The Management of Inoperable Gastrointestinal Obstruction in Terminal Cancer Patients

Abstract

The aim of the study was to assess vomit and pain control in terminal cancer patients with inoperable gastrointestinal obstruction, using a pharmacologic symptomatic treatment which prevents recourse to nasogastric tube placement and intravenous hydration, in hospital and home care settings. Twenty-two symptomatic patients, who were judged as inoperable, were treated with a pharmacologic association of morphine hydrochloride and scopolamine butylbromide as analgesics and haloperidol as an antiemetic. The drugs were administered by continuous subcutaneous infusion via a syringe driver or intravenously only when a central venous catheter had been inserted previously. Daily recordings included assessment of pain, number of vomiting episodes, dry mouth, drowsiness, and thirst sensation. Data were examined before starting the treatment (T0), 2 days after (T2) and 2 days before death (T-2). They showed that there was a significant decrease in the pain score (p less than 0.001) on T2 and a further decrease on T-2 (p less than 0.05). Vomiting was controlled in all patients, with the exception of three patients with upper abdomen obstruction who required nasogastric tube placement. Dry mouth showed an upward trend throughout the observation period (p less than 0.05) but was successfully treated by administering liquids by mouth or ice-cubes to suck. Drowsiness too presented an upward trend from T0 to T-2 (p less than 0.001). Only one patient out of 16 who reported to be thirsty required intravenous hydration. We believe that in terminal cancer patients, vomit and pain resulting from inoperable intestinal obstruction, with the exception of obstruction of the upper abdomen, can be controlled through administration of analgesic and antiemetic drugs, in the hospital and at home, without recourse to nasogastric tube placement or intravenous hydration.

Systematic review of the efficacy of antiemetics in the treatment of nausea in patients with far-advanced cancer

“…The current mechanistic approach to the management of nausea in advanced cancer which is based on the neuropharmacology of the putative "emetic pathway" should be the basis for choosing first-line antiemetic drugs (grade of recommendation: B [8,10] [8,9,17,37]). 5.…”

“…A second electronic search for studies specifically about nausea in inoperable bowel obstruction revealed 77 publications of which 12 (16%) appeared relevant. Of these 12, 5 met the inclusion criteria consisting of one meta-analysis [33], the two RCT considered in the metaanalysis [34,35] and two case series [36,37]. Hand searching identified another case series missed by the electronic search [38].…”

Parenteral versus enteral nutrition in cancer patients: indications and practice

“…Even intravenous hydration should be limited to meeting specific goals rather than correcting inadequate fluid intake. Differences in the mean survival from the appearance of bowel obstruction have been reported (ranging from 17 days to 3.7 months) in advanced cancer patients treated by medical management [5,46,48,70], depending on the different settings of the study and methodology of diagnosis. Clinical experience with the management of home PN in 13 cancer patients with bowel obstruction has recently been reported [45].…”

Nutrition in cancer patients

“…Unfortunately poor candidates for PN are evident retrospectively. Different mean survival times from the appearance of the bowel obstruction have been reported (ranging from 17 days to 3.7 months) in advanced cancer patients treated by medical management [6,24,43,64]. This wide variation may be due to the different settings of the study, the different combinations of drugs used, criteria of admission and method of diagnosis, as well as the patient population.…”