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Having ruled out constipation as a cause of symptoms, there are three possible approaches to managing a patient with malignant GI obstruction:
The medical approach to managing GI obstruction differs according to whether the obstruction is partial/sub-acute, functional or complete. The presence or absence of colic is also significant.
If the obstruction is thought to be partial, sub-acute or functional and in the absence of colic, consider a pro-kinetic approach. The obstruction may resolve.
Metoclopramide 30 - 60mg/24 hours via continuous subcutaneous infusion (CSCI). Sometimes higher doses are required.
Monitor for colic or signs of worsening obstruction. Metoclopramide should be discontinued if these symptoms occur
A cautious trial of faecal softener laxatives e.g. sodium docusate 100mg 8 hourly
Avoid lactulose as it may exacerbate bloating and colic
As a general principle, avoid stimulant laxatives
Corticosteroids may reduce bowel wall oedema
The aim is to optimise control of symptoms such as nausea, vomiting, colic and other abdominal pain. For some patients, vomiting may continue despite optimising antiemetic regimes.
Patients may wish to take small amounts of food and drink, if the nausea is well controlled. Occasional vomits may be an acceptable price to pay for the enjoyment of food; patient's choice and an individualised plan of management are paramount.
If clinically appropriate, morphine is the first line SC opioid: administer via continuous subcutaneous infusion (CSCI)
Hyoscine butylbromide: 60 - 120mg/24 hours via CSCI or
Glycopyrronium: 0.4 – 1.2mg/24 hours via CSCI
Haloperidol and/or cyclizine
Levomepromazine: 6.25mg - 25 mg/24 hours via CSCI as a (broad spectrum antiemetic)
Hyoscine butylbromide and glycopyrronium have antisecretory as well as antispasmodic effects.
Octreotide, a synthetic analogue of somatostatin, has hormone inhibitory, antisecretory and absorptive effects. It may reduce the volume of vomits in complete bowel obstruction. It should be considered as a 2nd line treatment when the above measures have failed to give adequate symptom control.
Drainage gastrostomy or nasogastric tubes may be considered, in discussion with the patient, to reduce symptom distress if all else fails.
If thirst is a severe and distressing symptom, consider a trial of intravenous (IV) or subcutaneous (SC) fluids.
Giving IV or SC fluids may increase the volume of vomits and risk increasing symptoms.
Most patients will be comfortable with good oral care including measures such as sucking ice cubes.
Good communication with patients and their family is recommended to clarify the risks and benefits of parenteral hydration.
The addition of an anxiolytic medication e.g. midazolam, to the CSCI regime may become appropriate if the patient is increasingly distressed by their symptoms despite the above measures.
See Care of the dying person for further details