Bowel Obstruction in Advanced cancer

Transcription

1 Bowel Obstruction in Advanced cancer Practical management Dr. Robin Love March 2015

2 Objectives Understand the causes of obstruction in cancer Be able to discuss goals of care with patients and family Plan various treatments depending on the goals of care and clinical context 2

3 Outline Case Epidemiology Pathophysiology Clinical Diagnosis Treatment Surgical Medical 3

4 Case 1 Norman 78 year old man, lives on Gabriola Island Cecal carcinoma resected 3 years later: recurrent obstructive Sx several admissions Admitted via ER with mild nausea, moderate abdominal pain, no flatus or stool for days 4

5 Epidemiology: Bowel Obstruction Occurs in 3-10% of all cancer-related terminally ill Most common Ovary 25% (10-42%) Colorectal 15% (5-25%) Less common Pancreas, gynecological, prostate, gastric, bladder 5

6 Gastrointestinal Tract Anatomy Typical Locations of Obstructions Esophageal Biliary Gastro duodenal Small Bowel Colorectal 6

7 Pathophysiology Small bowel (61%) or large bowel (33%) or both (20%) Single or multiple sites Partial or complete Malignant or benign causes Final common path: occlusion of the lumen of the bowel 7

8 Etiology: Related to the Cancer Tumour Mass Single or multiple Intraluminal Intramural Extraluminal Separate from the bowel Tumour invasion of mesentery, muscle or nerve plexus Volvulus/torsion Around tumour Around adhesions Around fistula Massive ascites Paraneoplastic syndrome Often Multifactorial 8

9 Etiology: Related to the Cancer treatment Adhesions Postoperative Malignant Post radiation Radiation enteritis Chemotherapy (ileus) 9

10 Etiology: unrelated or indirectly related to the cancer Constipation / Impaction Ileus Infection Drugs Diabetes Peritonitis Bowel infarction Other unrelated Hernia Diverticulitis Pancreatitis Inflammatory bowel disease Adhesions a significant number are benign causes 10

11 Diagnosis of Bowel Obstruction History Physical examination Imaging of the abdomen Plain films CT Contrast studies 11

12 Clinical: History and symptoms Rarely an acute event- usually develops slowly and often is partial Cramps, nausea, vomiting, abdominal distension Gradually become more severe and continuous 12

13 symptoms and signs Constant abdominal pain in 90% (related to the underlying tumor?) Intermittent colic in 75% Vomiting early and in large amounts in proximal (gastric,duodenal and small bowel) and later in large bowel 13

14 Radiology Plain radiographs useful (and easy) CT very useful to assess (new gold standard) Global extent of disease Staging including complications (ischemic bowel) Assist in choice of surgical treatment *if appropriate and patient is well enough 14

15 General approach. As with any problem in palliative care, we must consider whether our inquiries or investigations will change the management of the patient. 15

16 General approach This is rarely an emergency - take time to : Monitor Investigate appropriately Provide symptom control Remember the overall context (stage of disease etc) 16

17 Care the right thing for this particular patient 17

18 Principles of Care Primary areas of symptom control Pain Nausea Vomiting Thirst Secondary areas of support Nutrition, including hydration Education Patient & family support 18

19 Principles of Care Management is highly patient specific Stage of illness Goals and choices of patient Type of obstruction Performance status Prognosis 19

20 Active Treatment Approaches Active surgical Resection By-pass Venting Colostomy etc Gastrostomy Active medical Comfort Care only 20

21 Norman Surgery Day 2 Diffuse carcinomatosis Omental caking Not resectable, bypass not possible Moderate symptoms ( N, pain) 21

22 Active Surgical Not routine in our patient population, but should be considered in selected patients with mechanical obstruction single site of obstruction reasonable performance status and prognosis Excellent clinical judgment is necessary. Is it technically feasible and will the patient benefit? 22

23 Surgical 25-35% of obstructions due to benign factors or unrelated second primary Some individuals symptom free for long period after palliative surgery Operative mortality 10-20%, similar morbidity and complication rate Median post-op. survival months Surgical studies rarely look at Quality of Life 23

24 Poor prognostic factors Prior failed surgery Widespread carcinomatosis Gross Ascites Multiple levels of obstruction Multiple liver metastases Cachexia Elderly Previous radiotherapy to abdomen 24

25 Other Surgical / Interventional Options: decompression techniques Cecostomy etc Percutaneous Gastrostomy PEG Venting Gastrostomy Endoscopic Radiologic Very effective for persistent nausea and vomiting (up to 92%) 25

26 Other Surgical / Interventional Options Metal stents placed under endoscopic or fluoroscopic guidance Flexible and self expanding Expensive, not always available in Canada Overall cost effective Technical success rate 90% (??) Esophageal, gastro-duodenal, biliary, colorectal 26

27 Stent partially deployed 27

28 Norman Recurrence of distension, vomiting Still on dexamethasone and haldol Increase steroids, move to PCU Temporary NG tube (his choice) 28

