From the Guidelines
Management of small bowel obstruction in palliative patients with advanced metastatic cancer should prioritize a conservative approach focusing on symptom control, with surgical intervention considered only in highly selected cases. The initial management should include bowel rest, nasogastric tube decompression, intravenous fluids, and appropriate pain management with opioids such as morphine or hydromorphone 1. Anti-emetics and medications to reduce gastrointestinal secretions, such as octreotide, are also crucial in managing symptoms 1. Key considerations in the management of these patients include:
- The use of octreotide to reduce gastrointestinal secretions and associated symptoms, as supported by randomized controlled trials (RCTs) comparing octreotide with hyoscine 1
- The potential benefits of decompression percutaneous endoscopic gastrostomy tube placement in selected patients, with high rates of symptom resolution reported in case series 1
- The importance of multidisciplinary input and alignment with the patient's goals of care, focusing on comfort and quality of life rather than prolonging survival at the cost of increased suffering 1
- The need for careful patient selection for surgical intervention, taking into account factors such as performance status, disease burden, and potential for meaningful recovery 1.
From the Research
Management of Small Bowel Obstruction in Palliative Patients
- The management of small bowel obstruction in palliative patients with advanced metastatic cancer is a complex issue, with both surgical and nonsurgical options available 2.
- The goal of treatment is to restore bowel patency and palliate symptoms, with individualized treatment plans recommended due to the lack of difference in overall or obstruction-free survival based on management 2.
Medical Therapy
- Medical therapy with octreotide, dexamethasone, and metoclopramide has been shown to improve symptoms and bowel function in patients with malignant bowel obstruction and dysfunction 3.
- Octreotide is effective in reducing gastrointestinal secretions and colic, and is recommended as the drug of choice in managing malignant bowel obstruction 4.
- Scopolamine butylbromide is inferior to octreotide, but may still be used in some cases 5, 4.
- Antiemetics such as metoclopramide and olanzapine may be effective in reducing nausea and vomiting, but more randomized trials are needed to clarify their benefits 4.
Symptom Control
- Symptom control is a key aspect of managing small bowel obstruction in palliative patients, with medical measures such as analgesics, anti-secretory drugs, and anti-emetics used alone or in combination to relieve symptoms 6.
- Parenteral hydration may be indicated to correct nausea, and regular mouth care is recommended for dry mouth 6.
- A venting gastrostomy may be considered if drugs fail to reduce vomiting to an acceptable level 6.
Treatment Recommendations
- The Multinational Association of Supportive Care in Cancer (MASCC) recommends octreotide as the drug of choice in managing malignant bowel obstruction, with additional studies needed to clarify the benefits of other treatments 4.
- A collaborative approach involving both surgeons and physicians can offer patients an individualized and appropriate symptom management plan 6.