Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial

Octreotide infusion for malignant duodenal obstruction in a 12-year-old girl with metastatic peripheral nerve sheath tumor

Malignant bowel obstruction is a common complication of some adult malignancies. In childhood cancer, malignant bowel obstruction is relatively rare. Octreotide, an analogue of the hormone somatostatin, has been shown to be an effective treatment for this condition in adults. However, explicit description of its use for this indication in children was not discovered in the pediatric literature by this group of authors. The following report is that of a 12-year-old female who had copious bilious emesis secondary to malignant obstruction of the distal duodenum, which abated after treatment with a continuous intravenous octreotide infusion.

A prospective study on the efficacy of octreotide in the management of malignant bowel obstruction in gynecologic cancer

OBJECTIVE

Malignant bowel obstruction (MBO), of which symptoms lead to a poor quality of life, is a common and distressing clinical complication in advanced gynecologic cancer. The aim of this study was to prospectively assess the clinical efficacy of octreotide to control vomiting in patients with advanced gynecologic cancer with inoperable gastrointestinal obstruction.

METHODS

Patients with advanced gynecologic cancer, who presented at least one episode of vomiting per day due to MBO, were enrolled in this prospective study from 2006 to 2009. Octreotide was administered when necessary at doses starting with 300 μg up to 600 μg a day by continuous infusion for 2 weeks. Primary end point was vomiting control, which was evaluated by common terminology criteria for adverse events version 3 (CTCAE v3.0). Adverse events were also evaluated by CTCAE v3.0.

RESULTS

Twenty-two cases were enrolled in this study. Octreotide controlled vomiting in 15 cases (68.2%) to grade 0 and 3 cases (13.6%) to grade 1 on CTCAE v3.0. Overall response rate to octreotide treatment was 81.8% in our patients' cohort. Among 14 cases without nasogastric tube, the overall response rate was 93.1% (13/14). Among 8 cases with nasogastric tube, 4 cases were free of tube with decrease of drainage, and overall response rate was 62.5% (5/8). No major adverse events related to octreotide were reported.

CONCLUSIONS

We conclude that 300-μg/d dose of octreotide was effective and safe for Japanese patients with MBO by advanced gynecologic cancer. Octreotide could contribute to better quality of life by avoiding placement of nasogastric tube.

[Treatment of nausea and vomiting with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatinantagonists, benzodiazepines and cannabinoids in palliative care patients : a systematic review]

BACKGROUND

Various recommendations exist for the treatment of nausea and vomiting in palliative care but only few studies and even less systematic reviews look into antiemetic therapy for patients receiving palliative care.

OBJECTIVES

This systematic review aims to analyze the current evidence for antiemetic treatment with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids in palliative care patients with far advanced cancer not receiving chemotherapy or radiotherapy, acquired immune deficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), progressive heart failure, amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). Results regarding evidence of treatment with prokinetic and neuroleptic agents will be published separately.

METHODS

The electronic databases PubMed and EmBase were systematically searched for studies (published 1966-2011) dealing with antiemetic therapy in palliative care and electronic retrieval was completed by manual searching. Studies with patients undergoing chemotherapy or radiotherapy, pediatric studies and studies published in languages other than English or German were excluded. Studies addressing therapy with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines or cannabinoids were identified and selected for this systematic review.

RESULTS

In the general search 75 relevant studies were found. Of those 36 addressed 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids, 13 considered 5HT3 receptor antagonists, 10 somatostatin antagonists, 9 steroids, 5 cannabinoids, 4 anticholinergics, 1 antihistamines and none benzodiazepines. Furthermore six systematic reviews exist. Evidence for any drug used as an antiemetic is low. Concerning 5HT3 receptor antagonists data are insufficient for recommendations on the treatment of patients with AIDS and MS due to the small size of included patient groups. For patients with cancer contradictory results were published: the larger studies showed a positive effect of 5HT3 receptor antagonists and better efficacy, as compared to metoclopramide, dexamethasone and neuroleptics. Heterogeneous results were found for steroids, with a positive trend for patients with cancer. Data are insufficient for antihistamines. Studies prove effectiveness of butylscopolammonium in the treatment of nausea and vomiting caused by malignant gastrointestinal obstruction, whereas octreotide is superior to butylscopolammonium. Regarding benzodiazepines for symptom control of nausea and vomiting in palliative care patients no studies were detected. Cannabinoids were found to relieve nausea and vomiting in patients with cancer and AIDS but with notable side effects. Furthermore, the studies compared cannabinoids to less recent antiemetic drugs but not, for example to 5HT3 receptor antagonists. Regarding symptom control of nausea and vomiting in patients with COPD, progressive heart failure and ALS no studies were undertaken in patients receiving palliative care.

CONCLUSIONS

In palliative care patients with nausea and vomiting 5HT3 receptor antagonists can be used if treatment with other antiemetics, such as metoclopramide and neuroleptics is not sufficient. There is a trend that steroids in combination with other antiemetics improve symptom relief. Cannabinoids rather have a status as a second line antiemetic. In cases of nausea and vomiting caused by malignant gastrointestinal obstruction octreotide showed the best and butylscopolammonium bromide the second best results. Concerning antihistamines and benzodiazepines insufficient data was found. Recommendations in the literature are mainly based on studies in patients with cancer. The overall strength of evidence is low. More well designed studies in palliative care patients are needed in order to provide evidence-based therapy. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

Laparoscopic adhesiolysis: consensus conference guidelines

AIM

Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post-surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice.

METHODS

A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts.

RESULTS

Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion-preventing agents, the need for high-technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection.

CONCLUSION

Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.

