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Think octreotide for malignant bowel obstruction: octreotide is the go-to drug in patients with malignant bowel obstruction in palliative care.

DALLAS -- Octreotide is an extremely helpful yet underappreciated drug for the management of malignant bowel obstruction in the palliative care setting, Dr. Steven Pantilat said at the annual meeting of the Society of Hospital Medicine.

"I find a lot of the docs in my hospital--even some of the GI docs and surgeons--don't know about the literature on octreotide," added Dr. Pantilat, director of the Palliative Care Leadership Center at the University of California, San Francisco.

What the literature shows is that 70% of patients respond to the somatostatin analogue with reductions in nausea, vomiting, nasogastric secretions, and pain. This is the go-to drug in patients with malignant bowel obstruction in palliative care, he emphasized.

In contrast, the literature on the use of surgery for malignant bowel obstruction in patients with advanced cancer is exceedingly weak. These patients are so sick they generally don't live long enough to benefit from the operation.

"The obstructions are often multiple, which is why surgery is typically not a very good option in people with late cancer. You go in there to relieve one obstruction only to find they are multiple. Now you've got someone who not only has bowel obstruction but an operative wound and postoperative ileus on top of an obstructed bowel. You really haven't made them that much better," Dr. Pantilat continued.

Stenting can be quite helpful in the relatively uncommon situation where only a single obstruction is present, provided the obstruction is within reach of the endoscope from above or below.

So overall, medical therapy is the preferred approach to managing malignant bowel obstruction in patients with advanced cancer, Dr. Pantilat said.

Bowel obstruction is a common problem, affecting up to 28% of patients with colorectal cancer and 42% of those with ovarian cancer. Obstruction can be due to muscle paralysis, occlusion of the lumen by tumor, or both. The problem often comes on gradually, with nausea and/or vomiting, cramping, intermittent pain, anorexia, and infrequent liquid bowel movements.

The stomach produces up to 2 L of secretions per day, even in patients who aren't eating. When those secretions get backed up due to an obstruction, the bowel responds in the most unhelpful way: It increases secretion of water and sodium, ramps up peristalsis in an effort to push the obstruction downstream, and decreases absorption of secretions.

"What you'd really like the bowel to do is to decrease secretions, slow down peristalsis, and essentially relax. That's often enough to allow a complete obstruction to become partial and let things flow through," Dr. Pantilat said.

Relieving the condition can be accomplished by using a multipronged approach involving:

* Nasogastric suctioning. This is especially beneficial in patients obstructed at the gastric outlet or duodenum. "These are the people who think you're a genius if you put in a nasogastric tube. As uncomfortable as a nasogastric tube is, these patients are grateful for it," Dr. Pantilat said.

Up to 30% of patients experience relief from nausea within 3-7 days after placement of the nasogastric tube.

For those who don't, it's worth considering venting gastrostomy to drain the secretions. In any event, the goal is to discontinue use of the nasogastric tube after a few days in order to avoid the psychosocial sequelae of leaving it in long term.

* Opioids. These are by far the best drugs for relief of the pain and cramping that accompany malignant bowel obstruction. In this situation, the opioid side effect of decreased peristalsis is actually a benefit. Consider using transdermal fentanyl or another medicationin a nonoral formulation, since it's tough to know how much of an oral opioid the patient is really able to keep down.

Start the dose at 50 mcg subcutaneously every 8 hours, titrating as needed up to a dose of 200 mcg.

Alternatively, the drug can be given as a continuous intravenous or subcutaneous infusion at 20 mcg/hr.

* Anticholinergics. These can be used to decrease gastric secretions and gastrointestinal motility.

* Antihistamines. These agents can help to counteract nausea, and also can have a sedative effect. Promethazine is an especially good choice.

* Intravenous fluids. Patients with malignant bowel obstruction are frequently dehydrated.

"The goal is, after a few days, when patients feel better--their nausea is resolved, their pain is resolved, their cramping is resolved--to see if they can begin eating again, obviously starting with clear liquids," Dr. Pantilat said.


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Title Annotation:Geriatrics
Author:Jancin, Bruce
Publication:Internal Medicine News
Geographic Code:1USA
Date:Aug 1, 2007
Previous Article:Opioids unmatched for dyspnea in patients near end of life.
Next Article:Simple measures for dying patients can limit secretions, death rattle.

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