Lethal Obstipation
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?
The 2 cases presented sound like what I call pseudo-obstruction–cecum 12-13 cm with cecal perforation or impending perforation.
I do many colonoscopies on unprepped or poorly prepped patients. I use 3 L bags of NS with cystoscopy tubing and a pressure bag pumped up to 300 (rarely this breaks the bag of NS, but we just get another one and start over)–attach an IV extension to the cystoscopy tubing and put the male end into the biopsy channel through the rubber adapter (don’t flip the adapter open–go right through it–my Olympus rep taught me this trick–find the old-fashioned IV extensions without the Luer-locks on them)—then irrigate with this and suction until everything is as clear as possible—quite often the suction clogs, to fix this, I take off the suction valve and run the channel cleaning brush both ways.
This system works fairly quickly–you can instill 3-6 L in a reasonable time period. I use it for scopes for lower GI bleeding, possible pseudo-obstruction and just plain poor preps.
As far as surgery, I used to do tube cecostomies, but we had a run of pseudo-obstruction at our hospital recently—one of the other surgeons in town put in a tube cecostomy for pseudo-obstruction–when I took call for him, I was repeatedly called to replace the cecostomy tube which kept falling out.
After that, I had 2 Nursing Home type patients with pseudo-obstruction (1 has Alzheimer’s and advanced breast cancer, the other has chronic CHF, COPD, morbid obesity, recurrent UGI bleeding, refuses to walk, has cystostomy and recent pacemaker).
I used loop cecostomies on both patients and both are doing well. The nurses have had no trouble taking care of these cecostomies—I fashioned them so they protrude nicely above the abdominal wall. One of the patients did have diarrhea at first and we just put a Foley (urinary) catheter bag tubing into the bottom of the cecostomy bag (anchored by tying a Penrose drain around it) (essentially creating a wide-mouthed urostomy bag).
I have not had trouble with fecal contamination doing loop cecostomies (or loop transverse colostomies) for obstruction or pseudo-obstruction—I bring the loop up and tack it circumferentially to the dermis, then I put the ostomy bag on, then I reach into the bag to open the ostomy, then, if necessary, I put the suction (Yankauer or Poole) into the cecum to suction out as much stool as possible.
I have 2 comments: one philosophical and one practical.
1. Your patients (at least the first one) were terminal. And terminal patients per definition are TERMINAL and thus are dying or should do it soon …Do they need to die with a nasogastric tube in their nose and painful tubes hanging out of their tummy?
2. How to deal with medically- intractable constipation. Antegrade enemas through an APPENDICOCECOSTOMY has been of value in cases of intractable idiopathic constipation. No experience however in terminal cancer patients. I fully agree that FORMAL cecostomy is better than TUBE cecostomy as the latter tends to obstruct, fall off and, worse, leak around.
A private surgeon used to present every year his huge (over 100 cases) series of formal cecostomy, praising its advantages over tube cecostomy. We tried it eventually and were convinced although it requires eventually an operation for closure (obviously, does not apply to your terminal cases).
I thought a little follow up on my patients with constipation was in order. They both died within the past 24 hours. The patient I operated on with the perforated cecum did ok for a few days, then developed pneumonia. The family requested that he not be reintubated, and he died this morning. The other patient opened up transiently, but subsequently became thrombocytopenic, developed hepatic failure and died last night. He didn’t perforate his cecum, but his death could have been a lot more comfortable.
Both of these cases are disturbing, because to me they show American medicine at its worst. Both cases illustrate how we refuse to accept the inevitablity of death and continue to expend precious resources simply to prolong the process of dying. In both cases, neither the patients nor their families were adequately prepared for impending death. Therefore, when a sudden, catastrophic perforation occurred in the first case, and a painful, intractable case of pseudoobstruction developed in the second, neither family was ready to “pull the plug”. The physicians, not having prepared either themselves or their patients, were unwilling to forgo treatment of any potentially reversible condition, despite the fact that the handwriting was on the wall. Although I argued against aggressive intervention in both cases, I did not have the benefit of a prior relationship with the patients or their families, and, lacking the support of the primary physicians, was forced into the role of technician.
I don’t think this experience is unique to my small community. The doctors involved are all competent and caring, but that doesn’t alter my impression that, despite 20 years of intellectualization about “death with dignity”, we still do a poor job of preparing our patients for that final journey.
One final note – there is a good article on futile care in this month’s Bulliten of the American College of Surgeons by Joe Civetta. While he discusses the standard, quantitative definitions of futility, he also raises the cogent point that futility must be considered in light of the patient’s quality of life. It’s a good overview of a difficult topic, and I’d recommend reading it. I’m certainly going to send copies to my colleagues.
This is not American medicine at its worst, but perhaps its most characteristic. Americans view life as sacred, and American medicine submits to this belief, as it should. It is generally inconceivable to a non-medical person that anything could be worse than death. It is much easier to those of us who are more familiar with de ath to accept it as an alternative. But to most people it is the ultimate threat, something to be avoided at all costs. Unt il we reduce the fear of death, (which is a pretty tall order) it will not be a very common choice.
I recall the following patient: 82 year old woman admitted to the emergency room obtunded, with bowel obstruction due to large colon cancer. Hydrated in the ER, then taken to the OR at 2am for bowel resection. Three month course in the Surgical Intensive Care Unit notable for Bacterial sepsis, managed on dopamine, then norepinephrine infusions Fungal sepsis, managed with amphotericin Total parenteral nutrition, then gastric tube. Inability to wean from mechanical ventilation. Tracheostomy. Eventually transferred to a skilled nursing facility with trach on a t-piece, and gastric tube feedings. I learned all this from her medical record.
I met her SEVEN YEARS later when she came for cataract surgery at the age of 89. She had continued to recover in the nursing home, and had been living independently at home for six years. Her only complaint was that she had painters in her house that she had to clean up after. Was the outcome worth the great expense? I do not know, but it is difficult to determine with assurance when treatment is truly futile.