Drug management of visceral pain: concepts from basic research

Visceral pain is experienced by 40% of the population, and 28% of cancer patients suffer from pain arising from intra- abdominal metastasis or from treatment. Neuroanatomy of visceral nociception and neurotransmitters, receptors, and ion channels that modulate visceral pain are qualitatively or quantitatively different from those that modulate somatic and neuropathic pain. Visceral pain should be recognized as distinct pain phenotype. TRPV1, Na 1.8, and ASIC3 ion channels and peripheral kappa opioid receptors are important mediators of visceral pain. Mu agonists, gabapentinoids, and GABAB agonists reduce pain by binding to central receptors and channels. Combinations of analgesics and adjuvants in animal models have supra-additive antinociception and should be considered in clinical trials. This paper will discuss the neuroanatomy, receptors, ion channels, and neurotransmitters important to visceral pain and provide a basic science rationale for analgesic trials and management.

SALTO: a randomized, multicenter study assessing octreotide LAR in inoperable bowel obstruction

This phase II, multicenter, randomized, double-blind, non-comparative study assessed the efficacy and safety of immediate-release octreotide and octreotide LAR, in combination with corticosteroids and standard medical care, on the symptoms of inoperable malignant bowel obstruction (MBO) due to peritoneal carcinomatosis. The primary efficacy endpoint was "success" at day 14 defined as a composite endpoint including the absence of a nasogastric tube, and vomiting less than twice per day and no use of anticholinergic agents. Patients in the octreotide arm received octreotide LAR 30 mg intramuscular (im) on days 1, 29 and 57, as well as daily immediate-release octreotide 600 μg per day plus methylprednisolone on days 1 to 6. Placebo-treated patients received methylprednisolone and matched placebo instead of octreotide. Difficulties associated with enrolling patients at palliative-care stage meant only 64 patients (instead of the planned 102 patients) were randomized, 32 to octreotide and 32 to placebo. Despite randomization, more patients in the octreotide arm (46.4%) than in the placebo arm (21.9%) had a baseline Karnofsky score less than 50. An intention-to-treat analysis showed that in the octreotide and placebo arms, 12 (38%) and nine (28%), respectively, patients were successfully treated at day 14, which increased to 9/15 (60%) and 7/25 (28%), respectively, among patients with a baseline Karnofsky score greater or equal to 50. Octreotide-treated patients reported three drug-related adverse events (AEs), and no drug-related serious AEs or deaths. Octreotide LAR may have a key role in treating patients with a MBO due to peritoneal carcinomatosis, particularly in those with moderately severe disease.

Octreotide for malignant bowel obstruction: twenty years after

Malignant bowel obstruction (MBO) is a challenging complication of advanced cancer. Conservative treatment of inoperable MBO in terminal cancer patients has been found to be effective in controlling the distressing symptoms caused by this complication in inoperable cancer patients. Twenty years ago, octreotide was proposed to treat symptoms related to malignant bowel obstruction. Since then several reports have confirmed the efficacy of octreotide in the management of gastrointestinal symptoms of MBO. Fifteen randomized controlled trials or observational reports with a significant number of patients treated with octreotide have been reviewed; 281 patients were surveyed. Authors reported a therapeutic success ranging between 60% and 90%. Despite the limited number of controlled studies, the large experience acquired through 20 years suggests that octreotide is the first-choice antisecretory agent for MBO. As such, octreotide is the only drug approved by the health-care system in Italy for this treatment.

Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors influencing spontaneous resolution

Malignant bowel obstruction (MBO) is a frequent complication in advanced cancer patients, especially in those with abdominal tumors. Clinical management of MBO requires a specific and individualized approach that is based on disease prognosis and the objectives of care. The global prevalence of MBO is estimated to be 3% to 15% of cancer patients. Surgery should always be considered for patients in the initial stages of the disease with a preserved general status and a single level of occlusion. Less invasive approaches such as duodenal or colonic stenting should be considered when surgery is contraindicated in obstructions at the single level. The priority of care for inoperable and consolidated MBO is to control symptoms and promote the maximum level of comfort possible. The spontaneous resolution of an inoperable obstructive process is observed in more than one third of patients. The mean survival is of no longer than 4-5 weeks in patients with consolidated MBO. Polymodal medical treatment based on a combination of glucocorticoids, strong opioids, antiemetics, and antisecretory drugs achieves very high symptomatic control. This review focuses on the epidemiological aspects, diagnosis, surgical criteria, medical management, and factors influencing the spontaneous resolution of MBO in advanced cancer patients.

Pharmacological treatment of bowel obstruction in cancer patients

INTRODUCTION

Malignant bowel obstruction (MBO) is a common complication of advanced cancer, occurring most frequently in gynaecological and colorectal cancer. Its management remains complex and variable. This is in part due to the lack of evidence-based guidelines for the clinicians involved. Although surgery should be considered the primary treatment, this may not be feasible in patients with a poor performance status or advanced disease. Advances have been made in the medical management of MBO which can lead to a considerable improvement in symptom management and overall quality of life.

AREAS COVERED

This review emphasizes the importance of a prompt diagnosis of MBO with early introduction of pharmacological agents to optimize symptom control. The authors summarize the treatment options available for bowel obstruction in those patients for whom surgical intervention is not a feasible option. The authors also explore the complexities involved in the introduction of parenteral hydration and total parenteral nutrition in this group of patients.

EXPERT OPINION

It is not always easy to distinguish reversible from irreversible bowel obstruction. Early and aggressive management with the introduction of pharmacological agents including corticosteroids, octreotide and anti-cholinergic agents have the potential to maintain bowel patency, and allow for more rapid recovery of bowel transit. A combination of analgesics, anti-emetics and anti-cholinergics with or without anti-secretory agents can successfully improve symptom control in patients with irreversible bowel obstruction.

