Malignant Bowel Obstruction Clinical Guideline V1.0 ...€¦ · 2.1. Malignant Bowel Obstruction...

Malignant Bowel Obstruction Clinical Guideline

V1.0

November 2019

Malignant Bowel Obstruction Clinical Guideline V1.0 of 13

Summary

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)

Please e-mail patient details to Dr John Mcgrane, Consultant Clinical Oncologist (for registration purposes only)

IV fluids, SC/IV analgesia, Anti-emetics

PR exam

CT Thorax Abdomen Pelvis (with contrast where possible)

Abdominal distension

Vomiting

Not passing stool/flatus

Abdominal pain

Malignant Bowel Obstruction suspected

-Symptomatic measures -Imaging

Malignant

Bowel

Obstruction confirmed

Inform

-Relevant Surgical team

-Palliative Care

-Acute Oncology

Start MBO protocol

management plan

Drain any significant

ascites


1. 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. 1.3. Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in.

DPA18 is applicable to all staff; this includes those working as contractors and providers of services.

For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team [email protected]

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

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discussed 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


2.5. 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 150mg BD

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 eGFR<30)

Investigations and review

If known cancer primary check relevant tumour markers: CA125 – gynaecology, CEA – bowel, CA19-9 – pancreas and contact relevant cancer nurse specialist / team.

If unknown primary check tumour markers: CEA, CA125 + arrange suitable biopsy with radiology.

Gynae-Oncology Surgery / Oncology Site-Specific Team / Specialist Palliative Care Review

o Face to face senior review within 24 hours ideally (or telephone review if unavailable).

o Ideally review by all 3 teams until management plan finalised. o If Specialist Palliative Care team not available (e.g. at weekends),

telephone advice from Consultant on-call may be accessed at need via Specialist Palliative Care Advice Line 01736 757707.

o Oncology decision regarding role of chemotherapy may be taken at any point. If chemotherapy or surgery planned to be given, consider nutritional needs, e.g. TPN decision

A decision to proceed to surgery may be taken at any point if deemed appropriate by senior Gynae-Oncology surgical or GI surgical review.

Criteria for surgery: o Patient fit for surgery o Radiology suggesting high probability of single-site obstruction o Low tumour bulk on imaging o No previous bowel obstruction o 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 1 plus:

Adjust opioid for symptom control as appropriate

If NG tube in place :

Consider removal of NG tube if • Nausea and vomiting controlled /significantly improved, and volume of NG drainage <500mls previous 24 hours • Patient cannot tolerate NG tube

Hydration and

Nutrition

Parenteral fluid o Review need for intravenous fluid. If symptoms well controlled, allow

clear fluids by mouth and review need for iv fluids after 24 hours o May be appropriate to stop all parenteral fluids if patient clearly

deteriorating rapidly and end-of-life picture

Dietitian input o Consider electrolyte replacement/ refeeding syndrome and need

for IV Vitamin B (pabrinex) for 3 days o o If commencing clear liquids please refer using Maxims to

‘Dietetic (Cancer and Palliative Care) Inpatient Service, for patient specific nutritional advice.

Symptom Control

If nausea and vomiting remain uncontrolled consider change of anti-emetic in syringe driver in discussion with Specialist Palliative Care team.

If high volume vomiting /NG tube drainage more than 1000 mls in 24 hours despite nil by mouth and anti-emetics :

o Add or increase Hyoscine butylbromide to 120-160 mgs/24 hours (if patient previously on Cyclizine, anti-emetic should be changed)


Day 3 Management

As per day 2 plus:

Parenteral fluid: o If symptoms have become well controlled in last 24 hours, allow clear

fluids by mouth and review need for IV fluids after further 24 hours. o Stop parenteral fluids if tolerating oral fluids o Review nutritional needs / electrolyte replacement


If 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 Control

Adjust opioid and anti-emetic for symptom control as appropriate

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)

Gastrograffin swallow

100ml oral ‘Gastrograffin swallow’ may be tried therapeutically to reduce 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.


