Received: 1 March 2019 | Accepted: 3 March 2019

DOI: 10.1002/jso.25451

REVIEW ARTICLE

Malignant bowel obstruction

Robert S. Krouse MD, MS1,2,3

1
Department of Surgery, University of
Pennsylvania, Philadelphia, Pennylvania Abstract
2
Leonard Davis Institute of Health Economics, Malignant bowel obstruction (MBO) is a common problem for patients with advanced
Philadelphia, Pennsylvania
malignancy, especially colorectal and ovarian cancers. Symptoms include pain,
3
Department of Surgery, Corporal Michael J.
Crescenz Veterans Affairs Medical Center, bloating, nausea and vomiting, and inability to eat. Treatment options consist of a
Philadelphia, Pennsylvania wide range of surgical and nonsurgical interventions (medications, endoscopic, or
Correspondence interventional radiology approaches). Outcomes are variable no matter the strategy,
Robert S. Krouse, MD, Surgical Services (112), and the optimal approach is often not clear. Greater research is needed to assist
Corporal Michael J. Crescenz Veterans Affairs
Medical Center, 3900 Woodland Ave, decision‐making for clinicians treating patients with MBO.
Philadelphia, PA 19104.
Email: [email protected] KEYWORDS
bowel, malignant, nonsurgery, obstruction, surgery

1 | INTRODUCTION are important, they should also be individualized for each patient.
While it may be intuitive that relieving nausea and vomiting or the
Malignant bowel obstruction (MBO) is the most common indication ability to eat are paramount, there are many social and other factors
for palliative surgical consultation.1 It occurs most frequently with that influence patient priorities. In fact, being out of the acute‐care
ovarian and colorectal cancers, but can be seen with other abdominal setting is often the most important goal for patients facing the end of
and occasionally with nonabdominal malignancies. MBO may be life.4-10
directly related to the tumor, its treatment (eg, radiation enteritis), or
benign etiologies (eg, adhesions or internal hernia). In a recent review
2 | CLINICAL OPTIONS
of 334 patients with bowel obstruction and advanced malignancy,
obstructions were tumor‐related in 68%, adhesion‐related in 20%,
2.1 | Surgical options
and of unclear etiology in 12%.2
One problem in comparing studies with MBO are variable Persistent obstructions in the face of conservative therapy (usually
definitions of this condition. One accepted definition of MBO that nasogastric decompression, hydration, and bowel rest) or evidence of
can provide the framework comparing patients and outcomes is: (a) complete obstructions are signs that a surgical procedure may be
clinical evidence of a bowel obstruction via history, physical indicated. Many patients are deemed inoperable (6.2%‐50%).11 This
examination, or radiographic examination, (b) bowel obstruction may be due to poor operative risk or relative contraindications to
beyond the ligament of Treitz, (c) intra‐abdominal primary cancer surgery. Poor operative risk must be assessed based on comorbidities
with incurable disease, or (d) nonintra‐abdominal primary cancer (eg, cardiac and pulmonary function), amount and location of
3
with clear intraperitoneal disease. This definition ensures that it is metastatic disease (eg, overwhelming metastasis to the liver), and
established if a patient has an MBO preoperatively. Therefore, either current functional status. Potential contraindications for surgery in
retrospective or prospective studies would have similar populations patients with incurable cancer and MBO include ascites, carcinoma-
of patients. If determinations of MBO are changed intraoperatively, tosis and particularly the combination of ascites and carcinomatosis,
comparisons to those patients who do not have an operative multiple obstructions, low albumin, multiple prior surgeries, or a
procedure are flawed. In addition, this definition omits gastric outlet palpable intra‐abdominal mass.12-14
obstruction, which typically has a different treatment strategy. Although it is recognized that improvement in quality of life after
The goals of treatment include relieving the symptoms of nausea, surgery is variable (42%‐85%),11,15 there is no consistent parameter
vomiting, and pain, allowing oral intake, and permitting the patient to used to determine this clinical outcome. While operations may offer
return to their chosen care setting. Although all goals of treatment an advantage of increased survival, surgical risks must be carefully
J Surg Oncol. 2019;1-4. wileyonlinelibrary.com/journal/jso © 2019 Wiley Periodicals, Inc. | 1
2 | KROUSE