Malignant bowel obstruction: a review of current treatment strategies

Malignant bowel obstruction is common in individuals with intra-abdominal and pelvic malignancies and results in considerable suffering. Treatments target both the resolution of obstruction and symptom management. Emerging procedures include stents placement in the bowel to return patency and newer surgical procedures that are evolving to be less invasive. The use of medical interventions like corticosteroids, alone or in concert with additional drugs, can be utilized to achieve resolution of obstruction. Throughout treatment, it is important to also aggressively treat obstructive symptoms like pain and nausea/vomiting. This can mostly be achieved with medications, but use of venting percutaneous endoscopic gastrostomy (PEG) can also relieve symptoms. Parenteral hydration and nutrition use remain controversial with this population. The factor most closely tied to prognosis is performance status.

Treatment of early postoperative inflammatory small bowel obstruction with somatostatin: an analysis of 45 cases

AIM: To investigate the effect of treatment with somatostatin (SS) on early postoperative inflammatory small bowel obstruction (EPISBO).

METHODS: The clinical data for 76 patients with EPISBO were retrospectively analyzed. The patients were divided into two groups according to whether applying SS or not: treatment group [receiving routine therapy plus continuous intravenous infusion of SS (6 mg/d), n = 45] and control group (receiving only routine therapy, n = 31). The symptoms, signs, gastrointestinal decompression, haemoglobin, total protein, albumin, and mean therapy duration were compared between the two groups.

RESULTS: The time required for relief of abdominal distention and restoration of anal exhaust, the volume of gastrointestinal decompression, and mean therapy duration were significantly lower than in the treatment group than in the control group (4.03 d ± 1.21 d vs 6.54 d ± 1.19 d; 6.30 d ± 2.03 d vs 7.15 d ± 1.17 d; 436 mL ± 120 mL vs 580 mL ± 150 mL; 12.21 d ± 4.71 d vs 20.21 d ± 5.18 d; all P < 0.05). No significant differences were noted in the time required for relief of abdominal pain, nausea and vomiting and restoration of defecation between the two groups. Haemoglobin, total protein, albumin (43.61 g/L ± 8.35 g/L vs 37.61 g/L ± 4.71 g/L, P < 0.05) were significantly higher in the treatment group than in the control group.

CONCLUSION: SS can inhibit the secretion of digestive juices, lessen intestinal distension, improve the nutritional state, and thereby exert a therapeutic effect against EPISBO.

Strategies for diagnosis and treatment of small bowel obstruction

Small bowel obstruction, which is caused by a variety of etiological factors and mainly manifests as abdominal pain, vomiting and distension, is one of the most common acute abdomens. A rapid and accurate diagnosis of small bowel obstruction is needed to give reasonable and effective treatment to avoid its rapid deterioration. In this paper we discuss the strategies for diagnosis and treatment of small bowel obstruction through comparing different imaging methods for diagnosis of small bowel obstruction and reviewing the current situation of diagnosis and treatment of the disease in terms of pharmacotherapy, gastrointestinal decompression, and surgical intervention.

Malignant bowel obstruction: natural history of a heterogeneous patient population followed prospectively over two years

CONTEXT

The management of malignant bowel obstruction (MBO) is often challenging and frequently involves multiple treatment modalities, including chemotherapy, surgery, stenting, and symptomatic medical management.

OBJECTIVES

To describe the natural history of patients diagnosed with MBO who were admitted to a tertiary level hospital and followed by a multidisciplinary team that included medical oncologists, surgical oncologists, and palliative care specialists.

METHODS

Thirty-five patients admitted under medical or surgical oncology with a diagnosis of MBO were followed over a two-year period or until the time of death. Primary malignancies included colon, rectum, pancreas, biliary, breast, bladder, carcinoid, renal cell, gastric, lung, and melanoma. Clinical outcomes of interest included survival, percentage of patients receiving surgery and/or chemotherapy, total parenteral nutrition (TPN), insertion of venting gastrostomy tube, disposition, and rates of readmission to hospital.

RESULTS

Median survival was 80 days and three patients were alive at the time of study closure. At our center, 34% of patients underwent surgical intervention, 37% received at least one dose of post-MBO chemotherapy, and 43% received TPN. There was a cohort of patients (17%) who were alive at one year.

CONCLUSION

Interventions such as chemotherapy and TPN may be appropriate in a carefully selected subgroup of patients. A collaborative approach is required for the optimal clinical management and palliation of MBO.

Review article: palliative care in gynecologic oncology

Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.

Compatibility and stability of ternary admixtures of tramadol, haloperidol, and hyoscine N-butyl bromide: retrospective clinical evaluation

BACKGROUND

Combination of drugs for subcutaneous infusion is common practice in palliative medicine, however, there is no information pertaining to the compatibility and stability of tramadol combined in ternary admixtures and no information exists regarding its clinical performance.

METHODS

Tramadol hydrochloride, haloperidol lactate, and hyoscine N-butyl bromide have been examined for compatibility and stability when combined in solution under conditions mimicking their potential use via subcutaneous infusion in terminal oncology patients. Concentration ranges were 8.8-33.3 mg/mL, 0.208-0.624 mg/mL, and 3.33-6.67 mg/mL for tramadol hydrochloride, haloperidol lactate, and hyoscine N-butyl bromide. With these, 27 different admixtures were prepared and stored at 25 degrees C using 0.9% saline as diluent. Quantification was performed by high-performance liquid chromatography (HPLC). The clinical performance of the admixture was retrospectively assessed in 28 terminal oncology patients exhibiting Karnofsky's indexes of 10%-20%.