Day 4 Management

As per day 2 + 3 plus:

If high volume vomiting/NG drainage tube drainage greater than 1000 mls in 24 hours despite previous measures

o Increase Octreotide by a further 300 micrograms /24 hours in syringe driver


Day 5 Management

As per day 2, 3 + 4 plus:

If high volume vomiting/NG drainage tube drainage greater than 1000 mls in 24 hours despite previous measures :

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-Oncology Surgical,

Oncology, and

Specialist Palliative

Care review

Final decision regarding any surgical or interventional options of care

Final decision re whether there is any role for further oncological intervention

Definitive decision regarding TEP, setting limits to active treatment / ceiling of care, appropriate continuing activity level of care, ongoing level of nutritional support

Definitive decision regarding ongoing place of care if not made earlier and no possible surgical options.

If NOT for surgery, ongoing responsibility of care between Gynae-oncology, 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.


2.6. 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 monitored

The management of malignant bowel obstruction will be subject to 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 arrangements

Acute Oncology Guidelines are quality assured by the RCHT Acute Oncology Meeting which is a subgroup of the Oncology Clinical

Governance Group. This reports to the GS&C Quality and Safety Group.

Acting on recommendations and Lead(s)

Oncology Clinical Governance Group will act on any recommendations through the Chair, Dr Grant Stewart or the SACT

Chair, Dr Richard Ellis.

Change in practice and lessons to be shared

Education around the changes to practice is needed to ensure that all entry points to the Trust are aware of this guidance. There are

already good links to ED, AMU, SDEC and SDMA through the 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.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Malignant Bowel Obstruction Clinical Guideline V1.0

Date Issued/Approved: 07 October 2019

Date Valid From: November 2019

Date Valid To: November 2022

Directorate / Department responsible (author/owner):

Dr J McGrane (author) Richard Ellis (SACT Lead) Grant Stewart (Oncology Specialty Lead)

Contact details: 01872 258301

Brief summary of contents

This guideline applies to patients presenting to RCHT with potential bowel obstruction as a consequence of cancer. It defines the agreed optimal management.

Suggested Keywords: Malignant, Bowel, Ileus, Obstruction, Oncology, Cancer

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: Initial version

This document replaces (exact title of previous version):

New document

Approval route (names of committees)/consultation:

Oncology Clinical Governance General Surgery, Gynae-oncology and Cancer Quality & Safety Group

Care Group General Manager confirming approval processes

Charlotte Timmins

Name and Post Title of additional signatories

Not required

Name and Signature of Care Group/Directorate Governance Lead confirming approval by specialty and care group management meetings

{Original Copy Signed}

Name: Charlotte Timmins

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Clinical / Cancer / Acute Oncology


Links to key external standards None required

Related Documents: Reference and Associated documents

Training Need Identified? Education required but no training needed

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job

Title)

07.10.2019 V1.0 Initial version 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.


Appendix 2. Initial Equality Impact Assessment Form

Are there concerns that the policy could have differential impact on:

Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Name of the strategy / policy /proposal / service function to be assessed Malignant Bowel Obstruction Clinical Guideline V1.0

Directorate and service area: Oncology

New or existing document: New

Name of individual completing assessment: Grant Stewart

Telephone: 01872 258301

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

This guideline is developed to assist admitting and treating clinicians in the safe and effective management of patients with potential malignant bowel obstruction. It will have most relevance to doctors in 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 the outcome?

Clinical audit of management

5. Who is intended to benefit from the policy?

Clinicians who are admitting patient; patients who are receiving treatment; the wider Trust as patient flow will be improved.

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

Yes

Acute Oncology and Cancer Services

What was the outcome of the consultation?

Approval

7. 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.


Age × No differential impact

Sex (male,

female, trans-gender / gender reassignment)

×

No differential impact

Race / Ethnic communities /groups

×


Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.

×


Religion / other beliefs

× No differential impact

Marriage and Civil partnership


Pregnancy and maternity


Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

×


You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No X

9. If you are not recommending a Full Impact assessment please explain why.

Not indicated

Date of completion and submission

07.10.2019

Members approving screening assessment

Policy Review Group (PRG) Approved

This EIA will not be uploaded to the Trust website without the approval of the Policy Review Group. A summary of the results will be published on the Trust’s web site.


Appendix 3: Daily Checklist for Malignant Bowel Obstruction pathway

Day 1

Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

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 V1.0 ...€¦ · 2.1. Malignant Bowel Obstruction...

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