Malignant Bowel Obstruction Clinical Guideline - V2.0 January 2021 - RCHT
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Malignant Bowel Obstruction
Clinical Guideline
V2.0
January 2021Summary
Integrated Care Pathway for Clinical Diagnosis of Malignant
Bowel Obstruction
Suspected Malignant Bowel Obstruction
Abdominal distension
Abdominal pain
Nausea and vomiting +/- diarrhoea
Constipation or absence of PR flatus (patient may have diarrhoea in partial
obstruction)
Abdominal distension
Vomiting Malignant Bowel
Obstruction
Not passing stool/flatus suspected
Abdominal pain
IV fluids, SC/IV analgesia,
Anti-emetics -Symptomatic
PR exam measures
CT Thorax Abdomen Pelvis -Imaging
(with contrast where possible)
Malignant
Bowel
Obstruction
confirmed
Inform
Start MBO
-Relevant Surgical team Drain any
protocol
significant
-Palliative Care management
ascites
plan
-Acute Oncology
Please e-mail patient details to Dr John Mcgrane, Consultant Clinical
Oncologist (for registration purposes only)
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 2 of 131. Aim/Purpose of this Guideline
1.1. This guideline applies to patients presenting to RCHT with potential
malignant bowel obstruction (luminal narrowing of small or large bowel with clinical
evidence of bowel obstruction in the setting of metastatic intra-abdominal cancer).
1.2. This version supersedes any previous versions of this document.
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2. The Guidance
2.1. Malignant Bowel Obstruction (MBO) is the luminal narrowing of small or
large bowel with clinical evidence of bowel obstruction in the setting of metastatic
intra-abdominal cancer
2.2. MBO may be suspected if there is:
2.2.1. Abdominal distension
2.2.2. Abdominal pain
2.2.3. Nausea and vomiting +/- diarrhoea
2.2.4. Constipation or absence of PR flatus (patient may have diarrhoea
in partial obstruction)
2.3. If Malignant Bowel Obstruction is suspected:
2.3.1. IV fluids and electrolyte replacement
2.3.2. Analgesia: - SC Morphine
2.3.2.1. If opioid naïve, start at 10 - 20mg Morphine over 24 hours,
or 10mg-15mg over 24 hours if frail / low body weight (10mg SC
Morphine = 20mg oral morphine).
2.3.2.2. If already on opioids, opioid conversion dose to be
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 3 of 13discussed with the Hospital Palliative Care Team: Monday – Friday
0900 – 1700 or Specialist Palliative Care Advice Line 01736 757707
(out of hours)
2.3.2.3. If reduced renal function (eGFR < 30ml/min), use SC
Oxycodone at 50% dose of morphine doses above
2.3.2.4. If patient has a transdermal opioid (e.g. Fentanyl) on
admission keep this going and ADD SC opioid until palliative care input
2.3.2.5. Do not start transdermal opioids (e.g. Fentanyl) unless
under palliative care supervision
2.3.3. Anti-emetics: (Cyclizine SC or IV 150mg/24hrs first line - SC
preferred). (NB: Cyclizine may precipitate with Hyoscine butylbromide, and
with Oxycodone, when mixed in syringe driver)
2.3.4. Rectal examination: - consider suppositories / enema if faecally
loaded rectum
2.3.5. Consider NG / Ryle’s tube: if ongoing vomiting (and acceptable to
patient)
2.3.6. Investigations
2.3.6.1. Baseline blood tests including FBC, clotting, CRP, renal,
lactate, liver and bone profiles, and Mg2+
2.3.6.2. CT Thorax, Abdomen & Pelvis with contrast if renal function
allows (unless extensive co-morbidities)
2.4. If Malignant Bowel Obstruction is confirmed:
2.4.1. Please e-mail patient details to: Dr John Mcgrane, Consultant
Clinical Oncologist (registration only)
2.4.2. QDS Observations – Temperature, Pulse, BP, Resp Rate, Oxygen
saturation
2.4.3. Full Fluid Balance Chart, ESPECIALLY frequency, appearance
and VOLUME of vomits and/or NG drainage
2.4.4. Food Chart if eating and drinking
2.4.5. Stool Chart – including estimated VOLUME if profuse liquid stool
2.4.6. Catheterise if concerned re: dehydration / renal function
2.4.7. Dependent upon bed availability, transfer patient to Eden (or
designated Gynae surgery ward) or Lowen (Oncology Ward) if not for surgery
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 4 of 132.5. Daily Management (see Appendix 3 for Daily Checklist)
2.5.1. Day 1 Management:
Day 1 Management
Treatment Nil by mouth
IV fluids & electrolyte replacement
Anti-emetics
o - avoid metoclopramide if any possibility of complete and/or
mechanical obstruction
o Vomiting / Nausea = Cyclizine 150 mg in 24 hours SC or IV (SC
preferred) If not already on anti-emetic
Paracentesis to drain any significant ascites
Consider IV/SC Steroids.
o If commencing steroids, recommend starting dose of IV 6.6mg daily
(8mg equivalent) Dexamethasone or (6-16mg/24hrs), given
parenterally (iv or SC), as a morning dose once daily (or morning
/noon if BD).