RESULTS

All three drugs were very stable (>92%) at 25 degrees C for 15 days. Pain was completely controlled in all patients. Fifty percent of the patients suffered from 3-5 vomiting episodes per day and of these, 75% experienced complete control of the episodes. None of the patients showed local reactions after subcutaneous administration of the admixture.

RESULTS

Our results confirm the compatibility and stability of the ternary admixture and its utility in highly vulnerable patients exhibiting moderate symptoms.

Multicenter prospective study on efficacy and safety of octreotide for inoperable malignant bowel obstruction

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of octreotide for malignant bowel obstruction in a multicenter study.

METHODS

Terminally ill patients diagnosed with inoperable malignant bowel obstruction were treated with octreotide 300 microg/day. The primary endpoint was the overall improvement rate of subjective abdominal symptoms. The degrees of nausea, vomiting, abdominal pain, distension, anorexia, fatigue, thirst and overall quality of life were evaluated by the self-rating scores selected from the MD Anderson Symptoms Inventory and Kurihara's Face Scale.

RESULTS

Forty-nine patients were enrolled in the study, and 46 patients received study treatment, including 17 gastric, 13 colorectal, 7 ovarian and other cancers. The median survival time was 25 days. The number of vomiting episodes significantly correlated with the MD Anderson Symptoms Inventory nausea and vomiting scores (P< 0.001) before octreotide treatment. Of 43 patients evaluable for efficacy, the scores of all the MD Anderson Symptoms Inventory items except abdominal pain and the number of vomiting episodes improved during the first 4 days of octreotide treatment (P< 0.0062). The MD Anderson Symptoms Inventory scores were decreased in 59-72% of patients, and overall quality-of-life scores improved in 56% of patients. No serious adverse events were observed.

CONCLUSIONS

The high improvement rate in abdominal symptoms suggested the efficacy of octreotide in terminally ill patients with malignant bowel obstruction.

Predictors of survival in patients with non-curative stage IV cancer and malignant bowel obstruction

PURPOSE

Malignant bowel obstruction (MBO) occurs in up to 15% of patients admitted to palliative care wards and management can be clinically challenging. Survival is generally poor with a reported median survival of 1-3 months; however, there are no studies describing predictors of survival for patients with MBO.

PATIENTS AND METHODS

All patients admitted to a tertiary care hospital with a MBO were approached between March 1, 2006 and March 31, 2008 to enter the study. Demographic, clinical, laboratory, and radiographic information were prospectively collected from patient charts and the patient's functional status (Eastern Cooperative Oncology Group score, ECOG) at admission was recorded. Follow-up was until death or the end of the study (August 2008). Survival was estimated using Kaplan-Meier plots and Cox regression models were used to evaluate prognostic factors for survival.

RESULTS

Thirty-five patients were recruited. Median patient age was 61% and 46% were female. Median survival of the cohort was 80 days (range 7-873). Median survival for patients with an ECOG performance status of 0-1 (n = 15) was 222 days, for ECOG 2 patients (n = 9), 63 days and for patients with an ECOG 3/4 score (n = 11) it was 27 days. ECOG status was the strongest predictor of survival on the multivariate analysis. In addition, a low blood urea nitrogen level or a high albumin on admission was also associated with prolonged survival.

CONCLUSION

An ECOG score of 0/1 for patients with MBO in the setting of Stage IV non-curative cancer is the strongest predictor of overall survival.

A systematic review of the treatment of nausea and/or vomiting in cancer unrelated to chemotherapy or radiation

CONTEXT

A systematic review of antiemetics for emesis in cancer unrelated to chemotherapy and radiation is an important step in establishing treatment recommendations and guiding future research. Therefore, a systematic review based on the question "What is the evidence that supports antiemetic choices in advanced cancer?" guided this review.

OBJECTIVES

To determine the level of evidence for antiemtrics in the management of nausea and vomiting in advanced cancer unrelated to chemotherapy and radiation, and to discover gaps in the evidence, which would provide important areas for future research.

METHODS

Three databases and independent searches using different MeSH terms were performed. Related links were searched and hand searches of related articles were made. Eligible studies included randomized controlled trials (RCTs), prospective single-drug studies, studies that used guidelines based on the etiology of emesis, cohort studies, retrospective studies, and case series or single-patient reports. Studies that involved treatment of chemotherapy, radiation, or postoperation-related emesis were excluded. Studies that involved the treatment of emesis related to bowel obstruction were included. The strength of evidence was graded as follows: 1) RCTs, A; 2) single-drug prospective studies, B1; 3) studies based on multiple drug choices for etiology of emesis, B2; and 4) cohort, case series, retrospective, and single-patient reports, E. Level of evidence was determined by the Oxford Centre for Evidence-Based Medicine Levels of Evidence (May 2001) (A, B, C, D).

RESULTS

Ninety-three articles were found. Fourteen were RCTs, most of them of low quality, based either on lack of blinding, lack of description of the method of randomization, concealment, and/or attrition. Metoclopramide had modest evidence (B) based on RCTs and prospective cohort studies. Octreotide, dexamethasone, and hyoscine butylbromide are effective in reducing symptoms of bowel obstruction, based on prospective studies and/or one RCT. There was no evidence that either multiple antiemetics or antiemetic choices based on the etiology of emesis were any better than a single antiemetic. There is poor evidence for dose response, intraclass or interclass drug switch, or antiemetic combinations in those individuals failing to respond to the initial antiemetic.

CONCLUSION

There are discrepancies between antiemetic studies and published antiemetic guidelines, which are largely based on expert opinion. Antiemetic recommendations have moderate to weak evidence at best. Prospective randomized trials of single antiemetics are needed to properly establish evidence-based guidelines.

