Bowel obstruction medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Overview

The mainstay treatment of bowel obstruction is surgical and non-operative management. The role of medical therapy is supportive and is limited by palliative pain management in cancer patients, fluid and electrolyte replenishment, decreasing abdominal distension, peritumoral edema, intraluminal secretions, peristaltic movements, and control of nausea and vomiting.

Medical Therapy

The mainstay treatment of bowel obstruction is surgical and non-operative management. The role of medical therapy is supportive and is limited by control of vomiting and nausea, fluid and electrolyte replenishment, and palliative pain management in cancer patients. Glucocorticoids, octreotide and anticholinergic agents can be used to decrease abdominal distension, peritumoral edema, intraluminal secretions, and peristaltic movements. Antibiotics also play a role in treating infections but are not routinely recommended.[1][2][3][4][5][6][7][8][9]

  • 1 Antiemetics
    • 1.1 Antiemetics in cancer patients
      • 1.1.1 Adult
      • 1.1.2 Antiemetics in non-cancer patients
        • Preferred regimen (1): Promethazine 12.5-25 mg q4 - 6h PRN or PO, alternatively 12.5-25 mg q4 - 6h IV or IM
        • Preferred regimen (2): Ondansetron 4 - 8 mg q8-12hr PO or IV
      • 1.1.3 Pediatric
        • 1.1.3.1 Children 1 month - 12 years of age
        • 1.1.3.1 Children < 2 years of age
        • 1.1.3.2 Children > 2 years of age
          • Preferred regimen (1): Promethazine 0.25-1 mg/kg PO/PR q4-6hr; not > 25 mg
        • 1.1.3.2 Children > 12 years of age
          • Preferred regimen (1): Ondansetron 4 mg IV/IM or 16 mg PO 1 hr
  • 2 Fluid and electrolyte replacement
    • 2.1 Fluid replacement
      Note (1): Replacement is only necessary if deficit continues for >48h, or in excess of 2L in 24h
  • 3 Pain management in cancer/non-cancer patients
    • 3.1 Non-opioids
      • 3.1.1 Adult
        • Preferred regimen (1): Acetaminophen 325–1000 mg PO q4–6h PRN
        • Alternative regimen (2): Aspirin 325–650 mg PO q4h PRN
        • Alternative regimen (3): Diclofenac 50 mg PO BID-TID
        • Alternative regimen (3): Etodolac 200–400 mg PO q6–8h
        • Alternative regimen (4): Ibuprofen 400–600 mg POq 4–6h PRN
        • Alternative regimen (5): Indomethacin 25–50 mg PO TID
        • Alternative regimen (6): Ketoprofen 25–50 mg PO q6h–q8h
        • Alternative regimen (7): Ketorolac 10 mg PO q4–6h PRN or 30 mg IV/IM q6h
        • Alternative regimen (8): Meclofenamate 50–100 mg PO q4–6h PRN
        • Alternative regimen (9): Mefenamic acid 250 mg PO q4–6 PRN
        • Alternative regimen (10): Meloxicam 7.5–15 mg PO once daily
        • Alternative regimen (11): Nabumetone 100–2000 mg once daily
        • Alternative regimen (12): Naproxen 250–500 mg PO BID
        • Alternative regimen (13): Oxaprozin 1200 mg PO once daily
        • Alternative regimen (14): Piroxicam 20 mg PO once daily
        • Alternative regimen (15): Sulindac 150–200 mg PO BID
        • Alternative regimen (16): Tolmetin 200–600 mg PO BID-TID
        • Alternative regimen (17): Tramadol 50–100 mg PO q4–6h PRN; 100 – 300 mg QD for SR
        • Alternative regimen (18): Celecoxib 200 mg PO BID
    • 3.2 Opioids
      • 3.2.1 Adult
        • Preferred regimen (1): Morphine sulfate 10–30 mg q3–4h PO
        • Alternative regimen (1.2): Rectal suppository; 10–20 mg q4h
        • Alternative regimen (1.3): PRN; 2.5–10 mg q2–6h
        • Alternative regimen (1.4): Epidural; 3–5 mg once, then 0.1–0.7 mg/hr
        • Alternative regimen (1.5): Intrathecal; start 100:1 IT-to-IV, then titrate to pain
        • Alternative regimen (1.6): Controlled release tab 15–30 mg q8–12h
        • Alternative regimen (1.7): Sustained release tab 15–30 mg q8–12h
        • Alternative regimen (1.8): Extended release capsule 20 mg q24h, may increase by 20 mg increments every other day
        • Alternative regimen (1.9): Extended release capsule 30 mg q24h, may increase by 30 mg increments q4days (max 1600 mg/d)
        • Alternative regimen (2): Codeine 15–60 mg q4–6h (max 60 mg/d)
        • Alternative regimen (3): Dilaudid 2–8 mg q3-4h for PO and PR
        • Alternative regimen (4): Roxycodone 5–30 mg q4h
        • Alternative regimen (5): Oxycontin 10–160 mg q12h
        • Alternative regimen (6): Opana 5–10 mg q4–6h
        • Alternative regimen (7): Opana extended release 5–40 mg q12h
        • Alternative regimen (8): Propoxyphene HCl 65 mg q4h (max 390 mg/24h)
        • Alternative regimen (9): Methadone 2.5–10 mg q3-6h
          Note (1): Has very long half-life (8–60 hours)
        • Alternative regimen (10): Meperidine 50–150 mg q3–4h
          Note (2): Decrease dose if given IV, administer slow or via PCA. Not recommended for chronic use.
        • Alternative regimen (11): Fentanyl 25–100 mcg q1–2h or 0.5–1.5 mcg/kg/hr IV infusion via PCA
        • Alternative regimen (12): Actiq; start with 200 mcg for breakthrough pain episodes, then titrate to pain
        • Alternative regimen (13): Duragesic 25 mcg/h q72hr, may increase q3–6days
  • 4 Anti-edema
    • 4.1 Glucocorticoids
      • 4.1.1 Adult
          • Preferred regimen (1): Dexamethasone 6 - 16 mg IV or SC daily for 3 - 5 days, not > 7 days
          • Alternative regimen (1): Prednisolone 15 - 50 mg IV or SC daily for 3 - 5 days, not > 7 days
  • 5 Anti-secretion, anti-peristaltic, and anti-emetic
  • 6 Infection management
    • 6.1 Antibiotics
      • 6.1.1 Adult
        • Preferred regimen (1): Cefazolin 2 g IV q12hr severe infection, 3 g IV q12hr life-threatening infection
        • Alternative regimen (2): Cefoxitin 1 g IV q4hr or 2 g IV q6-8hr severe infection, 6-8 g/day maximum in life threatening
        • Alternative regimen (3): Cefotetan 2 g IV q12hr severe infection, 3 g IV q12hr life-threatening infection
        • Alternative regimen (4): Cefuroxime 1.5 g IV/IM q8hr severe infection; q6hr in life-threatening circumstances
        • Alternative regimen (5): Meropenem 1 g IV q8hr severe infection; not > 2 g IV q8hr
      • 6.1.2 Pediatric
        • 6.1.2.1 Neonate < 7 days old
          • Preferred regimen (1): Cefazolin 40 mg/kg q12h IV or IM daily divided
          • Alternative regimen (2): Cefuroxime 100 mg/kg q12h IV or IM daily divided
          • Alternative regimen (3): Meropenem 20 mg/kg q8h IV; not > 1 g q8h
        • 6.1.2.2 Infants > 7 days old
          • Preferred regimen (1): Cefazolin 25-100 mg/kg q6-8h IV or IM daily divided; not > 6 g daily
          • Alternative regimen (2): Cefoxitin 80-160 mg/kg q4-6h IV daily divided
          • Alternative regimen (3): Cefotetan 40-80 mg/kg q12h IV or IM daily divided
          • Alternative regimen (4): Cefuroxime 150 mg/kg q8h IV or IM daily divided
          • Alternative regimen (5): Meropenem 20 mg/kg q8h IV; not > 1 g q8h
  • 7 Prokinetics
    • Preferred regimen (1): Metoclopramide 10 mg q4h SC or 60 - 200 mg SC daily continuous injection
      • Note (1): Contraindicated in complete bowel obstruction
    • Alternative regimen (2): Domperidone 10 mg PO QID

