Reggie T. Saldivar and Roma Tickoo
Definition
• Any process, mechanical or functional, preventing the forward propulsion of bowel contents
• Can be partial or complete, single or multifocal & is a medical emergency
Risk Factors and Prevalence
• Common complication in pts w/abdominal or pelvic CAs
• Frequency as high as 42% of advanced ovarian CAs
• Small bowel > large bowel involvement
Clinical Manifestations
• Nausea, vomiting, abdominal pain, ± abdominal distention, hiccups
• Absent bowel sounds, hypoactive or high-pitched → impending obstruction
• Vomiting occurs early in proximal obstructions, late in distal
• Abdominal pain may be continuous (90%), colicky (75%)
Diagnosis
• Hx Æ prior abd surgery or malignancy must be sought
• PEx → fever, tachycardia, abd distention, paucity of bowel sounds, surgical abd scars. Rectal exam may reveal empty vault, mass or blood PR
• Imaging → dilated loops of bowel, air–fluid levels, transition point on CT
Management
Hydration
• Most pts w/bowel obstruction are dehydrated → ↑ secretion of water into bowel ↓ PO of fluids
• No correlation between intensity of thirst, dry mouth, & quantity of hydration administered (J Palliat Care 1998;9:298)
• Sx of dry mouth can be addressed w/sips of water, ice chips, & meticulous oral care(J Pain Symptom Manage 2000;19:23)
• Indications for hydration in terminally ill CA pts:
Prevent dehydration-induced agitation/confusion
Prev of prerenal failure w/resulting delirium, myoclonus, & seizures
• Limit PO to volume of UOP/24 h + 500 mL for insensible losses
Total Parental Nutrition
• Avoid routine use of TPN - controversial use in advanced incurable CA pts (Nutrition 1996;12:163)
• Selection of appropriate pts the most critical decision
• Will not correct CA-induced cachexia
• <50% of terminally ill CA pts experience sensation of hunger or thirst. Select pts at end of life – sips of water, soup, or ice chips may be offered for pleasure if tolerated.
• Nutritional benefits limited if delivered only for very short time
• Requires full discussion w/pt & family regarding risks, benefits, & triggers for discontinuation of TPN