o Check BM for hyperglycaemia at 6pm – prn Novorapid 4 units if BM
>20
o Ensure has IV gastric protection – PPI / Ranitidine
Ranitidine: If high bowel obstruction plus confirmed gastric dilatation
consider IV ranitidine 50mg BD (or equivalent such as Pantoprazole 40mg
IV OD)
NG (Ryles) tube placement (IF ACCEPTABLE TO PATIENT)
Pain Management
o Colicky pain - Hyoscine butylbromide 60-80mg/24 hours +/-
opiate
o Non-colicky pain - Morphine (or Oxycodone if eGFRo Good pre-morbid status
o No previous extensive abdominal surgery
If single site obstruction -consider a radiological / endoscopic stent if
appropriate
Early involvement of the Nutrition Support Team and Dietitians for Cancer
and Palliative Care is advised, especially if surgery or chemotherapy is
likely.
Consider Treatment Escalation Plan (TEP) and record limits of
activity of treatment if appropriate.
o Consider appropriate place of care – discussion with patient and
family if appropriate
2.5.2. Day 2 Management
Day 2 Management
As per day Adjust opioid for symptom control as appropriate
1 plus:
If NG tube Consider removal of NG tube if
in place : • Nausea and vomiting controlled /significantly improved, and volume of
NG drainageIf patient remains NBM in obstruction and considered for surgery or
chemotherapy - consultant level decision regarding Total Parenteral
Nutrition (TPN) (see 2.6). Please refer using Maxims to ‘Nutrition Team
(TPN) Inpatient Service.
Symptom Adjust opioid and anti-emetic for symptom control as appropriate
Control If high volume vomiting /NG tube drainage greater than 1000 mls in 24 hours
despite previous measures: Stop Hyoscine butylbromide.
Consider addition of Octreotide 300mcg over 24 hours via syringe driver
(Consultant level decision)
Gastrograff 100ml oral ‘Gastrograffin swallow’ may be tried therapeutically to reduce
in swallow oedema and promote luminal flow in patients who do not have high NG
output.
Evidence for this is stronger in the non-malignant setting but it may be
attempted if obstruction is ongoing.
2.5.4. Day 4 Management
Day 4 Management
As per day If high volume vomiting/NG drainage tube drainage greater than 1000 mls in
2 + 3 plus: 24 hours despite previous measures
o Increase Octreotide by a further 300 micrograms /24 hours in syringe
driver
2.5.5. Day 5 Management
Day 5 Management
As per day If high volume vomiting/NG drainage tube drainage greater than 1000 mls in
2, 3 + 4 24 hours despite previous measures :
plus: o Increase Octreotide by a further 300 micrograms /24 hours in syringe
driver – dose increases can continue by 300 mcg increments up to a
maximum dose of 1800 mcg per 24 hours according to response (after
which dose point there is little likelihood of additional benefit)
Gynae- Final decision regarding any surgical or interventional options of care
Oncology Final decision re whether there is any role for further oncological intervention
Surgical, Definitive decision regarding TEP, setting limits to active treatment / ceiling of
Oncology, care, appropriate continuing activity level of care, ongoing level of nutritional
and support
Specialist Definitive decision regarding ongoing place of care if not made earlier and no
Palliative possible surgical options.
Care If NOT for surgery, ongoing responsibility of care between Gynae-oncology,
review Oncology and Specialist Palliative Care until moved out of acute trust, or
death of patient if unfit to be moved.
Symptoms refractory to treatment and no surgical options, the role of
percutaneous endoscopic gastrostomy (PEG) insertion may be
considered for gastric drainage to avoid need for longer term NG tube. This
is best co-ordinated by the teams involved in ongoing care.
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 7 of 132.6. Total Parenteral Nutrition (TPN) feeding
2.6.1. TPN can only be administered in RCHT (or in the hospice setting
on an individual patient basis) and is not currently available in the out-
patient / home setting
2.6.2. Should only be considered in patients where stent / surgery /
chemotherapy is intended
2.6.3. Chemo naïve or platinum sensitive patients
2.6.4. 6 week trial – if no improvement for discontinuation
2.6.5. Prognosis should be expected to be over 3 months
3. Monitoring compliance and effectiveness
Element to be The management of malignant bowel obstruction will be subject to
monitored a future clinical audit.
Lead Dr Grant Stewart, Specialty Lead for Oncology
Tool Audit and review tool using a rolling database of all referrals and
this will form part of the service’s rolling quality assurance.
Frequency Ongoing review
Reporting Acute Oncology Guidelines are quality assured by the RCHT Acute
arrangements Oncology Meeting which is a subgroup of the Oncology Clinical
Governance Group. This reports to the GS&C Quality and Safety
Group.
Acting on Oncology Clinical Governance Group will act on any
recommendations recommendations through the Chair, Dr Grant Stewart or the SACT
and Lead(s) Chair, Dr Richard Ellis.