considered before an operation, as morbidity (7%‐44%) and mortality Center, Houston, TX, found that percutaneous gastrostomy tubes
(6%‐32%) are common, and the reobstruction rate (6%‐47%) and were utilized for palliation in 23% of small bowel obstructions in
readmission (38%‐74%) is high.16 patients with advanced malignancy.24 In combination with other
There is a myriad of situations one might encounter in the medical techniques, both open and percutaneous gastrostomy offers
operating room. Typically, the approach is unknown until exploring the the possibility of intermittent oral liquid intake.
abdomen. The optimal procedure is that which is the quickest, safest, Complications related to decompressive PEGs are rare, particu-
and most efficacious in alleviating the obstruction. If due to adhesions, larly when utilized for relatively short periods of time in the setting of
adhesiolysis alone might be the optimal surgical procedure. Bowel advanced malignancy.21 Venting gastrostomy tubes may also be
17,18
resection may lead to the best outcome, although bypass may be a placed percutaneously through interventional radiologic procedures.
better option when resection is not possible due to tumor burden or Percutaneous gastrostomy tube placement is possible in patients
deemed unsafe due to operative risks. In the setting of massive with ascites, although with a major complication rate of 10%, and
carcinomatosis, the placement of a gastrostomy tube for intermittent requires ascites management with paracentesis or intraperitoneal
venting might be optimal. Finally, an intestinal stoma may be necessary catheter placement.25
after resection or to adequately bypass the blockage.
Laparoscopic procedures may be attempted, although this
2.3 | Medical options
approach is often difficult due to adhesions, carcinomatosis, or
bowel dilatation. Cytoreductive procedures (resection of intraper- When patients are admitted to the hospital, conservative mea-
itoneal tumor) frequently carry high morbidity and usually are only sures (nasogastric tube, decompression, intravenous hydration, nil
considered with very low‐grade tumors, such as pseudomyxoma per os (nothing by mouth)) are typically initiated. Radiologic
peritonei. testing, typically including a computed tomography scan, will play a
Based on large, retrospective reviews it is clear that patients large role in determining if an operation should be considered or
treated with surgery have the longest survival, but this should not be only medical therapies will be implemented. While oral water‐
interpreted as evidence documenting the superiority of surgery over soluble contrast may have benefit in the benign setting, there is no
medical or procedural management.2 This finding is likely a reflection evidence that it is of benefit with an MBO.26 Total parenteral
of the practice of operating on patients with better performance nutrition is controversial and there is no evidence for improved
status with less advanced disease. survival or quality of life.27 Palliative pharmacologic therapies
have the goals of reducing intestinal inflammation and edema, and
controlling pain, nausea, vomiting, and dehydration. Pharmacologic
2.2 | Endoscopic approaches for MBO
options include: (1) anti‐secretory agents (eg, somatostatin analog,
Endoscopic procedures are typically suited for patients who are poor steroids, scopolamine); (2) pain medications (eg, morphine); and (3)
operative candidates or who decline an open operative intervention. antiemetic therapy (eg, haloperidol, prochlorperazine).
The major approaches include stenting and percutaneous endoscopic Opioids act both directly to relieve pain related to intestinal
gastrostomy (PEG) tube placement. obstruction, as well as to reduce painful bowel contractions against
Endoscopic stent placement may obviate the need for an the obstruction. Antiemetics can be given through a variety of
intestinal stoma for patients with a malignant large bowel obstruc- nonoral routes to control vomiting.28 Complete relief of emesis is
tion. While less durable for the relief of obstruction than surgical achieved in a minority of patients through antiemetics alone.
approaches, stenting is often more consistent with the patient’s goals Hormonal manipulation of gut activity has substantially added to
of care near the end of life. Stenting may also include procedures to the armamentarium of MBO management.
initially canalize the lumen (eg, laser or balloon dilatation). Octreotide, a synthetic analog of the gut hormone somatostatin,
Endoluminal wall stents have a high success rate for the relief of can decrease gastrointestinal secretions and reduces bowel motility,
symptoms (64%‐100%) in complete and incomplete colorectal often markedly reducing or resolving MBO symptoms.29 Duration of
19
obstructions, and in over 70% of upper intestinal malignant treatment may be short‐lived (median, 9.4‐17.5 days),29 although
obstructions including a gastric outlet, duodenal, and jejunal symptoms are frequently relieved for the life of the patients. In a
20
obstructions. While risks include perforation (0%‐15%), stent recent randomized controlled trial comparing octreotide with other
migration (0%‐40%), or reocclusion (0%‐33%), stents can frequently standardized medical therapies, octreotide did not show a clear
lead to adequate palliation for long periods of time.19 Stent occlusion benefit in the setting of MBO.30 A limitation of this study may be the
by tumor in‐growth is occasionally amenable to another endoscopic primary outcome of the number of days free of vomiting as reported
intervention. daily by patients over 72 hours, which may be unduly restrictive and
PEG tubes are generally well tolerated “venting” procedures that subjective. Also, there may be some patients in this trial who would
can alleviate symptoms of intractable vomiting and nausea for benefit from an early operation. The authors do acknowledge that
malignant small bowel obstructions and allow for discharge to home, further study is warranted. Anticholinergic medications, such as
21,22
typically with hospice care. They may also be associated with scopolamine, can decrease peristalsis and secretions and lead to
fewer hospital readmissions.23 A study from MD Anderson Cancer improved control of vomiting and intestinal colic for malignant
KROUSE | 3

