QUICK GUIDE BOWEL OBSTRUCTION

Assessment / Description IMPORTANT CONSIDERATIONS:

Malignant bowel obstruction is a recognised complication of advanced pelvic or abdominal
malignancy. May be made worse by adhesions from previous surgery/ radiotherapy. Symptom Control
Common symptoms associated with malignant bowel obstruction include abdominal pain,
abdominal colic, nausea and vomiting.
Pain:
The evidence base for management of malignant bowel obstruction is weak. • Opioid analgesia should be titrated to
control continuous abdominal pain.
An individualised approach to management is recommended for each patient and specialist • Colic should be managed with the

palliative care advice should be sought. reduction in dose or discontinuation of

• The diagnosis is made clinically through history and examination prokinetic drugs such as metoclopramide
This may be confirmed with imaging (abdominal X-ray or CT scan) depending on individual followed by the commencement of an anti-
circumstance and preferences spasmodic such as hyoscine butylbromide
• Consider if there are any surgical interventions possible
• Treat constipation if appropriate Reduction of secretions:
• Consider absorption of modified medications when deciding route • Patients experiencing large volume
vomiting should be prescribed anti-secretory
treatment.
Pharmacology options for Symptom Control in Malignant Bowel Obstruction • Octreotide is the recommended first line
**Dose adjustments may need to be made depending on renal and hepatic function** anti-secretory medication

Indication (s) Drug name Dose (over 24 hours Notes

via CSCI unless other- Reduction of nausea and vomiting:
wise stated) • Anti-emetics should be administered via the
Relief of Opioid via CSCI/24 Dependent on previous Absorption of oral formulation via gut subcutaneous route.
constant pain hours or transdermal dose may have been impaired, therefore Prokinetics are not advised in a bowel
Fentanyl patch when converting from oral to CSCI, obstruction affecting the small bowel or in a com-
consider adjusting the dose plete obstruction at lower levels of the bowel.
accordingly.

Relief of colic Hyoscine butylbromide 60 mg - 120 mg Do not combine with cyclizine in CSCI
as can cause crystallisation Corticosteroids:
• A five day trial of Dexamethasone 8 mg daily
Glycopyrronium 600 micrograms - 2.4 mg Does not crystallise
orally ,or similar dose, subcutaneously
Reduce Octreotide 300 - 600 micrograms. Can be considered first line. should be considered in all patients to
volume of Doses may be increased Alternatively use reduce tumour related oedema
gastrointestinal up to 1.2 mg in some hyoscine butylbromide
secretions cases under specialist but do not combine with cyclizine in
guidance CSCI as can cause crystallisation Laxatives:
• The use of stimulant laxatives should be
Hyoscine butylbromide 60 mg - 120 mg Do not combine with cyclizine in CSCI
as can cause crystallisation avoided. The use of stool softeners may be
appropriate.
Glycopyrronium 600 micrograms - 2.4 mg Does not crystallise with other
common injectable drugs

Interventions

Reduce tumour Dexamethasone 6.6 mg subcutaneously Given as a single dose or divided into Medication Delivery:
oedema. OD or 3.3 mg subcutane- 2 doses (before 2 p.m.) • Medication should be delivered via the
Reduce nausea ously BD (in morning) Late administration may cause
subcutaneous route due to potential
and vomiting insomnia /agitation
problems with absorption
Reduce Levomepromazine 2.5 mg - 25 mg May cause sedation. Use the lowest
nausea and effective dose. Higher doses may cause
vomiting sedation.
Nasogastric Tubes:
Metoclopramide 30 mg - 60 mg Contraindicated in complete bowel • A wide bore nasogastric tube should be
avoid in complete bowel There is an increased risk obstruction. considered for patients with upper
obstruction of neurological adverse Dose may be increased under
gastrointestinal obstruction or large
effects at doses higher Specialist Palliative Care advice.
than 30mg/24hour and if Monitor for increased abdominal volume vomiting.
used for longer than 5 colic.
days.
Venting Gastrostomies:
Haloperidol 1.5 mg - 5 mg Watch for extra-pyramidal side effects. • Venting gastrostomies or jejunostomies
May cause sedation should be considered for patients with
Cyclizine 150 mg Do not combine with hyoscine
malignant bowel obstruction who have a
be aware cyclizine is gut butylbromide in CSCI as can cause prognosis of greater than 2 weeks.
slowing crystallisation • Venting gastronomies have been shown to
be cost effective with low morbidity and
Ondansetron seek Specialist Palliative Care advice mortality.
Not licenced for SC use

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