What is the management of malignant small bowel obstruction (SBO)?

From the Guidelines

Management of malignant small bowel obstruction should prioritize a multidisciplinary approach, focusing on bowel rest, nasogastric tube decompression, and symptom control with medications such as octreotide, dexamethasone, and antiemetics, with surgical intervention considered on a case-by-case basis based on the patient's clinical status and prognosis. When considering the management of malignant small bowel obstruction, it is essential to weigh the benefits and risks of different treatment options, including medical and surgical interventions. The goal of treatment should be to maximize quality of life while minimizing treatment-related complications. Some key considerations in the management of malignant small bowel obstruction include:

• The use of octreotide, which has been shown to be effective in reducing gastrointestinal secretions and alleviating symptoms 1
• The role of dexamethasone in reducing peritumoral edema and relieving symptoms 1
• The importance of antiemetics, such as ondansetron or haloperidol, in managing nausea and vomiting 1
• The potential benefits and risks of surgical intervention, including bowel resection, bypass procedures, or stoma creation, which should be considered on a case-by-case basis based on the patient's clinical status and prognosis 1
• The use of self-expanding metallic stents as a palliative option for patients with poor surgical candidacy or extensive disease 1
• The consideration of a venting gastrostomy tube in end-stage disease where the goal is comfort 1 It is crucial to note that the decision between conservative versus invasive management depends on the patient's overall condition, extent of disease, previous treatments, nutritional status, and personal preferences, with the ultimate goal being to maximize quality of life while minimizing treatment-related complications 1.

From the Research

Management of Malignant Small Bowel Obstruction

• The management of malignant small bowel obstruction (MBO) can be challenging, and treatment options consist of a wide range of surgical and nonsurgical interventions 2.
• Medical therapy may provide rapid improvement in symptoms associated with MBO, including nausea, pain, and time to resumption of oral intake 3.
• The combination of dexamethasone, octreotide, and metoclopramide ("triple therapy") may be used to manage symptoms in patients with inoperable MBO, although there is no statistically significant difference in rates of de-obstruction compared to patients who receive no drug therapy 4.

Pharmacologic Management

• Octreotide is effective in reducing gastrointestinal secretions and colic, and thereby reduces nausea and vomiting caused by MBO 5.
• Scopolamine butylbromide is inferior to octreotide in the doses used in the comparison study 5.
• Olanzapine or metoclopramide may be effective in reducing nausea and vomiting secondary to partial bowel obstructions, and the panel suggests using either drug 5.
• Haloperidol has been used by convention as an antiemetic, but has not been subjected to a randomized comparison 5.

Treatment Approach

• The optimal approach to managing MBO is often not clear, and outcomes are variable no matter the strategy 2.
• Greater research is needed to assist decision-making for clinicians treating patients with MBO 2.
• The MASCC guideline update recommends octreotide in non-operable MBO, and suggests that additional studies are needed to clarify benefits of other medications 5.