gastrointestinal obstruction. Corticosteroids are commonly used as requiring surgical evaluation for palliation. Support Care Cancer.
2009;17:727‐734.
adjunctive agents or alone in MBO management, with the goals of
2. Pujara D, Chiang YJ, Cormier JN, Bruera E, Badgwell B. Selective
decreasing tumor‐associated bowel edema and of providing antie- approach for patients with advanced malignancy and gastrointestinal
metic benefits. Although meta‐analysis has suggested no statistical obstruction. J Am Coll Surg. 2017;225:53‐59.
benefit of corticosteroid use, a subset of patients may benefit from 3. Anthony T, Baron T, Mercadante S, et al. Report of the clinical protocol
31 committee: development of randomized trials for malignant bowel
them and medication‐related morbidity is low, particularly in
obstruction. J Pain Symptom Manage. 2007;34(1 suppl):S49‐S59.
patients in the terminal stages of their disease. While direct 4. Kaplan K. O., Peres J. R. Means to a better end: A report on dying
comparisons of these agents have not yielded clear recommenda- in America today. Last Acts. 2002. https://folio.iupui.edu/bit-
tions,32,33 a combination of these medications or “cocktail” may offer stream/handle/10244/469/meansbetterend.pdf?sequence=2. Ac-
cessed 30 January 2019.
synergistic benefits over single agents.34,35
5. Dunlop RJ, Davies RJ, Hockley JM. Preferred versus actual place of
death: a hospital palliative care support team experience. Palliat Med.
1989;3:197‐201.
2.4 | Surgery vs medical treatments
6. Higginson IJ, Sen‐Gupta GJA. Place of care in advanced cancer: a
It is difficult to compare disparate treatment modalities without a qualitative systematic literature review of patient preferences. J
Palliat Med. 2000;3:287‐300.
prospective trial. Patients may be sicker who receive nonsurgical
7. Hays JC, Galanos AN, Palmer TA, McQuoid DR, Flint EP. Preference
treatments,36,37 although this may be disputed.38 In retrospective for place of death in a continuing care retirement community.
analyses of variable methodologies, it appears that medical manage- Gerontologist. 2001;41:123‐128.
ment may be superior related to complications and in‐hospital death, 8. Tang ST. When death is imminent: where terminally ill patients with
cancer prefer to die and why. Cancer Nurs. 2003;26:245‐251.
although with no difference in overall survival. The actual quality of
9. Fried TR, van Doorn C, O’Leary JR, Tinetti ME, Drickamer MA. Older
life benefits are unclear. Prospective studies in MBO, while difficult persons’ references for site of terminal care. Ann Int Med.
to achieve, may help guide the treatment of individual patients. 1999;131:109‐112.
10. Hays JC, Gold DT, Flint EP, Winer EP. Patient preference for place of
death. In: de Vries B, ed. End of Life Issues: Interdisciplinary and
3 | CONC LU SION S Multidimensional Perspectives. New York: Springer; 1999:pp. 3‐21.
11. Feuer DJ, Broadley KB, Shepherd JH, Barton DP. Systematic review
of surgery in malignant bowel obstruction in advanced gynecological
