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Question

Difficulty: HardEnd-of-Life and Palliative Care

A 66-year-old woman is admitted to the hospital with intractable nausea, vomiting, and diffuse, crampy abdominal pain. She has a history of advanced ovarian cancer with extensive peritoneal carcinomatosis. Her last bowel movement was 5 days ago. Temperature is 37.1°C (98.8°F), blood pressure is 105/65 mm Hg, pulse is 110/min, and respirations are 18/min. The abdomen is markedly distended and tympanic, with high-pitched bowel sounds. A CT scan of the abdomen reveals multifocal complete small bowel obstructions with several transition points.

The surgical and oncology services evaluate the patient and determine she is not a candidate for surgical intervention or further chemotherapy. Following a goals-of-care discussion, the patient and her family elect to transition to a comfort-focused palliative approach. A nasogastric tube was placed in the emergency department, which currently drains 800 mL of bilious fluid daily. The patient is experiencing severe distress from the nasogastric tube and explicitly requests its removal. She is currently receiving a transdermal fentanyl patch and as-needed intravenous morphine, which provide partial relief of her pain.

After the nasogastric tube is removed, which of the following is the most appropriate next step in the pharmacologic management of this patient's symptoms?

  1. Initiate intravenous octreotide and dexamethasoneAnswer
  2. B
    Administer intravenous metoclopramide
  3. C
    Increase the dosage of the transdermal fentanyl patch
  4. D
    Administer oral polyethylene glycol
  5. E
    Consult gastroenterology for placement of a percutaneous endoscopic gastrostomy feeding tube

Answer

Initiate intravenous octreotide and dexamethasone
In patients with complete malignant bowel obstruction who are not surgical candidates and wish to avoid nasogastric intubation, medical management focuses on reducing gastrointestinal secretions and peritumoral edema. Octreotide (a somatostatin analog) significantly decreases the active secretion of gastric, pancreatic, and intestinal fluids, thereby reducing intraluminal volume, distension, and vomiting. Corticosteroids such as dexamethasone act synergistically by reducing peritumoral inflammatory edema, which can sometimes partially relieve the obstruction, while also providing independent antiemetic effects.

Step-by-Step Solution

1
Identify the patient's primary clinical issue and goals of care.
The patient has an inoperable, complete, multifocal malignant bowel obstruction (MBO) and has transitioned to comfort-focused care. She strongly desires the removal of her nasogastric tube.
Establishing the physiologic limitations (inoperable obstruction) and patient values (comfort, no NGT) dictates the boundaries of available medical therapies.
2
Determine the pathophysiologic drivers of the patient's symptoms.
The nausea, vomiting, and distension are driven by the accumulation of several liters of normal daily gastrointestinal secretions upstream of the obstruction, exacerbated by peritumoral inflammatory edema.
Targeting the source of the fluid and inflammation is required once mechanical decompression (NGT) is removed.
3
Select the appropriate pharmacologic agents to address the pathophysiology.
Octreotide and dexamethasone are selected.
Octreotide (a somatostatin analog) potently inhibits the secretion of gastric, pancreatic, and intestinal fluids. Dexamethasone reduces peritumoral inflammatory edema and has independent antiemetic properties.
4
Exclude contraindicated therapies.
Prokinetics (metoclopramide), enteral feeding, and laxatives are excluded.
These interventions either force motility against a fixed obstruction (risking perforation and worsening pain) or add unwanted volume to an already obstructed gastrointestinal tract.

Key Concept

Medical management of inoperable malignant bowel obstruction in palliative care relies on decreasing gastrointestinal secretions (octreotide) and reducing peritumoral edema (corticosteroids) while strictly avoiding prokinetics.
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Topics

End-of-Life and Palliative Care

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