P3B055: Malignant Bowel Obstruction in a Teenage Male Patient with Recurrent Metastatic Adenocarcinoma

Introduction: Malignant bowel obstruction (MBO) is uncommon in the relapsed/refractory pediatric oncology population. This case will describe the management of a malignant bowel obstruction in a teenage male with end stage adenocarcinoma of the colon.

Case Description: A teenage male patient with recurrent metastatic adenocarcinoma of the colon, was admitted to concurrent care hospice a short time after recurrent disease was found adjacent to the pylorus without definitive pyloric invasion. His oncologic history included primary colonic tumor resection and chemotherapy after initial diagnosis. The patient and family continued immunotherapy infusions but declined further surgical intervention.
Over time, the patient complained of increasing abdominal pain. His pain regimen included a fentanyl transdermal patch with as needed morphine. Initially his increased pain was attributed to opioid induced constipation, and was remedied with optimization of his bowel regimen. Abruptly, his pain again increased with pain scores higher than the patient had ever reported. His abdomen was also becoming increasingly distended. Imaging at this time showed progression of the lesion adjacent to the pylorus with a new complete MBO.
Octreotide and Decadron were then added to the patient’s medication regimen, and he was transitioned from the Fentanyl patch and as needed morphine to a Dilaudid PCA. After a weeks’ time the patients’ pain was dramatically reduced, and his functional status improved and remained stable for a short period of time until he reached end of life.

Discussion: Cited in adult supportive oncology literature, the classes of medications important to successful pain and symptom management for patients with MBO include antiemetics, laxatives, prokinetic agents, somatostatin analogs, analgesics, and corticosteroids. The literature recommends avoiding prokinetic agents in a complete MBO due to the risk of bowel perforation, but they may have benefit in a partial obstruction. As our patient had a complete MBO, we added octreotide and Decadron for their anti-secretory and anti-inflammatory effect and avoided prokinetic agents. We optimized his analgesics by transitioning to a Dilaudid PCA, as the patient had lost significant weight and family was finding it difficult to administer the as needed medications on time. Our overall goal with the above medical management was to reduce intestinal and pancreatic secretions, gastrointestinal mobility, biliary contraction, and intestinal edema. This led to improved quality of life.

Conclusion: Successful treatment of malignant bowel obstruction in adult and pediatric patients requires an interdisciplinary approach. Palliative care can assist with goals of care discussion and pain and symptom management. Although malignant bowel obstruction is less common in pediatrics, this case reminds pediatric oncology and pediatric hospice and palliative providers of the full armamentarium of medications available to treat gastrointestinal symptoms in the pediatric population.