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

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slide1

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.

module 3e symptoms bowel obstruction

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

Module 3e

Symptoms –Bowel Obstruction

bowel obstruction
Bowel obstruction . . .
  • Definition: mechanical or functional obstruction of the progress of food and fluids through the GI tract
bowel obstruction1
. . . Bowel obstruction
  • Impact: misery from nausea, vomiting and abdominal pain
bowel obstruction2
. . . 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.

key points
Key points
  • Pathophysiology
  • Assessment
  • Management
pathophysiology
Pathophysiology . . .
  • Intraluminal mass
  • Direct infiltration
  • External compression
  • Carcinomatosis
  • Adhesions
  • Other
pathophysiology1
. . . Pathophysiology
  • 2 liters / day orally
  • 8 liters / day gastric & intestinal secretions
  • Obstruction causes accumulation
  • Peristalsis causes distention, pain, nausea, and vomiting
assessment
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
management medical
Management . . .Medical
  • Opioids
    • Morphine – 89 % control
  • Antiemetics
    • Prochlorperazine – 13 % control
  • Steroids
    • Dexamethasone
management surgical
. . . ManagementSurgical
  • Surgical evaluation
  • Standard
    • Intravenous fluids
    • Nasogastric tube – intermittent suction
  • Inoperable
    • Stent placement
    • Venting gastrostomy
anticholinergics
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.

somatostatin
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
octreotide
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.

octreotide1
. . . 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
octreotide2
. . . Octreotide
  • Side effects
    • Mostly none
    • Dry mouth
    • Biliary sludge / stones
  • Studies in other palliative care settings
  • Subcutaneous administration
conclusions
Conclusions
  • Considerable symptom control challenge
  • Surgery for selected cases
  • Pharmacological management relieves symptoms in many patients
  • Antisecretory agents represent a significant advance
summary

Summary

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

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