MALIGNANT BOWEL OBSTRUCTION

MALIGNANT BOWEL OBSTRUCTION:

MALIGNANT BOWEL OBSTRUCTION DR.S.SREENIVASARAO MD,C.C.P.P.M , ASSIST PROFESSOR, DEPT.OF ANAESTHESIA, S.V.R.R.G.G.H.&S.V.M.C, TIRUPATI

PREVELANCE:

PREVELANCE OVARIAN CARCINOMA—5.5 to 42% COLORECTAL CARCINOMA—4.4 to 24% OTHER ADVANCED CANCERS—3 to 15%

CAUSES:

CAUSES PRIMARY CANCER RELAPSE AFTER SUEGERY CHEMOTHERAPY RADIOTHERAPY ASSOCIATED PATHALOGIES DIFFUSE CARCINAMATOSIS CONCOMITANT DISEASES DIABETES,PARA-NEOPLASTIC SYNDROME,PREVIOUS GASTRIC SURGERY CONTRIBUTING FACTORS DRUGS LIKE ANTICHOLENERGICS,OPIOIDS

MECHANISM:

MECHANISM WITH IN THE LUMEN FECAL IMPACTION TUMOUR ,POLYPOIDAL LESION METASTATIC NODULES OUTSIDE THE LUMEN ADHESIONS FIBROSIS NEUROGENIC INTESTINAL MOTILITY DISORDERS

PATHOPHYSIOLOGY:

PATHOPHYSIOLOGY OCCLUSION PREVENTS/DELAYS PROPULSION ACCUMULATION OF NON ABSORBED SECRETIONS ABDOMINAL DISTENTION BOWEL CONTINUES CONTRACT WITH UNCO-ORDINATED PERIST BOWEL STIMULATES SECRETIONS PRODUCES GASES INCREASED BACT.FLORA BOWEL DISTENTION

PATHOPHYSIOLOGY CONT..:

PATHOPHYSIOLOGY CONT.. BOWEL DISTENTION HYPERTENSIVE STATE ACTIVATION OF CYCLO-OXYGENASE RELEASE OF P.G.,POTENT SECRETOGOGUES,VIP RELEASED INTO PORTAL&PERIPHERAL CIRCULATION LOCAL INTESTINAL INFLAMMATION HYPEREMIA&OEDEMA OF INTSTINAL WALL& ACCUMULATION OF FLUID BOWEL DISTENTION FINALLY ALTERATIONS OF THE AUTO-REGULATORY,LOCAL & NEUROHORMONAL CONTROLE MECAHNISMS OF SPLANCHNIC FLOW------MULTIORGAN FAILURE HYPOVOLEMIA----DECREASE RBF &GFR---OLIGURIA,AZOTEMIA,HAEMOCONCENTRATION

PRESENT AS:

PRESENT AS HIGH LEVEL OBSTRUCTION VOMITING METABOLIC ALKOLOSIS HYPOCHLOREMIA,HYPOKALEMIA ASPIRATION,RESP.DIFFICULTY LOW LEVEL OBSTRUCTION CONSTIPATION DEFECIENCIES OF Cl,Na,K,HCO3 &STASIS OF BILIARY,PANCREATIC,INTESTINAL,&GASTRIC CONTENTS ACIDOSIS DUE TO ISCHEMIC LESIONS OR SEPTIC COMPLICATIONS

DIAGNOSIS:

DIAGNOSIS BY HISTORY PERSISTANT NAUSEA,VOMITING,ABDOMINAL PAIN,CONSTIPATION,DRY MOUTH INVESTGATIONS ABDOMINAL RADIOGRAPHY CONTRAST RADIOGRAPHY---SITE&EXTENT ABDOMINAL CT

MANAGEMENT:

MANAGEMENT DEPENDS ON PARTIAL OBSTRUCTION COMPLETE OBSTRUCTION CORRECT THE CORRECTABLE PARTIAL OBSTRUCTION REDUSE THE BOWEL WAL OEDEMA STIMULATE THE GUT MOTILITY

