This information is sourced from NICE and PANG:
Bowel obstruction in advanced illness is common, especially in cases of gynae or bowel cancer and can present insidiously. Bowel obstruction may be due to:
- a mechanical blockage e.g. tumour or external compression from ascites, or even from severe constipation
- peristaltic failure e.g. due to drugs such as opioids, cyclizine, in fact any anticholinergic drug
- a combination of both
Clinical features
Symptoms vary according to the level of the blockage in the GI tract.
Key symptoms of bowel obstruction include:
- intermittent nausea (often relieved by vomiting) - often high volume if the level of obstruction is small bowel or higher
- abdominal pain (may be colicky)
- abdominal distention (particularly if colonic obstruction)
- history of bowels not open and usually appetite loss
Late signs include:
- worsening nausea and/or faeculent vomiting as obstruction progresses
An initial approach to treatment
- Seek specialist advice early as management can be complex
- Remember the severe social impact that this syndrome can have - eating is at the heart of normal family life. Bowel obstruction and its associated symptoms can cause distress and demoralisation as normal social life is disrupted
- A low residue (low fibre) diet can help prevent bowel obstruction, or support recovery from a blockage - see resource on the right
Specialist care
- Imaging with CT
- Treatment options include NG tube if acceptable, possibly surgery, stenting or pharmacological (e.g.steroids, prokinetics, antispasmodics)
An approach to managing terminal bowel obstruction at home if admission is no longer appropriate
If due to peristaltic failure (absent bowel sounds):
- Stop or reduce the drugs that decrease peristalsis (for example cyclizine, tricyclic antidepressants, or opioids if appropriate)
- Start a prokinetic anti-emetic (e.g. metoclopramide e.g. 30 mg/24 hours) via a syringe pump or domperidone orally if tolerated
- If colic develops: stop the prokinetic anti-emetic and treat as below
If due to mechanical obstruction at any level of the bowel:
- Exclude constipation, or treat if present
- Treat nausea with cyclizine, up to 75 mg/24 hours via pump
- If nausea persists, add haloperidol, 2.5–5 mg/24 hours in a pump or as a single night-time dose if no pump is available
- Levomepromazine is another option; 5–12.5 mg/24 hours in a pump or as a single night-time dose - but can be very sedative even in low doses
- Avoid prokinetics
- A trial of dexamethasone 6mg orally or subcutaneously once daily
- It is useful to have hyoscine butylbromide available in case of severe colic 60–100 mg/24 hours via pump or 20 mg immediately by subcutaneous injection
- If large-volume vomiting persists then do contact your specialist palliative care team
Remember to treat the background abdominal pain