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Case History

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Image not available. A 59-year-old woman presents with abdominal distension against a background of advanced ovarian cancer with primary debulking surgery and multiple lines of palliative chemotherapy. Computed tomography (CT) scanning showed minimal ascites but progressive peritoneal nodules, including an indeterminate mass in the uterovaginal pouch. The pain became progressively worse over the next few days and was associated with faeculent vomiting. A plain X-ray of the abdomen showed small bowel obstruction.

What are the causes of malignant bowel obstruction?

What are the principles of management in this patient?

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Background

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What are the causes of malignant bowel obstruction?

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Image not available. Obstruction of the gastrointestinal (GI) tract is a not uncommon presenting feature of primary and recurrent colorectal cancers, and advanced or recurrent gynaecological malignancies. It accounts for 10% of the presentations of acute oncology. A proportion of these tumours will have their primary presentations as subacute obstruction through general surgical, GI and (less frequently) gynaecological cancer teams. The obstruction may be from a single site, as is most commonly the case in colorectal cancer where intraluminal disease is the major factor, or from multiple sites as a result of widespread intra-abdominal carcinomatosis, which cause mechanical disturbances of motility as well as involvement of mesenteric plexuses.1 In the case of recurrent cancer, a multidisciplinary team approach the surgical and non-surgical management of bowel obstruction is required.2 Where a palliative approach is adopted, management of the psychosocial issues of the patients and their families is required.

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Non-malignant causes of bowel obstruction should always be considered, particularly where previous surgery has been performed or radiation has been given to the abdomen or pelvis (Table 41.1).3,4

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Table Graphic Jump Location
Table 41.1Causes of bowel obstruction
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Diagnosis and initial management
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Diagnosis is based on the patient's history, clinical assessment and an initially plain abdominal X-ray. Pelvic examination may be helpful if relapse from a gynaecological primary is suspected and this provides a simple assessment of the extent of metastatic disease. Computed tomography is often helpful in delineating the site and extent of disease, although water-soluble oral contrast may be required and small-volume peritoneal disease may not be demonstrated. Where the patient is located in a medical assessment unit, close liaison with surgical teams is essential, and in the case of recurrent disease the responsible oncologist should be informed.

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Although imaging will usually identify the site of bowel obstruction, opioid therapy and electrolyte imbalance may complicate the clinical picture, as may dysmotility caused by concurrent medication. In the immunosuppressed patient secondary ...

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