MBO is a complex palliative care problem that surgeons often face in and gastrointestinal cancer. Gynecol Oncol. 1999;75:313‐322.
the acute‐care setting. For patients who have poor performance 12. Ripamonti C. Management of bowel obstruction in advanced cancer.
status and/or very advanced disease, comfort care measures are Curr Opinion Oncol. 1994;6:351‐357.
13. Blair SL, Chu DZ, Schwarz RE. Outcome of palliative operations for
optimal. For patients with a reasonably clear point of obstruction,
malignant bowel obstruction in patients with peritoneal carcinomatosis
especially if there is evidence of ischemia, a surgical approach may be from nongynecological cancer. Ann Surg Oncol. 2001;8:632‐637.
best. For most patients with MBO, outcomes and thus the ideal 14. Byrne ME, Cowan RA, Leska T, et al. Preoperative factors associated
approach is less clear. Each patient must be judged individually with with unsuccessful palliation following surgery for malignant bowel
obstruction in patients with recurrent ovarian cancer. Gynecol Oncol.
discussions regarding goals of care and realistic objectives of what
2018;149(suppl 1):224‐224.
treatments can truly achieve. Further research is needed to help 15. Miner TJ, Jaques DP, Shriver CD. A prospective evaluation of
surgeons with this difficult decision‐making issue. patients undergoing surgery for the palliation of an advanced
malignancy. Ann Surg Oncol. 2002;2002(9):696‐703.
16. Paul Olson TJ, Pinkerton C, Brasel KJ, Schwarze ML. Palliative
A C K N O W L E D GE M E N T surgery for malignant bowel obstruction from carcinomatosis: a
systematic review. JAMA Surg. 2014;149:383‐392.
The author would like to thank Mary Wagner for her editing, advice, 17. Legendre H, Vahhuyse F, Caroli‐Bose FX, Pector JC. Survival and
and guidance of this manuscript. quality of life after palliative surgery for neoplastic gastrointestinal
obstruction. Eur J Surg. 2001;27:364‐367.
18. Aranha GV, Folk FA, Greenlee HB. Surgical palliation of small bowel
CO NFLICT OF I NTERE ST obstruction due to metastatic carcinoma. Am Surgeon. 1981;
47:99‐102.
The author declares that there are no conflict of interest. 19. Harris GJC, Senagore AJ, Lavery IC, Fazio VW. The management of
neoplastic colorectal obstruction with colonic endoluminal stenting
devices. Am J Surg. 2001;181:499‐506.
OR CID 20. Soetikno RM, Carr‐Locke DL. Expandable metal stents for gastric
outlet, duodenal, and small intestinal obstruction. Gastrointest Endosc
Robert S. Krouse http://orcid.org/0000-0002-7176-461X Clin North Am. 1999;9:447‐458.
21. Campagnutta E, Cannizzaro R. Percutaneous endoscopic gastrostomy
(PEG) in palliative treatment of non‐operable intestinal obstruction
REFERENC ES due to gynecologic cancer: a review. Eur J Gynaecol Oncol. 2000;
21:397‐402.
1. Badgwell BD, Smith K, Liu P, Bruera E, Curley SA, Cormier 22. Zucchi E, Fornasarig M, Martella L, et al. Decompressive percuta-
JN. Indicators of surgery and survival in oncology inpatients neous endoscopic gastrostomy in advanced cancer patients with
4 | KROUSE

