Management of bowel obstruction in palliative care
Management of bowel obstruction in patients with palliative care needs depends on the cause and location of bowel obstruction (low bowel obstruction or gastric outlet or high bowel obstruction). Consider the potential benefits and burdens of each intervention, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care.
Although the development of a bowel obstruction can herald approaching death, it may also be a relapsing–remitting disorder with a long duration. Even when bowel obstruction is a terminal event, patients may survive for several weeks. Partial bowel obstruction can be a relapsing and remitting condition with a prognosis of weeks to months, while complete obstruction carries a short prognosis (days).
Initial management of bowel obstruction involves simultaneously:
- considering possible interventions to overcome the obstruction by surgical or, if relevant, oncological means (chemotherapy, immunotherapy or radiotherapy)—seek early specialist surgical or oncology advice. Patients must be well enough to undergo or to tolerate the intervention
- considering whether constipation could be causing or contributing to the obstruction and, if suspected, using a laxative—see Management of constipation causing or contributing to bowel obstruction
- managing symptoms, including pain and nausea and vomiting.
If surgical options are not available or not appropriate for a patient with bowel obstruction, focus on symptom management.
If a single site of obstruction is likely, or if a combination of constipation and partial obstruction may be responsible for a low bowel obstruction, dexamethasone may reduce tumour oedema and relieve the obstruction. Use:
dexamethasone 4 to 8 mg subcutaneously, daily. Assess after 1 week and stop if there is no benefit. If there is benefit, reduce to the lowest effective dose and use for the shortest possible time. For advice on stopping dexamethasone, see Rationalising corticosteroids used for symptom or complication management in palliative care. dexamethasone
Patients with bowel obstruction will not have an appetite or desire to eat or drink but may like to eat or drink for the taste. Oral intake of about 1 litre of fluids daily can be tolerated by many patients with bowel obstruction. Avoid overhydration with parenteral fluid as this can increase bowel intraluminal fluid. If a patient or their family or carer insists on having parenteral hydration, a limited, targeted trial of a small volume (approximately 500 mL daily) will usually have minimal effect on the amount of secretions, and consequently the frequency and volume of vomiting.