Pharmacologic Management of Malignant Bowel Obstruction: When Surgery Is Not an Option
Malignant bowel obstruction (MBO) complicates 3%-15% of cancers and often necessitates inpatient admission. Hospitalists are increasingly involved in treating patients with MBO and coordinating their care across multiple subspecialties. Direct resolution of the obstruction via surgical or interventional means is always preferable. When such options are not possible, pharmacological treatments are the mainstay of therapy. Medications such as somatostatin analogs, steroids, H2-blockers, and other modalities can be effective in palliation and possible resolution of obstruction. Awareness of these pharmacologic therapies can aid hospitalists in treating patients who are confronted with this devastating condition.
© 2019 Society of Hospital Medicine
SUBSEQUENT SUPPORTIVE CARE
While initial management of MBO often requires placement of an NG tube, prolonged placement can increase the risk for erosions, aspiration, and sinus infections. Removal of the NG tube is most successful when secretions are minimal, but this may not happen unless the obstruction resolves. Some patients may elect to keep an NG tube if symptoms cannot be otherwise controlled by medications.
A venting gastrostomy tube can be considered as an alternative to prolonged NG tube placement. The tube may help alleviate distressing symptoms and can enhance the quality of life of patients by allowing the sensation of oral intake, though it will not allow for absorption of nutrients.40 Although a low risk procedure, patients may be too frail to undergo the procedure and may have postprocedure pain and complications. Anatomic abnormalities such as overlying bowel may also prevent the noninvasive percutaneous approach.
In patients with unresolved obstruction, oral intake should be reinitiated with caution with the patient’s wishes taken into account at all times. Some patients may prioritize the comfort derived from eating small amounts over any associated risks of increased nausea and vomiting.
Parenteral nutrition should be avoided in those with inoperable MBO in the advanced stages. The risks of infection, refeeding syndrome, and the discomfort of an intravenous line and intermittent testing may outweigh any benefits given the overall prognosis.41,42
CONCLUSION
Hospitalists are often involved in the initial care of patients with advanced malignancy who present with MBO. When interventions or surgeries to directly alleviate the obstruction are not possible, pharmacologic options are essential in managing burdensome symptoms and improving quality of life. Early Palliative Care referral can also assist with symptom management, emotional support, clarification of goals of care, and transition to the outpatient setting. While patients with inoperable MBO have a poor prognosis, hospitalists can play a vital role in alleviation of suffering in this devastating complication of advanced cancer.
Disclosures
The authors have nothing to disclose.
