Unresectable Malignancy and Bowel Obstruction in the Acute Care Surgery Patient
Patients with incurable cancer who develop malignant bowel obstruction (MBO) represent a challenge for acute care surgeons. Most of these patients have a poor prognosis and limited survival. Surgical management, in carefully selected patients, may increas
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Unresectable Malignancy and Bowel Obstruction in the Acute Care Surgery Patient Zara Cooper, Elizabeth Lilley and Gregory J. Jurkovich
Abbreviations 5-HT3 cm CT D2 H1 L MBO mm MRI
Serotonin type 3 receptor Centimeter Computed tomography Dopamine type 2 receptor Histamine type 1 receptor Liters Malignant bowel obstruction Millimeter Magnetic resonance imaging
Background Malignant bowel obstruction (MBO) is a preterminal condition in patients with advanced, incurable cancer. An international committee on MBO defined it as a bowel obstruction beyond the ligament of Treitz occurring in a patient with either an incurable intra-abdominal primary malignancy or an extra-abdominal primary with clear intraperitoneal spread [1]. Ovarian and colorectal cancers are the most Z. Cooper (&) Harvard Medical School, Boston, MA 02115, USA e-mail: [email protected] E. Lilley The Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA 02120, USA e-mail: [email protected] G.J. Jurkovich Department of Surgery, University of Colorado, 12631 E. 17th Avenue, Aurora, CO 80045, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 J.J. Diaz and D.T. Efron (eds.), Complications in Acute Care Surgery, DOI 10.1007/978-3-319-42376-0_26
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common causes of MBO. Other causes include pancreatic, breast, and melanoma. Regardless of the primary cancer, patients with MBO have an underlying non-curable malignancy and present with similar clinical manifestations. Obstruction may be intra-luminal or extra-luminal. Intra-luminal obstructions are due to direct invasion of tumor into the bowel wall, resulting in intestinal linitis plastica. Extra-luminal obstructions are more common and are due to external tethering or compression from metastases or peritoneal carcinomatosis. An inflammatory reaction may occur in the tissue adjacent to the tumor, leading to edema and further luminal narrowing. In addition, tumor invasion into the bowel wall, mesentery, or nerves may lead to dysmotility. Of note, patients with MBO may have multiple, simultaneous causes of obstruction. For patients with incurable malignancies, development of MBO portends poor prognosis. Estimated survival after initial MBO diagnosis presentation ranges from 1 to 9 months [2]. The high symptom burden and frequent need for inpatient hospitalization during treatment for MBO contribute to high healthcare utilization and impaired quality of life for patients facing terminal illness [3]. Although most patients admitted with MBO are able to be discharged from the hospital, 27–48 % are readmitted with recurrent MBO [4–6]. The majority of patients initially have partial obstructions that gradually worsen. Episodes may be intermittent with spontaneous, symptom-free periods. As the disease process progresses, these intervals become shorter and more frequent, and patients may eventually develop complete obstruction.
Diagnosis Potential MBO diagnosis should be entertained for patients presenting with signs of o
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