Annals of Oncology 4: 15-21, 1993. © 1993 Kluwer Academic Publishers. Printed in the Netherlands. Special article Management of bowel obstruction in advanced and terminal cancer patients C. Ripamonti, 1 F. De Conno, 1 V. Ventafridda, 1 B. Rossi 2 & M. J. Baines 3 'Pain Therapy and Palliative Care Division, National Cancer Institute, 2 Surgical Division, Desio Hospital, Milan, Italy; 3 Sl. Christopher's Hospice, Sydcnham, London, U.K. Summary Background: Bowel obstruction is a common and distressing outcome in patients with abdominal or pelvic cancer. Patients and methods: Patients may develop bowel obstruction at any time in their clinical history, with an incidence ranging from 5.5% to 42% in ovarian carcinoma and from 10% to 28.4% in colorectal cancer. The causes of the obstruction may be benign postoperative adhesions, a focal malignant or benign deposit, relapse or diffuse carcinomatosis. The symptoms which are almost always present are intestinal colic (reported in 72%-76% of patients), abdominal pain due to distension, hepatomegaly or tumor masses (in 92% of patients) and vomiting (68%-10O%) of cases. Conclusion: While surgery must remain the primary treatment for malignant obstruction, it is now recognised that there is a group of patients with advanced disease or poor general condition who are unfit for surgery and require alternative management to relieve distressing symptoms. A number of treatment options are now available for the patient with advanced cancer who develops intestinal obstruction. In this review of the literature, the indications for surgery will be examined, the use of nasogastric tube and percutaneous gastrostomy evaluated and the place of drugs for symptom control described. Key words: bowel obstruction, advanced and terminal can- cer patients Introduction Bowel obstruction is a common clinical complication in patients with abdominal or pelvic cancers such as colonic, ovarian and gastric. Moreover, extra-abdomi- nal cancers, such as lung, breast, and melanoma can spread to the abdomen, causing secondary bowel ob- struction. Bowel obstruction can be caused by intesti- nal muscle paralysis (paralytic ileus) or occlusion of the lumen (mechanical ileus), or both, leading to the block- ing of faeces and gas through the intestinal passage. The obstruction can be partial or complete, single or multiple, due to benign causes (adhesions, post-irradia- tion bowel damage, inflammatory bowel disease, her- nia) or malignant causes (previous or new tumor, recur- rence, carcinomatosis). Pseudo-obstruction is caused by tumor infiltration of the mesentery or bowel muscle or, rarely, involve- ment of the coeliac plexus. It may also occur as a paraneoplastic neuropathy in patients with lung cancer [1,2]. Incidence Cancer patients may develop bowel obstruction at any time in their clinical history, more quickly at the ad- vanced stage [3]. The duration between initial tumor diagnosis and development of bowel obstruction is sig- nificantly longer between intra-abdominal (mean 22.4 months) and extra-abdominal (mean 57.5 months) tu- mors [4]. In patients with ovarian cancer, the incidence of obstruction ranges from 5.5% to 42% and from 10% to 28.4% in patients with colorectal malignancies [3, 5-13]. Gastrointestinal obstruction occurs in about 3% of advanced cancer patients who are receiveing hospice treatment [5]. Symptoms The diagnosis of bowel obstruction is based on clinical findings and radiological examination [14-16]. In advanced and terminal cancer patients, the onset of obstruction is rarely an acute event. Symptoms gradually worsen until they become continuous, and their presence and intensity depends on the level in- volved. Vomiting develops early and in large amounts in gastric, duodenal and small bowel obstruction, and develops later in large bowel obstruction. The inci- dence of vomiting is 68% and 100% according to two different studies [5, 17]. Vomiting can be intermittent or continuous. Pain is due to distension and abdominal colic in small and large bowel obstruction. It can also be due to the tumor masses present. The incidence of intestinal colic is about 75% [5, 17], while continuous abdominal pain is present in more than 90% of the pa- tients [5, 17]. In cases of complete obstruction, consti- pation is present for faeces and flatus. Sometimes over- flow diarrhoea results from bacterial liquefaction of the
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