Nausea and Vomiting in Advanced Cancer

Nausea and vomiting are relatively common in advanced cancer and is dreaded more than pain by patients. The history, pattern of nausea and vomiting, associated symptoms, and physical examination provides clues as to etiology and may guide therapy. Continuous severe nausea unrelieved by vomiting is usually caused by medications or metabolic abnormalities, while nausea relieved by vomiting or induced by eating is usually due to gastroparesis, gastric outlet obstruction, or small bowel obstruction. Drug choices are empiric or based on etiology. Metoclopramide has the greatest evidence for efficacy followed by phenothiazines and tropisetron. Corticosteroids have not been effective in randomized trials except in the case of bowel obstruction. Treatment of nausea unresponsive to first-line medications involves rotation to medications which bind to multiple receptors (broad-spectrum antiemetics), the addition of another antiemetic to a narrow-spectrum antiemetic (a serotonin receptor antagonist such as tropisetron to a phenothiazine), rotation to a different class of antiemetic (tropisetron for a phenothiazine), or in-class drug rotation. Venting gastrostomy, octreotide, and corticosteroids will reduce nausea and vomiting associated with malignant bowel obstruction.

Room for improvement? A quality-of-life assessment in patients with malignant bowel obstruction

This prospective study followed 35 patients admitted to hospital with malignant bowel obstruction (MBO) to evaluate quality of life (QOL). Subjects completed the Edmonton Symptom Assessment Scale (ESAS) and Rotterdam Symptom Checklist (RSCL) at recruitment, and at one week, one month and three months.The highest ranked ESAS scores at recruitment (which was generally 18-36 hours post admission to hospital) included loss of appetite (median=7.5), fatigue (6.5) and overall well-being (6.0). The total ESAS score improved by 7.5, 11.5 and 11.0 points respectively at one week, one month and three months (p<0.05, p<0.01, NS).RSCL median scores for physical and psychological subscales were high at baseline (36.2, 42.9) and improved significantly at one week and one month (p<0.05). Psychological functioning appeared to be worsening by three months and at no time did activity level improve significantly. The overall QOL score was extremely poor at baseline (6.0 median) improving to 3.3 at one month (median fall=1.0, p<0.05) and 3.4 at three months.Further work should address the lack of improvement in activity and apparent deterioration in psychological functioning after one month.

Surgical management of malignant bowel obstruction: strategies toward palliation of patients with advanced cancer

The management of malignant bowel obstruction is a challenging problem because of the poor definition of malignant bowel obstruction compounded by its myriad clinical presentations. Surgeons are called upon to perform invasive procedures designed to alleviate symptoms or correct the underlying obstruction. Unfortunately, interventions may carry a high rate of morbidity and mortality. Balancing these risks and potential benefits is complicated, and there is a paucity of data to help guide these difficult decisions. The surgeon is further handicapped when he or she is not understanding of the patient's disease status, prognosis, or long-term goals. Diligent discussion with the primary team and frank discussions with the patient and his or her family are essential to formulate an appropriate plan. It is also essential that the surgeon have a thorough understanding of the surgical options to relieve or palliate malignant bowel obstruction as well as effective nonsurgical interventions. The best approach may be appropriate surgical intervention coupled with aggressive medical management.

Current concepts in malignant bowel obstruction management

Malignant bowel obstruction (MBO) is a challenging complication of advanced cancer. Several pathophysiologic mechanisms are responsible for the syndrome, including mechanical compression, motility disorders, gastrointestinal secretion accumulation, decreased gastrointestinal absorption, and inflammation. The treatment of related symptoms requires a collaborative approach of surgical, interventional, and medical specialists. The surgical approach proves beneficial in selected patients with operable lesions, life expectancy greater than 2 months, and good performance status. Interventionalists place self-expanding metallic stents as a minimally invasive palliative method either as a definitive treatment or as a bridge to surgery. However, most patients with MBO are not candidates for surgery or stent placement. Medical management with opioids, antispasmodics, antiemetics, antisecretory agents, and corticosteroids is effective in controlling the symptoms associated with MBO. This article discusses the current understanding of MBO pathophysiology and emphasizes current MBO management concepts; it then reviews surgical, interventional, and medical approaches.

Pneumatosis Intestinalis: Can We Avoid Surgical Intervention in Nonsurgical Patients?

Pneumatosis intestinalis (PI) is the presence of gas within the wall of the gastrointestinal tract and represents a tremendous spectrum of conditions and outcomes, ranging from benign diseases to abdominal sepsis and death. It is seen with increased frequency in patients who are immunocompromised because of steroids, chemotherapy, radiation therapy, or AIDS. PI may result from intraluminal bacterial gas entering the bowel wall due to increased mucosal permeability caused by defects in bowel wall lymphoid tissue. We present a case of PI who was treated conservatively and in whom PI resolved completely and we present a literature review of conservative management. It is not difficult to make a precise diagnosis of PI and to prevent unnecessary surgical intervention, especially when PI presents without clinical evidence of peritonitis. Conservative treatment is possible and safe for selected patients. Awareness of these rare causes of PI and close observation of selected patients without peritonitis may prevent unnecessary invasive surgical explorations.

