Structural Emergencies
Bowel Obstruction
DEFINITION
• The interference or cessation of the normal passage of intestinal contents through the gastrointestinal tract
• The obstruction may be partial or complete
• May involve either the small or large bowel
• Paralytic ileus is a failure of normal motility in the absence of any mechanical obstruction.
• Obstipation refers to acute abdominal pain with the ability to pass flatus but not bowel movements.
EPIDEMIOLOGY
• The risk for the development of bowel obstruction is high in any patient with a history cancer and is considered a common occurrence in abdominal and pelvic disease. However, minimal data are available regarding incidence. (Note: constipation is a frequent occurrence in palliative care with a conservative estimate of 50% of all patients admitted to hospice care.)
• Nonmalignant obstructions: adhesions from previous surgeries, hernia, inflammatory bowel disease, fecal impaction, and bowel ischemia
• Malignant obstructions: a possible primary neoplasm in any part of the bowel, abdomen, or pelvis or as metastasis from multiple sites
• Posttreatment for malignancy can also cause obstruction: fibrosis from radiation, neurotoxic complications from chemotherapy
RISK FACTORS
SIGNS AND SYMPTOMS
• Presenting symptoms will vary depending on the site of the obstruction. The bowel secretes approximately 6-8 L daily.
• Anorexia, nausea, vomiting, abdominal distention, abdominal fullness, early satiety, dyspepsia, diminished or absent bowel sounds, abdominal or pelvic cramping, pain, constipation or conversely liquid stool
DIAGNOSTIC TESTS
• Abdominal x-ray films, computed tomographic (CT) or positron emission tomographic (PET) scans
• Complete blood cell count (CBC): elevated white blood cell count (WBC) suggests strangulation; elevated hematocrit may point to dehydration.
• Electrolyte studies: acid-base disturbances are common in small bowel obstruction.
TREATMENT
Pharmacologic Management
• Octreotide inhibits the release of several gastrointestinal hormones and reduces gastrointestinal secretions.
• Role of corticosteroids in treating bowel obstruction is still controversial but may be useful as adjuvant antiemetic.
• Laval and colleagues studied 80 cases of malignant obstruction by using a series of staged interventions:
Nonpharmacologic Management
• Immediate treatment is bowel rest and intravenous fluid replacement.
• Nasogastric tubes are useful to decompress and drain. A venting gastrostomy may be a palliative option.
• Surgical intervention has been traditional with the creation of an ostomy or a resection (removal of a portion of bowel). Recently, colorectal stents, implanted with use of endoscopy and fluoroscopy, are an option for palliative treatment.
Laval G., Arvieux C., Stefani L., et al. Protocol for the treatment of malignant inoperable bowel obstruction: A prospective study of 80 cases at Grenoble University Hospital Center. Journal of Pain and Symptom Management. 2006;31:502–512.
Ptok H., Meyer F., Marusch F., et al. Palliative stent implantation in the treatment of malignant colorectal obstruction. Surgical Endoscopy. 2006;20:909–914.
Von Gunten C., Muir J.C. Medical management of bowel obstruction. Journal of Palliative Medicine. 2002;5:739–740.
Cystitis
DEFINITION
• A painful bladder disorder caused by inflammation of the bladder epithelium (hemorrhagic, inflammatory, or infectious)
• Occurs when an inflammatory lesion or process compromises the ability to store urine in lower urinary tract
• Associated with cancer symptoms, treatment side effects, or disease sequelae
• Hemorrhagic cystitis: often the sudden onset of hematuria combined with bladder pain and irritative bladder symptoms
PATHOPHYSIOLOGY
• Problems are generally with the urothelium or with neuromuscular function.
• The mucosal lining of the bladder is made of multiple layers of epithelial cells.
• Distinction needs to be made among causes of symptoms:
• Symptoms may be similar, but tumor invasion is usually more insidious and gross hematuria is present.
• In chemotherapy induced cystitis, metabolites of cytotoxic drugs are excreted into renal system and reside in the bladder for extended periods of time.
• Radiation cystitis caused by external beam or interstitial therapy to the pelvis:
TREATMENT
• Type of treatment will be determined by cause and severity of cystitis.
• Preventive strategies, particularly in the immunocompromised, are key.
• Severity of bladder symptoms/disturbances can be evaluated by a Common Toxicity criteria scale.
Fitzgerald M. Urinary tract infection: Providing the best care. Retrieved November 1, 2006, from http://www.medscape.com/viewprogram/1920, 2004.
Gray M., Campbell F.G. Urinary tract disorders. In: Ferrell B., Coyle N. Palliative nursing. New York: Oxford; 2001:175–191.
Gupta K., Stamm W. Urinary tract infections. Retrieved November 1, 2006, from http://www.medscape.com/viewarticle/505095, 2005.
Neoplastic Cardiac Tamponade
PATHOPHYSIOLOGY
• Pericardium is a two-layered sac that encloses the heart and the great vessels that come off the heart.
• The pericardial space is created between the two layers that protect the heart (parietal and visceral) with normally a very small amount of fluid (50 mL) that serves as a lubricant.
• Collection of pericardial fluid accumulates (pericardial effusion), increasing pressure and compressing the heart. To maintain cardiac output, body attempts to compensate by increasing heart rate and peripheral vasoconstriction.
• Develops slowly or rapid onset. A slow onset can stretch to accommodate almost 4 L of fluid.
• Five grades of toxicity associated with pericardial effusion
SIGNS AND SYMPTOMS
• Initially difficult to detect until the fluid accumulation is significant (slowly developing effusions allow the pericardium to stretch)
• Hoarseness, cough or hiccups, difficulty swallowing (compression of trachea, esophagus, and nerves)
• Pericardial friction rub may be heard.
• Increased jugular venous distention (JVD)
• Kussmal’s sign (deep gasping respirations, frequently associated with diabetic coma)
• Systolic blood pressure decreases and diastolic pressure will rise (narrowing of pulse pressure).
• Paradoxical pulse (decline in systolic blood pressure on inspiration)
• Other signs of decreased cardiac output include tachycardia, anxiety, restlessness, peripheral cyanosis, oliguria, and shock.
CANCERS ASSOCIATED WITH DISORDER
• Tumors most often associated with pericardial metastasis are lung cancer, breast cancer, leukemia, Hodgkin disease, and melanoma.
• Primary tumors are rare and are usually mesotheliomas and sarcomas.
• Lung and breast cancers can spread by direct extension or lymphatic metastasis.
• Lymphomas and leukemias typically spread by hematogenous routes.
• Radiation therapy of 4,000 rad or greater to the mediastinum can lead to immediate or long-term complications.
DIAGNOSTIC TESTS
• Routine chest x-ray films initially reveal subtle changes and enlarged pericardial silhouette.
• Electrocardiogram (ECG) findings may be nonspecific—sinus tachycardia.
• Echocardiography—96% accuracy
• Computed tomography (CT) and magnetic resonance imaging (MRI) are noninvasive and reveal pleural effusion, masses, or pericardial thickening.
• Percutaneous pericardiocentesis
