Fast Fact and Concept #91: Interventional options for upper GI obstructions

Title: Fast Fact and Concept #91: Interventional options for upper GI obstructions

Author(s): James Ouellette, DO, ; Lisa Patterson, MD; Paula Termuhlen, MD

Patients with unresectable cancers of the upper gastrointestinal tract often suffer a very uncomfortable existence because of pain, nausea and vomiting, weight loss, cachexia and food fear. This can be related to gastric and duodenal cancers causing intrinsic obstruction of the intestinal lumen or pancreatic and biliary cancers causing extrinsic biliary compression. Management options vary depending on the site of obstruction, the patient functional status, the patient-defined goals for end of life care, and estimated prognosis. Fast Fact #45 discussed medical management options. This Fact Fact reviews interventional approaches, specifically for upper GI obstruction, especially when further curative surgery, external beam radiation, chemotherapy and medical management options may no longer be helpful. Listed below are treatment options for managing different sites of obstruction (listed from least invasive to most invasive). Management decisions for these problems are complex, requiring a multi-disciplinary approach (surgery, gastroenterology, radiology, palliative care) to achieve the best possible outcome with minimum morbidity.

Esophageal obstruction

1. External beam radiation therapy (successful in 40% of patients)
2. Endoscopic laser therapy (can be repeated every 4-6 weeks)
3. Endoscopic/fluoroscopic stent (different stent materials are available for different situations.)

Gastric or Duodenal obstruction

1. Nasogastric tube decompression (poor long-term solution due to discomfort)
2. Venting gastrostomy tube (PEG, laparoscopic G-tube, open g-tube)
3. Janeway gastrostomy (surgically created gastrocutaneous fistula)
4. Endoscopic/fluoroscopic stent across the site of obstruction (e.g. pylorus)
5. Laparoscopic gastrojejunostomy
6. Open gastrojejunostomy

If unable to restore continuity of the gastrointestinal tract with a surgical procedure to bypass the obstruction, a combination of a gastrostomy tube with a separate jejunostomy tube can be used. This can provide enteral nutrition to the small intestine while venting the stomach. Patients can enjoy the pleasure of eating, even if the food is drained through the G-tube.

Pancreaticobiliary obstructions

1. Stent placement across obstruction through endoscopic procedure (ERCP)
2. Stent/drain placement across obstruction by radiologic procedure (transhepatic)
3. Open choledochojejunostomy or hepaticojejunostomy

Adjuvant medications may augment the efficacy of these interventions.

1. Proton pump inhibitor to reduce gastric secretion;
2. Sucralfate (Carafate) slurry, 1 G. q6h, for patients with ulcerated esophageal or gastric lesions;
3. metoclopramide (Reglan) 10 mg tid, as a prokinetic drug;
4. octreotide (Sandostatin) 50-100 micrograms q6-8h for high volume output conditions.

References:

Acunas, B., Poyanli, A., Rozanes, I. Intervention in gastrointestinal tract: the treatment of esophageal, gastroduodenal and colorectal obstructions with metallic stents. Eur J Rad 42:240-248, 2002.

Choi, Y. Laparoscopic gastrojejunostomy for palliation of gastric outlet obstruction in unresectable gastric cancer. Surg Endosc 16:1620-1626, 2002.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Ouellette J, Patterson L and Termuhlen P. Fast Facts and Concepts #91 INTERVENTIONAL OPTIONS FOR TREATING MALIGNANT UPPER GI OBSTRUCTION May 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 6/2003

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice

Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery

Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Antibiotics, Blood products, Cancer, Clinical interventions, Gastrointestinal, Hydration, Interventional procedures, Non-oral feeding, Radiation or chemotherapy, Rehabilitation, Surgery

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).