Change in Education around the changes to practice is needed to ensure that
practice and all entry points to the Trust are aware of this guidance. There are
lessons to be already good links to ED, AMU, SDEC and SDMA through the
shared Acute Oncology Team. A formal education event is planned.
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Inclusion & Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 8 of 13Appendix 1. Governance Information
Malignant Bowel Obstruction Clinical Guideline
Document Title
V2.0
This document replaces (exact Malignant Bowel Obstruction Clinical Guideline
title of previous version): V1.0
Date Issued/Approved: 25th January 2021
Date Valid From: January 2021
Date Valid To: January 2024
Dr J McGrane (author)
Directorate / Department
Richard Ellis (SACT Lead)
responsible (author/owner):
Grant Stewart (Oncology Specialty Lead)
Contact details: 01872 258301
This guideline applies to patients presenting to
RCHT with potential bowel obstruction as a
Brief summary of contents
consequence of cancer. It defines the agreed
optimal management.
Malignant, Bowel, Ileus, Obstruction, Oncology,
Suggested Keywords:
Cancer
RCHT CFT KCCG
Target Audience
Executive Director responsible
Medical Director
for Policy:
Oncology Clinical Governance
Approval route for consultation
General Surgery, Gynae-oncology and Cancer
and ratification:
Quality & Safety Group
General Manager confirming
Charlotte Timmins
approval processes
Name of Governance Lead
confirming approval by specialty
Suzanne Atkinson
and care group management
meetings
Links to key external standards None required
Related Documents: Reference and Associated documents
Training Need Identified? Education required but no training needed
Publication Location (refer to
Policy on Policies – Approvals Internet & Intranet Intranet Only
and Ratification):
Document Library Folder/Sub
Clinical / Cancer Services
Folder
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 9 of 13Version Control Table
Version Changes Made by
Date Summary of Changes (Name and Job
No
Title)
07.10.2019 V1.0 Initial version John McGrane
20.01.2021 V2.0 Amendment of options for gastric protection. John McGrane
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the
express permission of the author or their Line Manager.
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 10 of 13Appendix 2. Equality Impact Assessment
Section 1: Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed
Malignant Bowel Obstruction Clinical Guideline V2.0
Directorate and service area: Is this a new or existing Policy?
Oncology Existing
Name of individual/group completing EIA Contact details:
Grant Stewart 01872 258301
1. Policy Aim
Who is the This guideline is developed to assist admitting and treating clinicians
strategy / policy / in the safe and effective management of patients with potential
proposal / service malignant bowel obstruction. It will have most relevance to doctors in
function aimed at? ED, AMU and other admitting areas.
2. Policy Objectives To standardise the management of patients with malignant bowel
obstruction.
3. Policy Intended
Outcomes
Improved patient care
4. How will
you measure
Clinical audit of management
the outcome?
5. Who is intended
Clinicians who are admitting patient; patients who are receiving
to benefit from the
treatment; the wider Trust as patient flow will be improved.
policy?
6a). Who did you Local External
Workforce Patients Other
consult with? groups organisations
X
b). Please list any Please record specific names of groups:
groups who have Acute Oncology and Cancer Services
been consulted
about this procedure.
c). What was the
outcome of the Approval
consultation?
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 11 of 137. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative impact
you need to repeat the consultation step.
Are there concerns that the policy could have a positive/negative impact on:
Protected
Yes No Unsure Rationale for Assessment / Existing Evidence
Characteristic
Age
X No differential impact
Sex (male, female
non-binary, asexual X No differential impact
etc.)
Gender
reassignment X No differential impact
Race/ethnic
communities X No differential impact
/groups
Disability
(learning disability,
physical disability,
sensory impairment,
X No differential impact
mental health
problems and some
long term health
conditions)
Religion/
other beliefs X No differential impact
Marriage and civil
partnership X No differential impact
Pregnancy and
maternity X No differential impact
Sexual orientation
(bisexual, gay, X No differential impact
heterosexual, lesbian)
If all characteristics are ticked ‘no’, and this is not a major working or service
change, you can end the assessment here as long as you have a robust rationale
in place.
I am confident that section 2 of this EIA does not need completing as there are no highlighted
risks of negative impact occurring because of this policy.
Name of person confirming result of initial
Grant Stewart (Oncology Specialty Lead)
impact assessment:
If you have ticked ‘yes’ to any characteristic above OR this is a major working or
service change, you will need to complete section 2 of the EIA form available here:
Section 2. Full Equality Analysis
For guidance please refer to the Equality Impact Assessments Policy (available
from the document library) or contact the Human Rights, Equality and Inclusion
Lead debby.lewis@nhs.net
Malignant Bowel Obstruction Clinical Guideline V2.0
Page 12 of 13Appendix 3: Daily Checklist for Malignant Bowel Obstruction
pathway
Day Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1
Palliative
care referral
Gynae
/surgery
referral
Oncology
team referral
Bowel/Flatus
recorded
Anti-emetics
Analgesia
IV fluids
NG (Ryles)
tube
Steroids
Dietitian
referral
TPN
Ocreotide
Gastrograffin
Swallow
(optional)
PEG tube
Malignant Bowel Obstruction Clinical Guideline V2.0
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