COMPLETE OBSTRUCTION:

COMPLETE OBSTRUCTION SURGERY SELF EXPANDING METALLIC STENTS SUCCESSFUL SURGICAL PALLIATION PT SURVIVAL>60 DAYS AFTER SURGERY ABILITY TO RETURN HOME RELEIF OF OBSTRUCTION POST OPERATIVELY >60DAYS PRGNOSTIC FACTORS FOR SP ABSENSE OF PALPABLE ABDOMINAL OR PELVIC MASSES VOLUME OF ASCITES < 3 L UNIFOCAL OBSTRUCTION PREOPERATIVE WEIGHT < 9 kg

PROXIMAL BOWEL OBSTRUCTION:

PROXIMAL BOWEL OBSTRUCTION PBO IS TREATED(PROXIMAL BOWEL DECOMPRESSION) BY NASOGASTRIC SUCTION/ DRAINAGE VENTING GASTROSTOMY PROLONGED NASOGASTRIC SUCTION ONLY BE CONSIDERED WHEN PHARMACOLOGICAL THERAPY FOR SYMPTOM CONTROLE IS INEFFECTIVE WHEN GASTROSTOMY CANNOT BE CARRIRD OUT AS TEMPARARY MEASURE TO REDUSE LARGE VOLUMES OF SECRETIONS DURING THE FIRST DAYS OF SUCH TREATMENT

COMPLICATIONS OF PRLONGED NGT:

COMPLICATIONS OF PRLONGED NGT PSYCHOLOGICAL DISTRESS PAIN EPISTAXIS TUBE MISPLACEMENT FREQUENT SPONTNEOUS EXPULSIONS SPONTANEOUS MIGRATION OF THE TIP OF THE TUBE NASAL/PHRYNGEAL IRRITATION NASAL CARTILAGE EROSION EXACERBATION OF OESOPHAGEAL REFLUX OESOPHGITIS OESOPHAGEAL PERFORATION,BLEEDING ,STRICTURES ASPIRATION PNEUMONIA PULMINARY INTUBATION INTERFERE WITHCOUGHING TO CLEAR PUL.SECRETIONS OTITIS MEDIA

DRUGS FOR INOPERABLE MBO:

DRUGS FOR INOPERABLE MBO ROUTE OF ADMINISTRATION A CONTINUOUS SC INFUSION PRE-EXISTING IV---USE IV RECTAL ,SUBLINGUAL RARELY USED DRUGS ANTIEMETICS ANTISECRETARY DRUGS STEROIDS ANALGESICS

Slide 14:

ANTISECRETARY DRUGS ANTI CHOLENERGICS HYOSCINE BUTYLBROMIDE 40-120mg/day SC,IV HYOSCINE HYDROBROMIDE 0.8 -2 mg/day SC GLYCOPYRROLATE 0.1-0.2mg t.i.d SC OR IV SOMATOSTATIN ANALOGUE OCTREOTIDE 0.2-0.9mg/day SC PROKINETIC DRUGS METACLOPRAMIDE 60-240mg/day ANTIEMETICS NEUROLEPTIC DRUGS HALOPERIDOL 5-15 mg/daySC METHOTRIMEPRAZINE 6.25-50mg/day SC PROCHLORPERAZINE 25mg tid CHLORPROMAZINE 50-100mg tid AND /OR OR ANTIHISTAMINE DRUGS CYCLIZINE 100-150 mg/day SC or 50 mg tid RECTALLY OR DIMENHYDRINATE 50-100mg SC PRN

Slide 15:

STEROIDS ANTI-INFLAMMATORY ACTIVITY----REDUCE PERITUMOUR OEDEMA INCREASE WATER&SALT ABSORPTION---REDUCING NET BALANCE OF WATER A7ELECTROLYTES IN THE INTESTINAL CONTENT DEXAMETHASONE==6—16 mg/day ANALGESICS TRANSDERMAL FENTANYL OR METHADONE HYDRATION &NUTRITION