Education in Palliative and End-of-life Care - Oncology

1. The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

2. EPEC – Oncology Education in Palliative and End-of-life Care – Oncology Module 3e Symptoms –Bowel Obstruction

3. Bowel obstruction . . . • Definition: mechanical or functional obstruction of the progress of food and fluids through the GI tract

4. . . . Bowel obstruction • Impact: misery from nausea, vomiting and abdominal pain

5. . . . Bowel obstruction Epidemiology • Prevalence • 3 % of all advanced malignancies • 11 – 42 % ovarian cancer • 5 – 24 % colorectal cancer • Prognosis – poor if inoperable • 64 days Krebs HR, Goplerud DR. Am J Obstet Gynecol, 1987. Ripamonti S, et al. J Pain Symptom Manage, 2000.

6. Key points • Pathophysiology • Assessment • Management

7. Pathophysiology . . . • Intraluminal mass • Direct infiltration • External compression • Carcinomatosis • Adhesions • Other

8. . . . Pathophysiology • 2 liters / day orally • 8 liters / day gastric & intestinal secretions • Obstruction causes accumulation • Peristalsis causes distention, pain, nausea, and vomiting

9. Assessment • Symptoms • Continuous distension pain 92 % • Intestinal colic 72 – 76 % • Nausea/vomiting 68 – 100 % • Abdominal radiograph • Dilated loops, air-fluid levels • CT scan • Staging, treatment planning

10. Differentiating small vs. large bowel obstruction

11. Management . . .Medical • Opioids • Morphine – 89 % control • Antiemetics • Prochlorperazine – 13 % control • Steroids • Dexamethasone

12. . . . ManagementSurgical • Surgical evaluation • Standard • Intravenous fluids • Nasogastric tube – intermittent suction • Inoperable • Stent placement • Venting gastrostomy

13. Antisecretory agents

14. Anticholinergics • Antispasmodic and antisecretory • Scopolamine • 10 – 100 mcg / hr SC / IV • 0.1 mg SC q 6 h and titrate • Glycopyrrolate • 0.2 - 0.4 mg SC q 2 – 4 h and titrate Baines M, et al. Lancet, 1985. Davis MP, Furste A. J Pain Symptom Manage, 1999.

15. Somatostatin • 14 amino acid polypeptide • Serum half-life = 3 minutes • Central action • Inhibits release of GH and thyrotropin • Peripheral action • Inhibits glandular secretion • Pancreas, GI tract

16. Octreotide . . . • Polypeptide analog of somatostatin • Serum half-life = 2 hr • Relieves symptoms of obstruction Ripamonti, et al. J Pain Symptom Manage, 2000. Mercadante, et al. Supportive Care Cancer, 2000. Fainsinger RL, et al. J Pain Symptom Manage, 1994.

17. . . . Octreotide • Octreotide 10 mcg/h continuous infusion • Titrate to complete control of N / V • If NG tube in place, clamp when volume diminishes to 100 cc and remove if no N / V • Try convert to intermittent SC • Continue until death

18. . . . Octreotide • Side effects • Mostly none • Dry mouth • Biliary sludge / stones • Studies in other palliative care settings • Subcutaneous administration

19. Conclusions • Considerable symptom control challenge • Surgery for selected cases • Pharmacological management relieves symptoms in many patients • Antisecretory agents represent a significant advance

20. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience