What is the assessment and plan for a 96-year-old patient with a colonic mass causing large bowel obstruction, who has Diabetes Mellitus (DM), uterine leiomyomatosis with right hydronephrosis, mild metabolic acidosis, acute kidney injury, and chronic anemia?

From the Guidelines

For this 96-year-old patient with a colonic mass causing large bowel obstruction and multiple comorbidities, I recommend urgent surgical consultation for colonic decompression, likely via a diverting colostomy, as this approach is reasonable for patients who are not candidates for resection, depending on the patient’s goals and functional status, as suggested by the most recent evidence 1.

Initial Management

Initial management should include:

• Bowel rest
• Nasogastric tube decompression
• IV fluid resuscitation with normal saline at 100-125 mL/hr
• Correction of electrolyte abnormalities The patient requires close monitoring of renal function with daily BUN/creatinine and electrolytes.

Comorbidity Management

For the acute kidney injury, ensure adequate hydration while avoiding fluid overload given the patient's age. The hydroureteronephrosis should be evaluated by urology for possible stent placement to relieve obstruction. Blood glucose should be maintained between 140-180 mg/dL using sliding scale insulin. For chronic anemia, check iron studies, B12, and folate levels; consider transfusion if hemoglobin is below 7 g/dL or if symptomatic. Pain management with low-dose opioids (morphine 2-4 mg IV q4h PRN) may be necessary. Given the patient's advanced age and multiple comorbidities, a goals-of-care discussion with the patient and family is essential to determine the appropriate level of intervention. The colonic mass requires biopsy for staging and treatment planning once the acute obstruction is addressed. This comprehensive approach addresses the immediate life-threatening bowel obstruction while managing the patient's complex comorbidities, as supported by recent clinical practice updates 1.

Surgical Considerations

In patients with malignant colonic obstruction who are candidates for resection, insertion of SEMS is a reasonable choice as a “bridge to surgery” to allow for one-stage, elective resection, as suggested by recent evidence 1. However, for this patient, given the advanced age and multiple comorbidities, a diverting colostomy may be a more appropriate initial approach, as it can provide immediate relief from the obstruction and allow for stabilization of the patient before considering further surgical intervention, as recommended by the guidelines 1.

From the Research

Patient Assessment

• The patient is a 96-year-old with a colonic mass causing large colon obstruction, diabetes mellitus (DM), uterine leiomyomatous with right hydroureteronephrosis, mild metabolic acidosis, acute kidney injury, and chronic anemia.
• The patient's uterine leiomyomatous is a benign gynecologic tumor, and its management should be considered in the context of the patient's overall health and other comorbidities 2, 3.
• The colonic mass causing large colon obstruction requires urgent attention, and the patient may benefit from a diverting ostomy to manage the obstruction 4, 5.

Management Plan

• The patient's management plan should involve a multidisciplinary approach, considering the patient's complex medical history and comorbidities.
• The use of a diverting ileostomy or colostomy may be necessary to manage the colonic obstruction, especially if the patient is at high risk for anastomotic leak or has a low pelvic anastomosis 4, 5.
• The patient's uterine leiomyomatous should be managed conservatively, considering the patient's age and overall health, unless it is causing significant symptoms or complications 2, 3.
• The patient's diabetes mellitus, mild metabolic acidosis, acute kidney injury, and chronic anemia should be managed concurrently, with a focus on optimizing the patient's overall health and reducing the risk of complications.

Decision-Making

• The patient's care team should involve the patient and their family in the decision-making process, using a shared decision-making framework to formulate a recommendation that takes into account the patient's priorities and values 6.
• The patient's prognosis and treatment options should be carefully evaluated, and the care team should provide a recommendation based on the patient's priorities and the likely prognosis and available treatment options 6.