Octreotide acetate successfully treated a bowel obstruction caused by peritoneally disseminated gastric cancer, thereby enabling the subsequent use of oral S-1 chemotherapy

A 68-year-old woman presented with severe bowel obstruction and was subsequently diagnosed with stage IV gastric cancer with peritoneal dissemination. She was immediately stabilized in the hospital with the placement of a nasointestinal tube. Abdominal computed tomography showed multiple intraperitoneal nodules consistent with peritoneal dissemination of the gastric cancer. The patient's inability to tolerate oral intake was a contraindication to using S-1 chemotherapy, currently one of the most effective medications used for gastric cancer in Japan. Therefore, she was initially treated with octreotide acetate (OA). Her bowel obstruction was sufficiently attenuated on the seventh day after the initiation of treatment with OA to permit the initiation of oral S-1, along with low-dose cisplatin (CDDP) and radiation. S-1 was orally administered at a dose of 100 mg/day per body (80 mg/m(2) per day) on days 1-28, and CDDP was infused at a dose of 7.8 mg/day per body (6 mg/m(2) per day) on days 1-5, 8-12, and 15-19. Radiation therapy (2 Gy/day for 5 days/week) was performed with the chemotherapy. Despite no change being shown on her imaging findings with the chemotherapy, the patient's bowel obstruction resolved and she was able to tolerate both liquids and solid food orally. She was discharged 2 months after admission. Seven months after beginning the chemotherapy, she was still doing well on outpatient chemotherapy with S-1 and CDDP, and had no decline in her quality of life or progression of her disease.

Cancer emergencies: the acute abdomen

The most common complaints among patients with cancer who present to the emergency department are related to the gastrointestinal system, and 40% of these patients complain of abdominal pain. These presentations can stem from the underlying malignancy itself, treatment directed toward the disease, or the full range of pathologies present in a healthy population. Immunosuppression may blunt many of the findings one expects in a healthy population of patients, thus rendering the clinical exam less reliable in many patients with cancer. Moreover, the degree of immunosuppression shapes both the types of pathologies the clinician should consider and the rate at which the disease may progress. Understanding the limitations of physical examination, pathophysiology of disease, and the methods by which these diagnoses are established is of critical importance in this population. This article focuses specifically on patients with cancer who present with an acute abdomen, and it discusses how a concurrent malignancy can shape the differential diagnosis in these cases.

Palliation of nausea and vomiting

Pain is a common symptom that patients describe and clinicians have to manage. Management plans are tailored to the complexity of the pain. This may require a multi-modal approach while involving the wider multidisciplinary team.

Radiological imaging change in a malignant bowel obstruction patient treated with octreotide

INTRODUCTION

Malignant bowel obstruction (MBO) is a complication in advanced cancer patients with abdominal and pelvic malignancy. Recent research has established the efficacy of octreotide for MBO-related symptom relief. The mechanism that octreotide increases water absorption in case of MBO has not been demonstrated except for experimental animal and normal human model.

CASE REPORT

We present a 60-year-old man with pancreatic cancer and MBO treated with octreotide. Radiological imaging showed the disappearance of large-volume fluid retention in the small intestine with alleviating vomiting within 2 days. This radiological change might result from the effect of octreotide increasing water absorption in intestine tract.

Efficacy of granisetron in the antiemetic control of nonsurgical intestinal obstruction in advanced cancer: a phase II clinical trial

The objective of this study was to assess antiemetic efficacy of granisetron in inoperable intestinal obstruction caused by advanced cancer. The study was open, prospective, and multi-centered. We assessed 24 patients (mean age: 61.3 years; 10 males, 14 females) with intestinal obstruction who were refractory to previous antiemetics. Obstruction involved the upper intestine in six patients, the lower intestine in three, and was at multiple levels in 15. Daily treatment included intravenous granisetron (3mg) and dexamethasone (8 mg); nasogastric drainage was not allowed. Subcutaneous haloperidol was available as rescue therapy. A numeric scale was used to evaluate nausea, pain, asthenia, and anorexia at baseline visit and every 24 hours up to the completion of four days of treatment (final visit). Treatment failure was defined as nausea >4 on the numeric scale, vomiting 2/day or more, and rescue therapy with haloperidol at 5mg/day or more. Of the 24 patients, 23 were evaluable for efficacy. Evaluation pre- vs. post-treatment indicated a significant decrease in the severity of nausea (score 6.9 vs. 0.8; P<0.001), number of episodes of vomiting (5.3 vs. 1.0; P<0.001), and abdominal pain (score 4.4 vs. 1.2; P<0.001). Nausea and vomiting control was achieved in 86.9% of patients. Although there was a trend toward greater efficacy in the lower and multiple levels of obstruction, the differences were not statistically significant owing, probably, to small sample size. We conclude that granisetron may be highly efficacious in the control of emesis resulting from intestinal obstruction caused by metastatic cancer, and can be used effectively in patients refractory to other antiemetics.

Malignant irreversible intestinal obstruction: the powerful association of octreotide to corticosteroids, antiemetics, and analgesics

In the case of malignant intestinal obstruction, surgery often carries important mortality and morbidity risks, and feasibility is neither realistic nor reasonable. A total of 4 clinical cases of intestinal obstruction caused by advanced gastrointestinal cancers in their terminal phase are described. The association of analgesics, corticosteroids, antiemetics, and octreotide was effective to relieve symptoms of intestinal obstruction for the remaining lifetime. The insertion of a nasogastric tube was avoided in 3 of 4 cases. Death occurred 51, 56, and 64 days after clinical and radiological diagnosis of irreversible intestinal obstruction. This combination of drugs appears very powerful and well tolerated. The relatively long survival that was observed should encourage future studies of longer half-life somatostatin analogues with no need of continuous infusion or multiple daily injections.

