What is the best course of action for a patient with ovarian mucinous cystadenocarcinoma, status post surgery and chemotherapy, with recurrence and liver metastases, now presenting with vomiting after food and water intake and no stool output in the colostomy bag?

Immediate Management of Bowel Obstruction in Metastatic Ovarian Cancer

This patient requires urgent hospitalization for management of malignant bowel obstruction, with immediate nasogastric decompression, IV fluid resuscitation, antiemetic therapy, and surgical consultation to determine if palliative intervention is feasible. 1

Acute Presentation Assessment

This patient presents with classic signs of bowel obstruction in the setting of progressive metastatic disease:

• Vomiting after all oral intake combined with absent colostomy output indicates complete or near-complete obstruction 2
• The presence of liver metastases after multiple lines of therapy (primary surgery, chemotherapy, HIPEC, adjuvant chemotherapy) suggests progressive disease with likely peritoneal involvement 1
• This clinical scenario represents a medical emergency requiring immediate intervention to prevent aspiration, severe dehydration, and electrolyte derangements 2, 3

Immediate Interventions (First 24 Hours)

Hospitalization is mandatory with the following steps:

• Nasogastric tube placement for gastric decompression to relieve vomiting and prevent aspiration 2
• IV fluid resuscitation with electrolyte replacement, as patients typically develop severe dehydration and metabolic alkalosis 2, 3
• Complete blood count and comprehensive metabolic panel to assess for neutropenia, anemia, renal function, and electrolyte abnormalities 2, 3
• Antiemetic therapy with ondansetron 8-24 mg IV or 5-HT3 antagonists, plus metoclopramide or prochlorperazine if gastroparesis contributes 4, 5
• Octreotide 100-150 μg SC three times daily or 25-50 μg/hr IV to reduce gastrointestinal secretions and improve symptoms 2, 3

Diagnostic Workup

CT imaging of chest/abdomen/pelvis with IV contrast is essential to:

• Determine the level and cause of obstruction (tumor mass, peritoneal carcinomatosis, adhesions) 1
• Assess for bowel perforation, ischemia, or closed-loop obstruction requiring emergency surgery 2
• Evaluate extent of peritoneal disease and liver metastases 1

Stool studies are NOT indicated in this setting, as the obstruction is mechanical rather than infectious 2, 3

Surgical Consultation and Decision-Making

Secondary cytoreductive surgery for recurrence is controversial and has no proven benefit, particularly in patients with:

• Progressive disease on chemotherapy 1
• Disseminated peritoneal disease 1
• Liver metastases indicating systemic progression 1

However, palliative surgical intervention may be considered if:

• A single, discrete obstruction point is identified that can be bypassed 1
• The patient has adequate performance status and life expectancy exceeding 2-3 months 1
• Complete or near-complete resection of obstructing lesions appears feasible 1

A permanent colostomy has deleterious effects on quality of life, so if surgical intervention is pursued, every effort should be made to create a reversible diversion or bypass 1

Medical Management if Surgery Not Feasible

If imaging reveals diffuse peritoneal carcinomatosis or the patient is not a surgical candidate:

• Continue octreotide to reduce secretions and nausea 2, 3
• Maintain NPO status with nasogastric decompression as needed for comfort 2
• Parenteral nutrition may be considered if prognosis exceeds several weeks, though this decision should align with goals of care 2
• Transition to palliative care with focus on symptom management and quality of life 1

Chemotherapy Considerations

Mucinous ovarian carcinoma is notably resistant to standard platinum-taxane regimens, and this patient has already progressed through multiple lines including HIPEC 6

• Gastrointestinal cancer regimens (5-fluorouracil/oxaliplatin or capecitabine/oxaliplatin) represent alternative options for mucinous histology 6
• However, chemotherapy should NOT be initiated until the bowel obstruction is resolved, as it will worsen nausea/vomiting and cannot be absorbed if given orally 1, 2
• Enrollment in a clinical trial should be considered for recurrent/progressive mucinous ovarian cancer if the patient's performance status improves 6

Critical Pitfalls to Avoid

• Do not attempt oral intake or medications until obstruction is relieved, as this will worsen vomiting and risk aspiration 2
• Do not delay nasogastric decompression in patients with persistent vomiting, as this provides immediate symptomatic relief 2
• Do not pursue aggressive surgical debulking in patients with disseminated peritoneal disease and progression on chemotherapy, as this has no proven benefit and high morbidity 1
• Recognize that chemotherapy-induced complications (neutropenic enterocolitis, C. difficile) are possible but less likely given the mechanical obstruction picture 2, 3

Prognosis and Goals of Care Discussion

This clinical scenario—recurrent mucinous ovarian cancer with liver metastases, progression after HIPEC, and now malignant bowel obstruction—carries a very poor prognosis 1, 7

• Early palliative care consultation should be initiated to discuss goals of care, advance directives, and symptom management strategies 1
• Quality of life should be the primary outcome measure when deciding between aggressive intervention versus comfort-focused care 1