Pharmacologic Management of Malignant Bowel Obstruction: When Surgery Is Not an Option

Abstract

Malignant bowel obstruction (MBO) complicates 3%-15% of cancers and often necessitates inpatient admission. Hospitalists are increasingly involved in treating patients with MBO and coordinating their care across multiple subspecialties. Direct resolution of the obstruction via surgical or interventional means is always preferable. When such options are not possible, pharmacological treatments are the mainstay of therapy. Medications such as somatostatin analogs, steroids, H2-blockers, and other modalities can be effective in palliation and possible resolution of obstruction. Awareness of these pharmacologic therapies can aid hospitalists in treating patients who are confronted with this devastating condition.

Epidural pain management in advanced gastric cancer with inoperable malignant bowel obstruction

“…Presented is a case of MBO secondary to adhesions or metastasis, worsened by a component of opioid-induced ileus. Current literature describes management of MBO to follow nearly identical pathways as other bowel obstructions; immediate NPO and NGT decompression, fluid resuscitation, pain management (opioids, especially fentanyl), assessment of mechanical versus functional mechanism, antiemetic agents (haloperidol, ondansetron), assessment of operability, corticosteroids to decrease bowel wall oedema, antisecretory agents (octreotide), pro-motility agents (metoclopramide) 1 2 4–6. Unfortunately, in cases such as the one described here, MBOs can be inoperable, unresponsive to medical management and cause pain that cannot be overcome with traditional opioid analgesia.…”

Gastro-Intestinal Symptoms in Palliative Care Patients

“…GI obstructions occur in up to 15% of cancer patients and are more commonly seen in colon cancers (10-29% of colon cancer patients) and ovarian cancers (20-50%) [2,21,22]. Other cancers that cause obstructions are stomach, pancreas, bladder, uterine, melanoma, lung and breast cancers [2,18,23,24]. They often occur in the context of very advanced illness, and as such require a palliative approach.…”

“…They often occur in the context of very advanced illness, and as such require a palliative approach. The literature quotes prognoses varying from a few weeks to many months, the latter patients having received disease-modifying therapy and interventions [22,23,25]. Symptoms of GI obstruction may have been waxing and waning for weeks due to subocclusion prior to presenting with a complete obstruction [10,23,26,27].…”

Inoperable Bowel Obstruction in Ovarian Cancer: Prevalence, Impact and Management Challenges

“…Corticosteroids can relieve acute symptoms of MBO, likely due to an anti-inflammatory and anti-secretory effect, which decrease intestinal wall edema and promote salt and water absorption. 78 …”

“…29 Corticosteroids can relieve acute symptoms of MBO, likely due to an anti-inflammatory and anti-secretory effect, which decrease intestinal wall edema and promote salt and water absorption. 78 In a small clinical trial, 35 patients with MBO mostly due to ovarian cancer were randomized to dexamethasone 4 mg every 6 hours or placebo for 5 days; all patients received standardized medical management with fluids, analgesia antiemetics and laxatives. In the dexamethasone group, 62% of patients showed resolution of obstruction at day 5, compared to 57% in the placebo group; numbers were too small to allow a formal statistical analysis.…”