Guideline sources The following summarized guidelines for the management of malignant bowel obstruction (MBO) are prepared by our editorial team based on guidelines from the Multinational Association of Supportive Care in Cancer (MASCC 2022), the American Gastroenterological Association (AGA 2021), the European Society of Medical Oncology (ESMO 2021), and the Multinational Association of Supportive Care in Cancer (MASCC/ESMO 2016). 1 2 3 4 Guidelines 1. Medical management Antiemetics: As per MASCC 2022 guidelines, consider administering octreotide to reduce vomiting in patients with MBO. C Show 7 more As per ESMO 2021 guidelines: Administer octreotide or haloperidol for nausea and vomiting in patients with MBO. B Administer metoclopramide with caution in patients with partial bowel obstruction. B Do not use metoclopramide in patients with complete bowel obstruction. B https://web.pathway.md/diseases/recsxQZMFfRieOBdx 1/4 6/29/23, 6:18 AM Malignant bowel obstruction Pathway As per ESMO 2016 guidelines, administer octreotide, dosed around the clock, in addition to a conventional antiemetic in patients with bowel obstruction. B Show 2 more Laxatives: consider administering oral osmotic laxatives for the management of impaired bowel movements in patients with partial bowel obstruction, but avoid using in complete MBO. C Corticosteroids: consider administering corticosteroids for acute symptoms of MBO and for short- term benefits. C Opioids: insufficient evidence to support the use of opioids for the treatment of pain associated with MBO. I Anticholinergics: consider administering anticholinergics (hyoscine butylbromide) to reduce abdominal pain in patients with MBO. C Water-soluble contrast agents: insufficient evidence to determine the efficacy of oral water- soluble contrasts in patients with MBO. I 2. Nonpharmacologic interventions Nutrition: keep the patient NPO initially when diagnosed with MBO, and then switch to a symptom-led, slow and graded reintroduction to oral diet when acute MBO resolves fully or partially, including clear fluids, free or full fluids, texture-modified low-fiber diet (soft, minced, and pureed) and if tolerated back to normal-textured low-fiber diet. B Show 6 more 3. Therapeutic procedures General principles: decide on specific interventions in patients with alimentary tract obstruction in a multidisciplinary setting including oncologists, surgeons and endoscopists and take into account the characteristics of the obstruction, patient's expectations, prognosis, expected subsequent therapies and functional status. B Bowel decompression: consider placing a nasogastric tube for temporary decompression in patients with acute MBO. C Show 2 more Self-expanding metallic stents: As per MASCC 2022 guidelines, perform self-expanding metallic stent placement as the preferred alternative for the management of patients with single-level large bowel obstruction when technically feasible and in the absence of colonic perforation. B As per AGA 2021 guidelines, consider placing self-expanding metal stents as a bridge to surgery to allow for one-stage, elective resection in patients with malignant colonic obstruction being candidates for resection. C Show 3 more https://web.pathway.md/diseases/recsxQZMFfRieOBdx 2/4 6/29/23, 6:18 AM Malignant bowel obstruction Pathway 4. Surgical interventions Palliative surgery: As per MASCC 2022 guidelines: Consider performing palliative surgical intervention in highly selected patients with a multi-level obstruction. C Consider performing less invasive surgical interventions in patients with advanced cancer undergoing palliative surgery for MBO because of high risk of surgical complications. C As per AGA 2021 guidelines, consider performing diverting colostomy as a reasonable option, depending on the patient's goals and functional status, in patients with malignant colonic obstruction not being candidates for resection. C Clinical findings Symptoms Past medical history Abdominal pain Malignancy Bloating Abdominal exam Constipation Dry mouth Abdominal distension Fatigue bowel sounds Hematochezia Imaging findings Hungrer Nausea Colonic dilation Shortness of breath Intestinal air-fluid levels Somnolence Tenesmus Vomiting Weight loss Vital signs Hypotension Tachycardia Integument exam Dehydration References 1. Ainhoa Madariaga, Jenny Lau, Arunangshu Ghoshal et al. MASCC multidisciplinary evidence-based recommendations for the management of malignant bowel obstruction in advanced cancer. Support Care Cancer. 2022 Mar 10. Open https://web.pathway.md/diseases/recsxQZMFfRieOBdx 3/4 6/29/23, 6:18 AM Malignant bowel obstruction Pathway 2. Osman Ahmed, Jeffrey H Lee, Christopher C Thompson et al. AGA Clinical Practice Update on the Optimal Management of the Malignant Alimentary Tract Obstruction: Expert Review. Clin Gastroenterol Hepatol. 2021 Sep;19 9 1780 1788. Open 3. F Roila, A Molassiotis, J Herrstedt et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol. 2016 Sep;27(suppl 5):v119-v133. Open 4. G B Crawford, T Dzier anowski, K Hauser et al. Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines. ESMO Open. 2021 Aug;6 4 100225. Open https://web.pathway.md/diseases/recsxQZMFfRieOBdx 4/4