Nasogastric intubation plus IV fluids is still considered the standard management to decompress the bowel prior to surgery or pending a decision regarding possible surgery. However, it should only be atemporarymeasure. Continuation of "maintenance" IV fluids can make nausea and vomiting harder to control in the palliative setting.
Short-term subcutaneous fluids however may be indicated if the patient is symptomatic with dehydration.
In the terminal phase, IV fluids and nasogastric tubes should be avoided if at all possible. Perform frequent mouth cares.
Unless a surgical approach is being considered, patients should be allowed to take oral fluids and food as tolerated.
If surgery is clearly not appropriate or against the patient's wishes, an attempt should be made to palliate symptoms using active medical management.
Factors which suggest a poor outcome from surgery include: diffuse intraperitoneal carcinomatosis, severe ascites, previous abdominal or pelvic radiotherapy, palpable abdominal masses, liver or other distant metastases, low serum albumin and multiple levels of obstruction.
The aim of medical treatment is to minimise symptoms of pain, colic, nausea and vomiting, to provide freedom from medical technology and “tubes” if possible and to facilitate discharge home if that is the wish of the patient and their family.
Patients with recurrent bowel obstructions can be managed in the community without admission using subcutaneous infusions and palliative care nursing input.
Transfer to the Hospice may be appropriate in “terminal” obstruction – this must be discussed with Palliative Care Service prior to discussing this option with the patient or family.
Medical Management
General
Small meals, reduced roughage, eating early in the day or when best tolerated.
Ensure Plus/Fortisip.
Analgesia
Paracetamol PO QID. (IV Paracetamol rather than PR can be used short term if oral tablets are not tolerated.)
Morphine subcut via regular bolus doses or by continuous infusion – oral morphine is unlikely to be absorbed.
Antiemetics
Haloperidol (via regular subcut bolus doses or by continuous infusion).
Cyclizine(via subcutaneous infusion).
Metoclopramide-contraindicated in gastric outlet obstruction and complete high bowel obstruction (via regular subcutaneous boluses or infusion).
Nozinan (via regular subcutaneous boluses or infusion).
Anticholinergics
Antispasmodic (i.e. analgesic) and antisecretory (i.e. reduces nausea and vomiting) properties.
Hyoscine butylbromide (Buscopan™) 10 – 20 mg subcut q8h prn can be used for colicky pain.
Buscopan™ via subcut infusion (40-120 mg/24 hours) is standard treatment for established and irreversible obstruction. Must not be used in conjunction with metoclopramide.
Steroids
Dexamethasone may have a role in reducing peri-tumour oedema and thus reversing obstruction although there is limited evidence to support this practice. It is often used intravenously for a trial period.
Steroids can be used for their antiemetic properties. See Dexamethasone as a second-line antiemetic.
Octreotide
Interrupts the gastrointestinal hormone cascade which results in reduced secretions and motility.
Well established role when symptoms not controlled with opioids, antiemetics and anticholinergics. Evidence also exists for use in acute management of bowel obstruction.
Requires a special authority number for use in the community - see PHARMAC website: http://www.pharmac.co.nz. Approved for use in patients 'with nausea and vomiting due to malignant bowel obstruction where treatment with antiemetics, rehydration, antimuscarinic agents, corticosteroids and analgesics for at least 48 hours has failed'.
Also has a role in the management of fistulae, however it is not funded for this use.
Can be given in subcutaneous boluses with starting dose of 100 microgram TDS. The usual dose range for infusions is 200-600 micrograms / 24 hours subcut.
