I’d like some advice on managing patients with advanced obstipation.
Last week I was called to see a patient with a cecal perforation. He is 83 years old and has prostate cancer metastatic to the spine, with 2 compression fractures. He was being treated with Leupron, Duragesic patches and Morphine PCA for breakthrough pain. He also has advanced COPD as well as ASCVD. He developed progressive abdominal distention and pain, with an x-ray picture of obstipation, unresponsive to enemas or Lactulose. The day before he perforated, his white count rose to 19.9 and his cecum was 12 cm. Because there was a question of a cutoff sign in the descending colon, a gastrografin enema was performed, and showed no mechanical obstruction. An hour later, the patient developed increased pain and became shocky. I was consulted, and despite advising the family that he was not likely to survive, they insisted that he be operated upon. At laparotomy he had generalized peritonitis, however his perforation was fresh and the fecal peritonitis was limited. The cecum was viable after decompression, so I repaired the perforation in two layers of Vicryl and inserted a tube cecostomy and G-tube. His septic shock has resolved, and he was extubated today on POD #3. Of course, if he survives without further sepsis and multi-system failure, all he has to look forward to is a few more months of pain from his prostate cancer. Not exactly a therapeutic triumph.
Today, I was asked to see a 63 year old man with progressive stage D2 prostate CA, 3 weeks s/p ORIF of a pathologic left femur fracture, on Duragesic (fentanyl) as well as ketaconazole, Adriamycin and solumedrol. He was admitted 2 days ago for abdominal pain which was felt to be secondary to obstipation, and was treated with enemas, milk of magnesia and lactulose without significant bowel movements and with no improvement in his pain. On exam, he has hypoactive bowel sounds, abdominal distention with diffuse, mild tenderness but no guarding. Rectal shows no stool, blood, masses or tenderness. His flat plate shows stool throughout the colon with a 13 cm cecum as well as dilated small bowel loops. His WBC is 2.2 (up from 1.8 yesterday) and his electrolytes are normal. I have inserted a NG tube, started Toradol and stopped the Duragesic, put mineral oil down the NG and ordered oil retention enemas. Another flat plate is ordered for the morning.
I must confess that I haven’t seen a case of cecal perforation from obstipation before. I have seen pseudo-obstruction perforate, and the results have usually been fatal. However, most of the cases of pseudoobstruction I have seen have been gaseous distention, not massive fecal impaction. Also, those patients were generally not on high doses of narcotics.
I’d appreciate any suggestions as to the management of these diffucult cases. Obviously, a morphine drip would be an appropriate choice, but if the patient and family are not ready to take that step, are there any other options? Colonoscopic decompression is not possible given the fecal loading, and a pre-emptive cecostomy, although possible, carries a high risk of massive fecal contamination. Would anyone consider a loop ileostomy?