The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPECTM-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 secretion • 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 to100 micrograms per hour SC/IV • 0.1 mg SC every 6 hours and titrate • Glycopyrrolate • 0.2-0.4 mg SC every 2 to 4 hours 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 growth hormone and thyrotropin • Peripheral action • Inhibits glandular secretion in Pancreas, GI tract

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

17. . . . Octreotide treatment • Octreotide 10 micrograms per hour via continuous infusion • Titrate to complete control of nausea and vomiting • If NG tube in place, clamp when volume diminishes to 100 cc and remove if no nausea and vomiting • Try converting to intermittent SC injection • Continue until death

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

19. Conclusions Bowel obstruction management: • Considerable symptom control challenge • Surgery for selected cases • Pharmacologic 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.