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Zorluk: OrtaEnd-of-Life and Palliative Care

A 62-year-old woman is evaluated at home by a hospice physician for severe abdominal pain and vomiting. She has widely metastatic ovarian cancer complicated by extensive peritoneal carcinomatosis. Two weeks ago, she transitioned to home hospice care with the explicit goal of maximizing comfort. She strongly refuses any hospitalizations, surgical interventions, or invasive procedures, including nasogastric intubation.

For the past 48 hours, she has had worsening colicky abdominal pain, significant nausea, and multiple episodes of large-volume, bilious emesis. Her last bowel movement was four days ago. Her current medications include a continuous subcutaneous morphine infusion for baseline pain control.

Vital signs show a heart rate of 110/min and a blood pressure of 90/60 mmHg. Physical examination reveals a visibly distended abdomen that is tympanic to percussion. Bowel sounds are high-pitched and tinkling. The physician diagnoses a malignant mechanical bowel obstruction.

Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Administer oral metoclopramide
  2. B
    Transfer the patient to an inpatient unit for nasogastric tube placement
  3. C
    Administer subcutaneous methylnaltrexone
  4. D
    Order a plain radiograph of the abdomen
  5. Administer subcutaneous octreotideCevap

Cevap

Administer subcutaneous octreotide
Malignant bowel obstruction (MBO) is a common, distressing complication of advanced abdominal and pelvic malignancies, particularly ovarian cancer. In patients with terminal illness who refuse or are not candidates for surgical decompression or nasogastric (NG) tube placement, symptom management is the primary goal. Subcutaneous octreotide, a somatostatin analog, is highly effective for MBO in the hospice setting. It inhibits the secretion of gastric, pancreatic, and intestinal fluids and decreases splanchnic blood flow. This rapidly reduces intraluminal volume, thereby relieving bowel distension, colicky abdominal pain, nausea, and vomiting without the need for invasive mechanical decompression.

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1
Identify the primary clinical diagnosis.
The patient is experiencing a malignant mechanical bowel obstruction (MBO) due to peritoneal carcinomatosis from ovarian cancer.
The symptoms of colicky pain, large-volume bilious emesis, lack of stool, and a distended, tympanic abdomen with high-pitched bowel sounds are classic for MBO.
2
Evaluate the patient's goals of care and constraints.
The patient is on home hospice care with strict comfort goals and a documented refusal of surgery, hospital transfer, or nasogastric (NG) tube placement.
Management must align with the patient's values, meaning symptom control must be achieved using non-invasive, home-based pharmacological therapies rather than mechanical decompression.
3
Select the appropriate targeted pharmacologic intervention.
Subcutaneous octreotide is selected to manage the MBO.
Because an NG tube is refused, GI secretions must be reduced pharmacologically. Octreotide inhibits GI secretions and reduces splanchnic blood flow, effectively alleviating the distension, colicky pain, and vomiting associated with MBO.

Anahtar Kavram

Pharmacologic management of malignant bowel obstruction in hospice care
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Konular

End-of-Life and Palliative Care

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