Hyoscine butylbromide - a review on its parenteral use in acute abdominal spasm and as an aid in abdominal diagnostic and therapeutic procedures

BACKGROUND

Being a quaternary ammonium compound derived from scopolamine, the alkaloid hyoscine butylbromide (HBB) exerts anticholinergic effects without side effects related to the central nervous system because it does not pass the blood-brain barrier. Clinical experience with this antispasmodic dates back to the 1950s and led to its registration for treating abdominal cramps/spasm and for diagnostic imaging purposes. OBJECTIVES AND SCOPE: This review focuses on the therapeutic efficacy and safety of the parenteral administration of HBB for treating biliary and renal colic and acute spasm in the genito-urinary tract. In addition, its value for diagnostic or therapeutic procedures in the abdomen, as well as for labour and palliative care, is reviewed. With the generic and trade name of the drug combined with various search terms related to the relevant clinical applications, a thorough literature search was performed in the Medline and EMBASE databases in April 2008.

FINDINGS

In most clinical studies, recommended doses of 20-40 mg HBB were injected, mainly intravenously. Fast pain reduction was achieved by HBB in renal colic; about 90% of the patients showed good to moderate analgesic responses after 30 min and the onset of action was noticeable within 10 min. Similarly, a pain reduction of 42-78% was observed in patients with biliary colic within 30 min after a single intravenous injection of 20 mg. In contrast, no analgesic efficacy of a single injection of 20 mg was found after surgical or shock-wave procedures in the urogenital area. Administration of HBB prior to, or during, radiological imaging distended the gastrointestinal (GI) tract in double-contrast barium and computed tomographic colonography studies and reduced motion artefacts in magnetic resonance imaging. This improved diagnostic image quality and organ visualisation. Pre-medication led to shorter and easier endoscopy in some, but not all, studies. Because of cervical relaxation, HBB shortened total labour duration with 17-67%. It also relieved pain and reduced GI secretions in terminal cancer patients with inoperable bowel obstruction. With regard to its safety profile, parenteral administration of HBB is associated with mild and self-limiting adverse events, typical for anticholinergic drugs.

CONCLUSIONS

These clinical results of rapid action and beneficial efficacy combined with good tolerability support the use of HBB in a range of indications related to acute abdominal spasm, in labour and palliative care and for supporting diagnostic and therapeutic abdominal procedures, where spasm may be a problem.

Evidence-Based Recommendations for Cancer Nausea and Vomiting

The experience of patients living with cancer and being treated with chemotherapy often includes the symptoms of nausea and vomiting. To provide a framework for high-quality management of these symptoms, we developed a set of key targeted evidence-based standards through an iterative process of targeted systematic review, development, and refinement of topic areas and standards and consensus ratings by a multidisciplinary expert panel as part of the RAND Cancer Quality–Assessing Symptoms Side Effects and Indicators of Supportive Treatment Project. For nausea and vomiting, key clinical standards included screening at the initial outpatient and inpatient visit, prophylaxis for acute and delayed emesis in patients receiving moderate to highly emetic chemotherapy, and follow-up after treatment for nausea and vomiting symptoms. In addition, patients with cancer and small bowel obstruction were examined as a special subset of patients who present with nausea and vomiting. The standards presented here for preventing and managing nausea and vomiting in cancer care should be incorporated into care pathways and should become the expectation rather than the exception.

Management of malignant bowel obstruction

Malignant bowel obstruction (MBO) is a common and distressing outcome particularly in patients with bowel or gynaecological cancer. Radiological imaging, particularly with CT, is critical in determining the cause of obstruction and possible therapeutic interventions. Although surgery should be the primary treatment for selected patients with MBO, it should not be undertaken routinely in patients known to have poor prognostic criteria for surgical intervention such as intra-abdominal carcinomatosis, poor performance status and massive ascites. A number of treatment options are now available for patients unfit for surgery. Nasogastric drainage should generally only be a temporary measure. Self-expanding metallic stents are an option in malignant obstruction of the gastric outlet, proximal small bowel and colon. Medical measures such as analgesics according to the W.H.O. guidelines provide adequate pain relief. Vomiting may be controlled using anti-secretory drugs or/and anti-emetics. Somatostatin analogues (e.g. octreotide) reduce gastrointestinal secretions very rapidly and have a particularly important role in patients with high obstruction if hyoscine butylbromide fails. A collaborative approach by surgeons and the oncologist and/or palliative care physician as well as an honest discourse between physicians and patients can offer an individualised and appropriate symptom management plan.

Established and potential therapeutic applications of octreotide in palliative care

Octreotide acetate was developed as a pharmacologically stable, long-acting analogue of the hormone somatostatin. Mimicking the actions of somatostatin, octreotide has been used for its antisecretory effects. Randomized control trials have established the efficacy of octreotide for malignant bowel obstruction and for chemotherapy-induced diarrhea. Octreotide has proven to be an effective agent for symptoms of carcinoid syndrome. Newer uses include for bone marrow transplantation, infectious diarrheal syndromes, and management of hepatic metastases. More evidence is needed for the establishment of its efficacy for hypercalcemia, pain, pleural effusions, diarrhea after celiac plexus block, and malignant ascites.

Common gastrointestinal symptoms in pediatric palliative care: nausea, vomiting, constipation, anorexia, cachexia

Gastrointestinal symptoms are suffered commonly by children at the end of life. Diagnosis and management of these common symptoms include careful history and physical examination to assess for possible causes; treatment - pharmacologic and nonpharmacologic; and a discussion with patients and families of care goals. Aggressive management of these symptoms is essential to improving the quality of life for these children.

Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction

Malignant bowel obstruction (MBO) is a commonly encountered palliative care problem. There have been very few comparative trials in this area, and consequently there is very little clinical evidence upon which therapy can be rationally based. The purpose of this paper is to highlight the discussion and decision-making process that was undertaken by the Clinical Protocol Subcommittee during the development of a proposed clinical trial of best medical care versus surgical or endoscopic treatment for MBO. The development of the proposed clinical trials followed an orderly process. The first step taken was a discussion of a specific definition for MBO. Once agreed upon, this definition helped identify inclusion and exclusion criteria for the proposed trial. This was followed by an extensive literature review, which helped define both surgical and endoscopic approaches to MBO as well as what constituted best medical care. An extensive discussion was then undertaken concerning the best outcome measure of success for medical, surgical, and endoscopic interventions. All of the above steps culminated in two proposed protocols, one for MBO of the small intestine distal to the ligament of Treitz and a second for colonic obstructions. The small intestinal trial is designed to compare surgical intervention versus best medical care, whereas the colonic trial seeks to compare surgery with endoscopically-placed intraluminal stents coupled with best medical care.

The rationale for a multimodal approach in the management of breakthrough cancer pain: a review

Breakthrough pain has been described differently in various countries, and not surprisingly, recommendations for its management vary according to the institution. Usually when breakthrough pain occurs, the patient's pain has already been managed according to the World Health Organization 3-step ladder for cancer pain. After this point, the treatment choice is usually based on clinical judgment, the physician's personal experience with interventional procedures, and local resources available. Opioids remain the mainstay of the management of breakthrough cancer pain. However, the combination of radio-oncology, adjuvant drugs, and interventional pain procedures can improve pain relief. This review addresses those questions and proposes a multimodal approach to manage breakthrough cancer pain.

Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review

The use of symptomatic agents has greatly improved the medical treatment of advanced cancer patients with inoperable bowel obstruction. A systematic review of studies of the most popular drugs used in the medical management of inoperable malignant bowel obstruction was performed to assess the effectiveness of these treatments and provide some lines of evidence. Randomized trials that involved patients with a clinical diagnosis of intestinal obstruction due to advanced cancer treated with these drugs were reviewed. Five reports fulfilled inclusion criteria. Three studies compared octreotide (OC) and hyoscine butylbromide (HB), and two studies compared corticosteroids (CSs) and placebo. Globally, 52 patients received OC, 51 patients received HB, 37 patients received CSs, 15 patients received placebo, and 37 patients received both placebo and CSs. On the basis of these few data, the superiority of OC over HB in relieving gastrointestinal symptoms was evidenced in a total of 103 patients. The latter studies had samples more defined in terms of stage and inoperability, and had a shorter survival in comparison with studies of CSs (less than 61 days, most of them less than 20 days). Data on CSs are less convincing, due to the methodological weakness of existing studies. This review confirms the difficulties in conducting randomized controlled trials in this population.

Regional Cancer Pain Syndromes

Cancer pain often presents in a body region. This review summarizes articles from 1999-2004 relevant to cancer pain syndromes in the head and neck, chest, back, abdomen, pelvis, and limbs. Although the evidence is limited, progress is being made in further development of the evidence base to support and guide current practice.

Difficult Pain Syndromes

Cancer pain is prevalent in approximately two thirds of all cancer patients and can undermine the quality of life in this patient population. Uncontrolled pain can cause physical as well as psychological distress in cancer patients. As the disease progresses in cancer, pain and suffering increase. Knowledge about pain management is paramount in the comprehensive treatment of cancer patients. Difficult cancer pain syndromes may arise from interruption of bone, viscera, and neural structures by malignant spread of the disease. Familiarity with opioids, adjuvants, and procedures that can abate pain in cancer patients is discussed in a practical manner for clinical application in this text.

Palliating Patients Who Have Unresectable Colorectal Cancer: Creating the Right Framework and Salient Symptom Management

The last phases of colorectal malignant illness may be the most challenging and saddening for all involved, but they offer opportunities to become the most rewarding. This transformation of hopelessness to fulfillment requires a willingness by surgeon, patient, and patient's family to trust one another to realistically set goals of care, stick together, and not let the treatment of the disease become a surrogate for treating the suffering that characterizes grave illness.

Tramadol and hyoscine N-butyl bromide combined in infusion solutions: compatibility and stability

BACKGROUND

More than two-thirds of patients with metastatic cancer experience pain. Tramadol is one of the most interesting and useful weak opioids used by palliative care units to treat moderate to moderately severe pain. Relief of distressful symptoms in terminally ill patients is of prime importance; a common practice is to administer opioid analgesics in conjunction with other drugs as hyoscine N-butyl bromide, which is very useful in reducing secretions in patients with inoperable malignant bowel obstruction. The pursuit for excellence in symptom control in patients unable to take oral medication has led to the administration of medications by other routes such as the subcutaneous route.

PURPOSE

The purpose of this study was to fulfill the lack of information regarding the compatibility and physical stability of tramadol hydrochloride and hyoscine N-butyl bromide combined in infusion solutions.

METHODS

The stability of nine admixtures (stored in polypropylene syringes) at 4 and 25 degrees C was assessed over a period of 15 days.

RESULTS

Nonstatistically significant losses of tramadol HCl and a maximum loss of 7% for hyoscine N-butyl bromide were obtained. Therefore, tramadol HCl (dose range, 100-400 mg/day) can be formulated together in saline with hyoscine N-butyl bromide (dose range 40-80 mg/day) for s.c. infusion using a 60-ml drug infuser for a duration of 7 days.

A guide to understanding malignant bowel obstruction

Malignant bowel obstruction (MBO) is a common occurrence in patients with abdominal and pelvic malignancies. MBO is a complex problem that is a result of a cascade of pathophysiological events. For many patients near the end of life, aggressive medical management of this problem is necessary because patients are not candidates for surgery. An assessment and thoughtful examination of options for intervention is important in aligning treatments with patients' goals of care. The palliative care nurse has an important and privileged role in nursing, educating and advocating for patients with MBO. This article reviews the normal and abnormal physiology of the gastrointestinal tract. Advice is provided for the assessment and management of the physical and psychological symptoms of MBO in patients near the end of life.