References

  1. Sagar PM, MacFie J, Sedman P, May J, Mancey-Jones B, Johnstone D (1995). "Intestinal obstruction promotes gut translocation of bacteria". Dis. Colon Rectum. 38 (6): 640–4. PMID 7774478.
  2. LE QUESNE LP (1955). "Fluid balance in intestinal obstruction". Postgrad Med J. 31 (355): 227–33. PMC 2500705. PMID 14371195.
  3. Khoo D, Hall E, Motson R, Riley J, Denman K, Waxman J (1994). "Palliation of malignant intestinal obstruction using octreotide". Eur. J. Cancer. 30A (1): 28–30. PMID 7511400.
  4. Spears H, Petrelli NJ, Herrera L, Mittelman A (1988). "Treatment of bowel obstruction after operation for colorectal carcinoma". Am. J. Surg. 155 (3): 383–6. PMID 3344898.
  5. Ripamonti CI, Easson AM, Gerdes H (2008). "Management of malignant bowel obstruction". Eur. J. Cancer. 44 (8): 1105–15. doi:10.1016/j.ejca.2008.02.028. PMID 18359221.
  6. Blair SL, Chu DZ, Schwarz RE (2001). "Outcome of palliative operations for malignant bowel obstruction in patients with peritoneal carcinomatosis from nongynecological cancer". Ann. Surg. Oncol. 8 (8): 632–7. PMID 11569777.
  7. Higashi H, Shida H, Ban K, Yamagata S, Masuda K, Imanari T, Yamamoto T (2003). "Factors affecting successful palliative surgery for malignant bowel obstruction due to peritoneal dissemination from colorectal cancer". Jpn. J. Clin. Oncol. 33 (7): 357–9. PMID 12949063.
  8. Frank C (1997). "Medical management of intestinal obstruction in terminal care". Can Fam Physician. 43: 259–65. PMC 2255220. PMID 9040913.
  9. Mercadante S, Ferrera P, Villari P, Marrazzo A (2004). "Aggressive pharmacological treatment for reversing malignant bowel obstruction". J Pain Symptom Manage. 28 (4): 412–6. doi:10.1016/j.jpainsymman.2004.01.007. PMID 15471659.

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