THE MEDICAL MANAGEMENT OF INTESTINAL OBSTRUCTION

Antiemetics for inoperable bowel obstruction are best given via CSCI

  • It is always worth performing a rectal examination to rule out constipation before confirming a diagnosis of intestinal obstruction.
  • Development of malignant bowel obstruction can be a slow and insidious process with episodes of paralytic ileus and mechanical obstruction over days to weeks.
  • Careful assessment of the clinical symptoms/signs is essential for the most appropriate management.
  • Paralytic ileus (e.g. electrolyte disturbance or autonomic dysfunction) may mimic intestinal obstruction but is potentially reversible. Colic is usually not a feature in such patients and clinical examination may reveal absence of or reduced bowel sounds.
  • Mechanical intestinal obstruction (e.g. as a result of adhesions or tumour) will usually present with colic and clinical examination may reveal increased bowel sounds. This can generally be divided into:-
    • Subacute or partial obstruction (intermittent symptoms of colicky abdominal pain, nausea and vomiting, reduced frequency of passing flatus and opening bowels) which may resolve for a limited time
    • Complete obstruction (sustained symptoms of colicky abdominal pain, nausea and vomiting and absence of flatus and stool) which is irreversible
  • Surgical intervention or stenting may be helpful for a small number of patients. A palliative bypass with or without stoma formation may be indicated if there is single level obstruction. Diffuse intra-abdominal disease or ascites are contraindications for palliative surgery.
  • The main principles of management are to control nausea, colic and other abdominal pain using drugs shown in the Section: Syringe Driver 
  • It is possible to keep a patient’s symptoms controlled with subcutaneous medications given via a syringe driver/pump. Some patients may prefer occasional vomits (as long as nausea is well controlled) to avoid naso-gastric tube (NGT) insertion. Other patients with obstruction and large volume vomiting may prefer NGT insertion to avoid persistent vomiting.
  • Dry mouth can be managed with regular oral care and ice cubes to suck
  • Intravenous or subcutaneous fluids may be considered if the patient is dehydrated and thirsty
  • In partial malignant obstruction the combination below can be effective in restoring bowel function:-

Do not use metoclopramide in patients with intestinal colic and in those with Parkinson’s spectrum disorders.

  • When complete intestinal obstruction occurs, prokinetic agents and bulk-forming or stimulant laxatives are contra-indicated.
  • Patients may be able to tolerate small amounts of food and drink, if the nausea is well controlled. A low residue diet may be better tolerated (soft low fibre foods)

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.