small‐bowel obstruction is feasible and effective: a large prospective nasogastric tubes: a prospective randomized trial. J Pain Symptom
study. Support Care Cancer. 2016;24:2877‐2882. Manage. 2000;19:23‐34.
23. Lilley EJ, Scott JW, Goldberg JE, et al. Survival, healthcare utilization, 33. Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison
and end‐of‐life care among older adults with malignancy‐associated of octreotide and hyoscine butylbromide in controlling gastrointest-
bowel obstruction: comparative study of surgery, venting gastro- inal symptoms due to malignant inoperable bowel obstruction.
stomy, or medical management. Ann Surg. 2018;267:692‐699. Support Care Cancer. 2000;8:191.
24. Badgwell BD, Contreras C, Askew R, et al. Radiographic and clinical 34. Calabrese R, Mian M, Wang C, Walter M, Case A. A retrospective
factors associated with improved outcomes in advanced cancer review of the management of malignant bowel obstruction at a large
patients with bowel obstruction. J Palliat Med. 2011;14:990‐996. tertiary cancer care center (FR481A). J Pain Symptom Manage.
25. Shaw C, Bassett RL, Fox PS, et al. Palliative venting gastrostomy in 2018;55:631‐632.
patients with malignant bowel obstruction and ascites. Ann Surg 35. Minoura T, Takeuchi M, Morita T, Kawakami K. Practice patterns of
Oncol. 2013;20:497‐505. medications for patients with malignant bowel obstruction using a
26. Syrmis W, Richard R, Jenkins‐Marsh S, Chia SC, Good P. Oral water nationwide claims database and the association between treatment
soluble contrast for malignant bowel obstruction. Cochrane Database outcomes and concomitant use of H2‐blockers/proton pump inhibi-
Syst Rev. 2018;3. CD01201 tors and corticosteroids with octreotide. J Pain Symptom Manage.
27. Sowerbutts AM, Lal S, Sremanakova J, et al. Home parenteral 2018;55:413‐419.
nutrition for people with inoperable malignant bowel obstruction. 36. Woolfson RG, Jennings K, Whalen GF. Management of bowel
Cochrane Database Syst Rev. 2018;8. CD0128 obstruction in patients with abdominal cancer. Arch Surg. 1997;
28. Ripamonti C. Management of bowel obstruction in advanced cancer. 132:1093‐1097.
Curr Opin Oncol. 1994;6:351‐357. 37. Mangili G, Aletti G, Frigerio L, et al. Palliative care for intestinal
29. Mercadante S, Caraceni A, Simonetti MJ. Octreotide in relieving obstruction in recurrent ovarian cancer: a multivariate analysis. Int J
gastrointestinal symptoms due to bowel obstruction. Palliat Med. Gynecol Cancer. 2005;15:830‐835.
1993;7:295‐299. 38. Bateni SB, Gingrich AA, Stewart SL, et al. Hospital utilization and
30. Currow DC, Quinn S, Agar M, et al. Double‐blind, placebo‐controlled, disposition among patients with malignant bowel obstruction: a
randomized trial of octreotide in malignant bowel obstruction. J Pain population‐based comparison of surgical to medical management.
Symptom Manage. 2015;49:814‐821. BMC Cancer. 2018;18:1166.
31. Feuer DJ, Broadley KE. Systematic review and meta‐analysis of
corticosteroids for the resolution of malignant bowel obstruction in
advanced gynecological and gastrointestinal cancer. Ann Oncol.
How to cite this article: Krouse RS. Malignant bowel
1999;10:1035‐1041.
32. Ripamonti C, Mercadante S, Groff L, Zecca E, De Conno F, Casuccio obstruction. J Surg Oncol. 2019;1‐4.
A. Role of octreotide, scopolamine butylbromide and hydration in https://doi.org/10.1002/jso.25451
symptom control of patients with inoperable bowel obstruction and