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Bowel obstruction in palliative care


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Complete bowel obstruction in the terminally ill patient


The scenario of persistent vomiting and colicky abdominal pain in a terminally ill patient with metastatic cancer causing bowel obstruction, is a major challenge for doctors involved in the palliative treatment of their patients. When all surgical options have been explored and considered futile, it is time to commence appropriate medical management to minimise the suffering for such a patient.

The traditional approach of IV fluids and nasogastric suction whilst awaiting surgery is quite inappropriate for the continuing medical management of irreversible complete bowel obstruction in a patient with terminal cancer. IV fluids increase the hydration and potential for more gastric and bowel secretion with resultant vomiting. Dehydration is a better tolerated option, so long as diligent mouth care is attended to.

NG tubes are very irritating if used for more than a few days and are disliked by both patients and their families. It is far more dignified to die without a drip and an NG tube.

However, there are a small number of cases, particularly in those with high obstruction and frequent high volume vomits where continued use of an NG tube is unavoidable.
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Can the obstruction be relieved medically?


Sometimes obstruction, particularly if only partial, can be relieved by the use of steroids in an attempt to reduce peri-tumour oedema and open the stenosis.

The dose used is controversial, but at St. Vincent's PCU, we use dexamethasone 4mgm qid. initially and reducing to 4mgm mane after a few days. Because the patient is unlikely to absorb this medication given orally, it is recommended that it be given subcutaneously through a butterfly needle. Because dexamethasone is incompatible with other agents it should be an SC site separate from that used for other drugs. The effectiveness of this treatment is controversial and further research is being done to further define the role of steroids in bowel obstruction.

In addition faecal softeners are sometimes useful in partial bowel obstruction. Laxatives that stimulate peristalsis may cause colicky pain and are not recommended.
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Reducing nausea and vomiting


Vomiting may be due to the obstruction or metabolic problems or both. The aim is to eliminate nausea and reduce vomiting to once or twice per day. This can be done by:

  1. Restricting oral fluids to small frequent quantities of nutritious fluid low residue) whilst continuing diligent mouth care. Ice can be helpful to keep the mouth moist.
  2. Removing IV therapy as mentioned above.
  3. If the obstruction is high, metoclopramide as a gastric emptying agent may make the situation worse and is contraindicated. If the obstruction is lower in the bowel and only partial, cisapride may have a role to play.

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The centrally acting agents are usually what is needed to reduce the amount of vomiting. The ones used commonly are:

Haloperidol


This is a powerful antiemetic and can easily be given by the SC route. The dose used is 5- 15mgm/day - parkinsonian side effects may occur in higher doses.

Cyclizine


Cyclizine is an antihistamine (HI blocker) that acts on the vomiting centre in the area postrema. The dose used is 100-150mgm/day and again it can be given by the SC route. It can be used in association with haloperidol.

NB. This drug requires special authority from Canberra - contact St. Vincent's PCU for further details. It is not an expensive drug and has been used extensively in the UK for many years.
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Hyoscine butybromide (Buscopan)


This drug reduces the volume of gastric secretions leading to fewer and smaller vomits. The dose used is 60-200mgm/day and again can be given by the SC route and it mixes well with morphine.

It can be given either four hourly SC or via a syringe driver by continuous infusion.
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Reducing abdominal pain


Abdominal pain can be either colicky or continuous and is to some degree opioid responsive. In addition to the use of SC morphine in carefully titrated doses, it is often necessary to add an antispasmodic for colicky pain.

Hyoscine butybromide (Buscopan) is best used in doses up to 200mgm/day and has the advantage over Hyoscine hydrobromide in having less CNS side effects (particularly drowsiness and confusion).

Side effects of Hyoscine butybromide are usually mild such as dry mouth from the anticholinergic effects. Tachycardia, accommodation disturbances, somnolence, urinary retention and low blood pressure are much less common side effects.

Again, it may be useful to give Hyoscine butybromide via a syringe driver particularly for home use. The device can be loaded also with morphine in the syringe for 24 hour use - a daily community nurse visit for reloading may be needed.
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Results of medical management of terminal malignant bowel obstruction


Control of continuous abdominal pain is very good with 89 per cent of patients becoming pain free. Colic is harder to treat and 31 per cent of patients continue to have mild colic. The management of nausea and vomiting is more difficult and the majority of patients continue to vomit about once a day, but experience little nausea.*

Some patients can live for weeks or even years with multiple level acute episodes of bowel obstruction using the above methods. Even if life is very limited, the above measures can make an important contribution to the quality of life in the last few days.


Dr Andrew Binns is the medical director for the palliative care unit at St Vincent’s Hospital, Lismore, NSW, Australia.

* Baines MJ, Oliver DJ, Carter RL. Medical management of intestinal obstruction in patients with abdominal malignant disease: a clinical and pathological study. Lancet, 1985; ii.990-3.


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