Waikato DHB Palliative Care Guidelines

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5. Intestinal obstruction

Common complication of advanced abdominal or pelvic malignancy.

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Frequently multi-factorial in origin.

Can occur at multiple sites especially in patients with peritoneal involvement.

Management depends on what is considered to be both possible and appropriate.

Surgical advice should always be considered.

Stage of illness, previous surgical findings, estimated prognosis and the wishes of the patient MUST be considered.

The clinical presentation and subsequent management depends on whether the obstruction is:

acute or subacute
partial or complete
low, high or multiple.

Causes

Mechanical e.g. cancer, constipation, radiotherapy or surgical stricture.

Paralytic e.g. autonomic nerve disruption (diffuse malignant disease in the retroperitoneum), drug effects (anticholinergics, opioids), post-operative, peritonitis, metabolic (uraemia), radiation fibrosis, vascular insufficiency.

5.1 General considerations

In the palliative setting IV fluids and nasogastric tubes are rarely required.

If surgery is clearly not appropriate or against the patient's wishes, an attempt should be made to palliate symptoms using active medical management.

Factors which suggest a poor outcome from surgery include; diffuse intraperitoneal carcinomatosis, severe ascites, previous abdominal or pelvic radiotherapy, palpable abdominal masses, liver or other distant metastases, low serum albumin and multiple levels of obstruction.

The aim of medical treatment is to minimise symptoms of pain, colic, nausea and vomiting, to provide freedom from medical technology and “tubes” if possible and to facilitate discharge home if that is the wish of the patient and their family.

IV fluids are sometimes required initially if the patient is very dehydrated but will usually be withdrawn even if the bowel obstruction does not resolve. Intermittent subcutaneous fluids may be appropriate. Continuation of “maintenance” fluids can make nausea and vomiting harder to control.

Patients should be allowed to take oral fluids and food as tolerated.

Patients with recurrent bowel obstructions can be managed in the community without admission using subcutaneous infusions and palliative care nursing input.

5.2 Medical management

See Medical management of Bowel Obstruction

Information last reviewed: March 2012	Please foward any enquiries about this document to Sandra.Haggar@waikatodhb.health.nz
Next review date: March 2014	For Palliative Care advice, please call (07) 839 8691 or the specialist on-call.