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Handbook of Palliative Medicine

Bowel Obstruction

Bowel obstruction may occur due to the disease itself or complex metastatic disease within the peritoneum. It can be caused by mechanical obstruction (narrowing of the intestinal lumen from either internal or external masses) or a reduction in motility or a combination of the two. This makes it a complex condition with multiple symptoms which can be difficult to control. Early referral to specialist palliative care is therefore recommended, especially in advanced disease.

Symptoms

  • Vomiting - often without much nausea
  • Constipation although small volumes of stool or flatus may continue to be passed
  • Abdominal pain either colicky or generalised
  • Abdominal swelling
  • Reduction in bowel sounds

Causes

  • Primary tumours - colonic or ovarian most commonly
  • Peritoneal metastases
  • Post operative adhesions or radiation fibrosis
  • Bowel wall malignant infiltration disrupting peristalsis
  • Autonomic nerve plexus damage but tumour infiltration

Non-drug treatment

  • Surgical interventions - resection or stenting
  • Nasogastric tube insertion to decompress stomach and drain volume
  • Venting PEG insertion
  • Hydration with IV fluids 
  • Consider nutritional factors

Drug treatments

  • Constant abdominal pain may respond to opioids (syringe driver likely required as vomiting and obstruction will reduce or prevent oral absorption)
  • Nausea without colic may improve with prokinetic antiemetic
  • If colicky pain: stop bowel stimulant medications such as senna and prokinetics
  • Anticholinergic drugs (hyoscine butylbromide) may reduce colic and improve nausea by reducing gastric secretions
  • Second line antiemetic with or without colic is levomepromazine
  • If vomiting persists despite 2 or more antiemetics plus hyoscine butylbromide other anti-secretories may be considered (octreotide, granisetron)
  • In partial or intermittent obstruction softening laxatives may be beneficial
  • Chemotherapy and radiotherapy may be considered to shrink tumour bulk and relieve obstruction
  • If too unwell or chemoradiotherapy not planned dexamethasone 8-16 mg daily may reduce oedema at tumour sites and alleviate obstruction