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Palliative care of bowel obstruction in cancer patients

Author
Sebastiano Mercadante, MD
Section Editor
Eduardo Bruera, MD
Deputy Editors
Diane MF Savarese, MD
Wenliang Chen, MD, PhD

INTRODUCTION

Bowel obstruction occurs when there is reduced or absent progress of the forward flow of gastric and intestinal contents through the gastrointestinal tract. Bowel obstruction caused by cancer is referred to as malignant bowel obstruction [1]. In everyday practice, however, it is often difficult to differentiate malignant from benign bowel obstruction, as cancer patients, especially those who have a history of abdominal surgery, can develop bowel obstruction from benign etiologies (eg, adhesions). Regardless of etiology, management of bowel obstruction in patients with advanced stage cancer can be difficult; a decision to proceed to surgical intervention requires careful weighing of risks and benefits, including an assessment of the estimated life expectancy and the patient’s goals and preferences for care.

In this topic, we discuss the etiologies, clinical features, diagnostic evaluation, and management of bowel obstruction in cancer patients. General discussions of small and large obstruction can be found in other topics. (See "Overview of management of mechanical small bowel obstruction in adults" and "Overview of mechanical colorectal obstruction".)

EPIDEMIOLOGY

Malignant bowel obstruction is common in patients with abdominal or pelvic cancers. It is most prevalent in ovarian cancer (5.5 to 42 percent), colorectal cancer (4.4 to 24 percent), and gastric cancer [2]. Uncommonly, metastases from extraabdominal cancers, including breast cancer, lung cancer, and melanoma, can also cause malignant bowel obstruction. Malignant bowel obstruction presents most frequently in advanced stage cancer patients. In a large cohort study of 490 cancer patients from MD Anderson, the anatomic sites of obstruction were classified as gastric outlet, small bowel, and large bowel in 16, 64, and 20 percent, respectively [3].

ETIOLOGY AND PATHOPHYSIOLOGY

Intestinal obstruction may be caused by benign or malignant etiologies (table 1). Distinguishing benign causes from malignant bowel obstruction in a cancer patient can be challenging but has profound impacts upon management decisions and prognosis [4]. Among cancer patients, large bowel obstruction is four to five times less frequent than small bowel obstruction, and the causes differ substantially [3]. Most small bowel obstructions are due to benign causes, whereas malignant causes predominate in large bowel obstructions.

Benign etiologies — Bowel obstruction can be caused by nonmalignant causes, including postsurgical adhesions, radiation enteritis, or other infectious or inflammatory gastrointestinal diseases (eg, abscess, phlegmon) (table 1). Benign conditions are more commonly observed when the obstruction is in the small bowel, where primary tumors are rare.

                                      
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Literature review current through: Nov 2017. | This topic last updated: Sep 16, 2017.
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