NG intubation plus IV fluids is still considered the standard management to decompress the bowel prior to surgery or pending a decision regarding possible surgery. However, it should only be atemporarymeasure.
In the palliative setting IV fluids and nasogastric tubes should be avoided if at all possible.
If surgery is clearly not appropriate or against the patient's wishes, an attempt should be made to palliate symptoms using active medical management.
Factors which suggest a poor outcome from surgery include: diffuse intraperitoneal carcinomatosis, severe ascites, previous abdominal or pelvic radiotherapy, palpable abdominal masses, liver or other distant metastases, low serum albumin and multiple levels of obstruction.
The aim of medical treatment is to minimise symptoms of pain, colic, nausea and vomiting, to provide freedom from medical technology and “tubes” if possible and to facilitate discharge home if that is the wish of the patient and their family.
IV fluids are sometimes required initially if the patient is very dehydrated but will usually be withdrawn even if the bowel obstruction does not resolve. Intermittent subcutaneous fluids may be appropriate. Continuation of “maintenance” fluids can make nausea and vomiting harder to control.
Patients should be allowed to take oral fluids and food as tolerated.
Patients with recurrent bowel obstructions can be managed in the community without admission using subcutaneous infusions and palliative care nursing input.
Transfer to the Hospice may be appropriate in “terminal” obstruction – this must be discussed with Palliative Care Service prior to discussing this option with the patient or family.
Information about this Canterbury DHB document (4104):