29 Medical Treatment of Obstruction: symptom relief and possible reversal NG tube and rehydration: 30-50% will reverse (but usually takes several days) Temporary patients choice Medications: Analgesics Motility agents Antiemetics Antisecretory 29

30 Medical Treatment of Obstruction: Analgesics Usual opioids by parenteral route (s.c., transdermal etc) anticholinergics for colicky pain Scopolamine hydrobromide mg sc q2-4h 30

31 Medical Treatment of Obstruction: Motility agents Metoclopramide: 10-40mg sc qid (Domperidone po only) The classic approach is not to use it in complete obstruction because it might cause increased cramps. No evidence for this How do you really know complete vs. partial vs. ileus? My approach: try it for all and see if increased cramps 31

32 Medical Treatment of Obstruction: antinauseants Metoclopramide sc qid Haloperidol mg sc/po/iv q12h and prn 32

33 Medical treatment of obstruction: corticosteroids Dexamethasone 10-20mg daily for trial of five days (mechanism unknown- helps the nausea, may relieve obstruction by reducing bowel wall edema) Reduce peritumoral edema Antisecretory : reduce water and salt secretion 33

34 Medical Treatment of Obstruction: Antisecretory Octreotide mcg sc q 8h Reduce GI secretions Slow intestinal motility Increase absorption of water and electrolytes Good clinical evidence to support use in malignant bowel obstruction (RCT s total vomiting control in 92%) Use it early in obstruction Rapid and effective 34

35 Grenoble Study JPSM June 2006 Stage 1: NG, hydrate, haldol, scopolamine, steroids, analgesics Stage 2 (after 5 days): still obstructed? Stop steroids and scopol., and start octreotide Stage 3 : gastrostomy Sx control in 90% without ng tube 35

36 Comfort : for all patients Pain Colic Continuous pain Nausea & vomiting Mouth Care and Thirst Nutrition Emotional support 36

37 Comfort Care Only Very advanced stage of disease Multiple medical problems Desire to stay at home In complete obstruction the average survival is days **(often misinformed about a quick demise) 37

38 Norman Start octreotide 200 tid sc Metoclopramide 20 sc qid Dexamethasone 8 mg sc daily Settled well, bowels remained open Discharged home day 14 Managed well at home (Gabriola Island) with sc meds, low residue diet. Died 1 month later at home 38

39 Overall approach 1. If urgent (severe Sx) ng suction 2. Start optimal medical management in almost all patients unless really end stage 3. Metoclopramide plus octreotide plus dexamethasone (+/- haldol) (can combine in one CSCI) is easy and very effective 4. Consider hydration options (may reduce nausea) 5. Consider other options/investigations 6. Acceptable level of control may be vomiting 1-2 times/day ( as long as nausea is well controlled) 39

40 40

41 References 1. Ripamonti et al, Clinical practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer (2001) 9: Ripamonti, C and E. Bruera Palliative Management of Malignant Bowel Obstruction Int J Gynecol Cancer 2002, 12: Mercadante,S et al. Aggressive Pharmacalogical Treatment for Reversing Malignant Bowel Obstruction J of Pain and Symptom Mgt. 2004, 28: No.4, Mercadante,S et al Comparison of octreotide and hyoscine butylbromide in controlling GI symptoms due to malignant inoperable bowel obstruction. Support Care Cancer (2000) 8: Dean,Andrew The Palliative effects of Octreotide in Cancer patients Chemotherapy 2001;47 Suppl 2:

42 References 6.Mystakidou,K et al. Comparison of Octreotide Administration vs Conservative Treatment in the Management of Inoperable Bowel Obstruction in Patients with Far Advanced Cancer: a randomized, Double-blind, Controlled Clinical Trial. Anticancer Research : Brooksbank, MA et al. Palliative Venting Gastrostomy in Malignant Intestinal Obstruction. Palliative Medicine 2002; 16: Krouse,RS et al. When the Sun can set on Unoperated Bowel Obstruction: Management of Malignant Bowel Obstruction J Am Coll Surg 2002, 195: No Keymling,M Colorectal Stenting Endoscopy 2003; 35: Baron, TH. Expandable Metal Stents for the Treatmentof Cancerous Obstruction of the GI Tract. NEJM 2001,344:22;

43 References 11. Pothuri, b et al. PEG tube placement in patients with MBO due to ovarian carcinoma. Gynecologic Oncology 96 (2005) Laval,G. et al. Protocol for the Treatment of Malignant Bowel Obstruction: A prospective study of 80 cases at Grenoble University Hospital Center. JPSM Vol 31 NO 6. June 2006 p Mangili, G. et al. Palliative Care for intestinal obstruction in recurrent ovarian cancer: a multivariate analysis. Int Journal of Gynecologic Cancer Vol 15 issue 5 p Mercadante,S et al. Medical Treatment for Inoperable Malignant Bowel Obstruction: a Qualitative Systematic Review. JPSM Vol 33 No. Feb 2007 p