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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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Education in palliative and end of life care oncology

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