Becky Owen 22/2/12
Jan 03, 2016
Becky Owen22/2/12
OverviewCase StudyClinical PresentationManagementCase Study UpdateSummaryQuestions
Mrs JL55 yr Ovarian CarcinomaDiagnosed 20104 cycles palliative chemotherapyStable disease until June 2011Increased abdominal distension, nausea,
vomiting, weight lossCT – disease progression, subacute small
bowel obstructionWhat would you do next?
Bowel Obstruction in Palliative CareDue to functional or mechanical obstruction
of bowel lumen and/or peristaltic failureCan be partial or completeCan occur at any level
Oesophageal Gastric outlet & proximal small bowel Distal small bowel Large bowel
CausesThe cancer itselfPast treatment
Adhesions, postradiation ischaemic fibrosis
Drugs Opioids, antimuscarinics
Debility Faecal impaction
Unrelated benign condition Strangulated hernia
Clinical PictureAbdominal painAbdominal distensionVomitingNauseaIntestinal colicVariable bowel habit
Bowel obstruction – Pathophysiology Partial or complete bowel obstruction Reduction or stop movement Increased bowel contractions Intestinal content Increased bowel distension Increased luminal content Increased gut epithelial surface area Increased bowel secretions (H2O,
NaCl) Damage epithelium Oedema and hyperaemia Production noiceceptive mediators
Continuous pain
Colicky pain Nausea and vomiting
Management - SurgeryConsider if;
Single discrete organic obstruction i.e. adhesions, isolated neoplasm
Good performance status Patient willing to undergo surgery
Contra-indications; Previous laparotomy findings preclude prospect of
successful intervention Diffuse intra-abdominal carcinomatosis Massive ascites (re-accumulates rapidly after
paracentesis)
Management - MedicalFocus on symptomatic reliefAnti-emeticsOpioidsReview laxativesCorticosteroidsAnti-secretory drugsOctreotide
Anti-emeticsPatient without colic + passing flatus –
Prokinetic first drug of choicePatient with colic – antisecretory +
antispasmodic drug (Buscopan)
To be aware of anti-cholinergic effect of some drugs – can inhibit gut motility
OctreotideSynthetic analogue of somatostatin with
longer duration of actionInhibitory hormone – found throughout the
bodyInhibits release of Growth Hormone, TSH,
Prolactin, ACTH in hypothalamusInhibits peptides of Gastro-enteropancreatic
system
Octreotide and bowel obstruction<50% patients – respond to typical starting
dose of 300 micrograms/24hr75-90% respond to 600-800 micrograms/24hrComparisons with buscopan – Octreotide
more effective and rapid relief of nausea, vomiting and reduced NG output
NB after 4-6 days overall symptom comparison is similar
Lanreotide – alternative sandostatin analogue available in depot formations
Octreotide and ascitesCan suppress diuretic induced activation of
renin-aldosterone-angiotensin systemMay interfere with ascitic fluid formation by
reducing splanchnic blood flow or as a result of a direct tumour anti-secretory effect
May also help improve efficacy of diuretics in cirrhosis
Undesirable effects from OctreotideBolus SC injection painfulDry mouthFlatulenceNauseaAbdominal painDiarrhoeaImpaired glucose toleranceGallstones
CautionsInsulinomaType 1 diabetesCirrhosisRenal FailureAvoid abrupt withdrawal of short-acting
octreotide after long-term treatmentMonitor thyroid function
Octreotide Drug Interactions Octreotide markedly reduces plasma
ciclosporin concentrations and inadequate immunosuppression may result.
Octreotide CSCI Compatability2 drug compatibility data for octreotide and;
Morphine sulphate, metoclopramide, hyoscine butylbromide, diamorphine, alfentanil (in WFI)
Check PCF4 / palliativedrugs.comConflicting observational reports with
levomepromazine
Depot Formulation of OctreotideSandotatin – 10-30mg every 4/52
Relative bio-availability of 60% compared to SC Deep IM injection
Used in patients with symptoms already controlled with octreotide therapy
Lanreotide – 60mg every 4/52‘Somatuline Autogel’ preparation can be given
SC
Management - InterventionsDependant on level and extent of obstructionStentsVenting gastrostomy
Mrs JL Cont.Not suitable for surgery/interventionNo colic – initially trialled metoclopramide
CSCINot effective – converted to levomepromazine
CSCI (12.5mg over 24 hr)Ongoing large volume vomits – octreotide
added to CSCI (1 mg over 24 hr)Helped stabilise symptoms and allow for
period of 6/52 at home with family
In SummaryOne of the most challenging problems in
palliative careTo focus on improving quality of lifeIf focal obstruction – consider possibility /
suitability of interventionRarely need IV fluids or NG tube to relieve
symptoms
Any Questions?
ReferencesPalliative Care Formulary 4th Edition; R Twycross, A
Wilcock.Symptom Management in advanced cancer 3rd Edition; R
Twycross, A Wilcock.