

Author(s): Ripamonti C, Twycross R, Baines M, Bozzetti F, Capri S, De Conno F, Gemlo B, Hunt TM, Krebs H-B, Mercadante S, Schaerer R, Wilkinson P
Reference: Supportive Care Cancer 2001; 9: 223-233

Abstract: 

Malignant bowel obstruction (MBO) is a distressing outcome in patients with abdominal and pelvic primary cancer or metastases. In highly selected groups of patients, retrospective and autoptic studies have estimated that MBO occurs in 4% to 28.4% of patients with gastrointestinal cancer and in 5% to 51% of patients with gynecological disease, in particular with ovary cancer, where it is a major cause of death. As a consequence of the partial or complete occlusion of the lumen, the accumulation of the unabsorbed secretions produce nausea, vomiting, pain, abdominal distension and colicky activity (not present in functional obstruction) to surmount the obstacle that causes intermittent colicky pain.

Because the obstruction of the lumen develops slowly and often remains partial, MBO in advanced cancer patients is rarely an emergency event and intestinal strangulation is uncommon, thus there is time to evaluate the most suitable therapeutic intervention for each patient.

A Working Group was established by the Board of Directors of the European Association for Palliative Care. The aim of the Steering Group was to review issues relating to bowel obstruction in end-stage cancer and to make recommendations for management. The authors applied a systematic review methodology that showed the relative lack of RCTs in this area. The aim was to review published data and also to provide clinical opinion where data were lacking. The group reviewed all the available data, discussed the evidence and discussed what practical recommendations could be derived from it.

The Working Group reached the consensus for the following recommendations:

1.Curative or palliative surgical intervention should be considered in all patients with MBO, however surgery should not be undertaken routinelymetastases producing symptoms difficult to control such as severe dyspnea

2. A nasogastric tuble (NGT) should be used only as a temporary measure because it is intrusive and distressing for the patients and may cause local complications

3. Medical measures such as analgesics, anti-secretory drugs (hyoscine butylbromide, glycopyrrolate, octreotide) and anti-emetics (metoclopramide in patients with partial occlusion and no colic; haloperidol, cyclizine, prochlorperazine) should be used alone or in association with anti-secretory drugs to relieve symptoms thus avoiding the placement of the NGT

4. A venting gastrostomy should be considered if drugs fail to reduce vomiting to an acceptable level

5. Total Parenteral Nutrition (TPN) should be considered only for patients who may die of starvation rather than from tumour spread

6. Parenteral hydration (intravenous or via hypodermoclysis) is sometimes indicated to correct nausea, whereas regular mouth care is the treatment of choice for dry mouth.

7. A collaborative approach involving both surgeons and physicians can offer patients an individualized and appropriate symptom management plan.

Why I chose this article.

This is an article published two years ago, however the management of symptoms due to MBO in advanced and terminal cancer patients is still of extreme actuality.

The paper highlights a series of questions that doctors need to consider when faced with end-stage cancer patients with bowel obstruction: Is the patient fit for surgery? Is it necessary to use a venting NGT in inoperable patients or is it more suitable to perform a gastrostomy? Is there a place for stenting? What drugs and what routes of administration are indicated for symptom control? What is the role of TPN and parenteral hydration?

These clinical-practice recommendations are able to give an answer to most of the above mentioned questions.

The PDF file with the full text of this paper can be down loaded at http://www.eapcnet.org Click on PUBLICATIONS.

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC