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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Had a radical cystectomy for bladder cancer. What treatment should be taken for Small-Bowel Obstruction?

Answered by
Dr. Ketan Vagholkar

Gastroenterologist, Surgical

Practicing since :1989

Answered : 883 Questions

Posted on Tue, 8 Jan 2013 in Abdominal Pain
Question: My mother is a 68 year old female who had a radical cystectomy in 2008 for stage 4 bladder cancer. She was symtpom free until Oct 1, 2012, when she was admitted to the hospital with a small bowel obstruction. 7-8 day stay in the hospital seemed to remedy the issue, ng tube, worked her way to solids, then discharged. The next Friday she was again hospitalized with right upper quadrant pain and was told she needed her gallbladder removed. She was discharged a few days later. Later in the week, she experienced the symptoms that were associated with the SBO. Violent vomiting and severe abdominal pain. She was admitted and they recommended surgery to lyse some adhesions. After the surgery, the doctor informed us that due to the radiation she received for treating her cancer, the bowel appeared fused and almost brain-like. He indicated that any additional surgeries may be catastrophic. She was released two weeks later after holding down solids. One week after that stay, she went back to the ER with the same symtpoms. This time, the CT scan revealed a "questionable SBO XXXXXXX They admitted her and started the process of ng tube, liquids, etc. One week later, the GI doc ordered a barium series that revealed a high grade partial obstruction of the third part of the duodenum above her stoma for the ileal conduit. We have not heard from that GI doc again. A week later, they removed the ng tube, and began the process of administering TPN therapy. The plan was to send her home with this therapy. A few days later, she began violently vomiting after a few sips of soda. They ordered the ng tube back in and rushed her for an obstruction series (nonp-barium). She was told by the surgeon's PA and the radiologist that the xray appeared normal. Her surgeon attributed that to the fact that she had just vomited right before the xray was taken. He indicated that that may have relieved the SBO temporarily. Last night her surgeon basically said due to the radiation he is afraid to operate. One wrong move and it could be "catastrophic XXXXXXX Other than keeping an ng tube in my mother and having her hooked up to TPN therapy, I am desperately seeking advice on what to do next. I am not even sure if she has a SBO now due to the films returning as negative and her initial CT scan showing a very minimal if not questionable SBO upon her last admission. This will be her 7th admission into the hospital in 2 months. It is becoming unethical in my mind to keep her suffering the way she is. Any advice on where to go from here is appreciated.
Answered by Dr. Ketan Vagholkar 14 hours later
Thanks for writing in.
Your mother has various surgical issues which are causing complications.
Radical surgery, radiotherapy, and multiple surgical procedures has caused extensive adgesions in the peritoneal cavity. The adhesions caused by cancer therapy are very dense. Any heroic attempt by the surgeon would cause more harm than good to the patient.
I would suggest
1. Continue with TPN as when required.
2. Conservative approach to intermittent bouts of bowel obstruction provided the episode does not get complicated by strangulation.
3. The attending doctors are justified in their conservative approach to the patient.
4. A liquid diet would be preferable for a long time as this would reduce significantly the chances of the patient going into acute obstruction.
5. Monitoring of blood levels of nutrients such as proteins, vitamins and trace elementsinorder to detect deficiencies and therby correct them promptly.
5. Avoid effervescent drinks as they cause distension and increase the peristaltic contractions.
I hope this answers your querry.
With regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ketan Vagholkar 2 days later
Thank you for your answer. She has not eaten in about 2 weeks and continues to vomit even with the NG tube. Any type of motion makes her ill. She has now acquired a VRE infection of her urine as well. Could there be any other condition that is causing such symptoms, persisent vomiting, etc.? After her last adhesion surgery she has faired progressively worse. Why I ask, is that is her x-rays always come back normal, showing no obstruction. Her medical doctor has recommended she give up the fight and be put in hospice. She is still ambulatory and alert, functioning like a normal person. Putting her in hospice at this point seems inhumane. I just want to make sure they are looking at her holistically and not just assuming this is all from the SBO.
Thank you for your help.
Answered by Dr. Ketan Vagholkar 17 hours later
As your mother is vomiting even with an RT in place it suggests the severity of obstruction. The only option now would be to administer parentral nutrition only. Proper antibiotics to control infection based on the culture report will help.No further surgery is possible. Only supportive care is required.
You should continue giving her supportive care parentrally. The chances of cure for the adhesions is extremely less.
I hope this answers your doubt.
With regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

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