Manejo terapéutico actual de la oclusión intestinal maligna no quirúrgica
Palabras clave:
OBSTRUCCIÓN INTESTINAL, NEOPLASIASResumen
Introducción: la oclusión intestinal (OI) es una complicación frecuente de los pacientes oncológicos en etapa terminal. Cuando no es posible la cirugía, el tratamiento es médico, sin embargo este aún no está protocolizado.
Objetivo: analizar el tratamiento de pacientes con diagnóstico de oclusión intestinal maligna (OIM) fuera de sanción quirúrgica.
Material y método: trabajo retrospectivo descriptivo de diez pacientes atendidos por la Unidad de Cuidados Paliativos del Servicio de Oncología del Hospital Central de las Fuerzas Armadas, diagnóstico de OIM desde el 1º de enero de 2009 al 31 de diciembre de 2010.
Resultados: separamos a los pacientes según resultado terapéutico: en quienes revirtió la OIM (6/10) y en quienes no revirtió la OIM (4/10). En el primer grupo la edad media fue de 55 años, la causa de oclusión en 5/6 pacientes fue íleo adinámico. El tratamiento terapéutico comenzó entre el primer y el sexto día de iniciado los síntomas. Todos los pacientes utilizaron dexametasona, metoclopramida, antiácidos y analgésicos, hioscina en 5/6 pacientes, neostigmina fue utilizada en dos pacientes con dolor mínimo, haloperidol y levomepromazina en dos pacientes en que predominaron los vómitos. La sobrevida media fue de 39 días. En el segundo grupo la edad media fue de 75 años. La causa de OIM fue mecánica en 2/4 pacientes. Todos presentaban más de tres comorbilidades. Todos los pacientes utilizaron metoclopramida, dos de ellos haloperidol y tres dexametasona. Sobrevida media: nueve días.
Discusión: obtuvimos buenos resultados al iniciar tempranamente un plan con corticoides, haloperidol, analgesia y neostigmina, que deberán ser validados en un estudio prospectivo y con mayor número de pacientes.
Citas
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(33) Ripamonti C, Mercadante S, Groff L, Zecca E, De Conno F, Casuccio A. Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial. J Pain Symptom Manage 2000; 19(1): 23-34.
(34) Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Support Care Cancer 2000; 8(3): 188-91.
(2) Tuca A, Martínez E, Güell E, Gómez Batiste X. Obstrucción intestinal maligna. Med Clin (Barc) 2010; 135(8): 375-81.
(3) Anthony T, Baron T, Mercadante S, Green S, Chi D, Cunningham J, Herbst A, et al. Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction. J Pain Symptom Manage 2007; 34(1 Suppl): S49-59.
(4) Pontificia Universidad Católica de Chile. Escuela de Medicina. Manual de patología quirúrgica: oclusión intestinal. Disponible en: http://escuela.med.puc.cl/paginas/publicaciones/patolquir/patolquir_016.html (Consulta: 22 de noviembre de 2011).
(5) Baines M, Oliver DJ, Carter RL. Medical management of intestinal obstruction in patients with advanced malignant disease: a clinical and pathological study. Lancet 1985; 2(8462): 990-3.
(6) Ripamonti C, Twycross R, Baines M, Bozzetti F, Capri S, De Conno F, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer 2001; 9(4): 223-33.
(7) Ventafridda V, Ripamonti C, Caraceni A, Spoldi E, Messina L, De Conno F. The management of inoperable gastrointestinal obstruction in terminal cancer patients. Tumori 1990; 76(4): 389-93.
(8) Fainsinger RL, Spachynski K, Hanson J, Bruera E. Symptom control in terminally ill patients with malignant bowel obstruction. J Pain Symptom Manage 1994; 9(1): 12-8.
(9) Laval G, Arvieux C, Stefani L, Villard ML, Mestrallet JP, Cardin N. Protocol for the treatment of malignant inoperable bowel obstruction: a prospective study of 80 cases at Grenoble University Hospital Center. J Pain Symptom Manage 2006; 31(6): 502-12.
(10) Mercadante S, Casuccio A, Mangione S. Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review. J Pain Symptom Manage 2007; 33(2): 217-23.
(11) Porzio G, Aielli F, Verna L, Galletti B, Shoja E Razavi G, Ficorella C. Can malignant obstruction in advanced cancer patients be treated at home? Support Care Cancer 2011; 19(3): 431-3.
(12) Mercadante S, Ferrera P, Villari P, Marrazzo A. Aggressive pharmacological treatment for reversing malignant bowel obstruction. J Pain Symptom Manage 2004; 28(4): 412-6.
(13) Ripamonti CI, Easson AM, Gerdes H. Management of malignant bowel obstruction. Eur J Cancer 2008; 44(8): 1105-15.
(14) Ross DD, Alexander CS. Management of common symptoms in terminally ill patients: part I. Fatigue, anorexia, cachexia, nausea and vomiting. Am Fam Physician.2001; 64(5): 807-14.
(15) Ripamonti CI, Fagnoni E, Magni A. Management of symptoms due to inoperable bowel obstruction. Tumori 2005; 91(3): 233-6.
(16) Navarro Campoamor J, Jiménez Fonseca P. Cuidados paliativos: guía práctica. Madrid: Médica Panamericana, 2009. p. 4-7.
(17) Muir CJ, von Gunten CF. Antisecretory agents in gastrointestinal obstruction. Clin Geriatr Med 2000, 16(2): 327-34.
(18) Ripamonti C, Mercadante S. How to use octreotide for malignant bowel obstruction. J Support Oncol 2004, 2(4): 357-64.
(19) Shima Y, Ohtsu A, Shirao K, Sasaki Y. Clinical efficacy and safety of octreotide (SMS201-995) in terminally ill Japanese cancer patients with malignant bowel obstruction. Jpn J Clin Oncol 2008, 38(5): 354-9.
(20) De Conno F, Caraceni A, Zecca E, Spoldi E, Ventafridda V. Continuous subcutaneous infusion of hyoscine butylbromide reduces secretions in patients with gastrointestinal obstruction. J Pain Symptom Manage 1991; 6(8): 484-6.
(21) Allen GS. Nausea and vomiting. En: Hanks, G., Cherny, N., Christakis, N., Fallon, M., Kaasa, S., Portenoy, R, eds. Oxford textbook of palliative medicine. 4th ed. New York: Oxford University Press, 2005. p. 459- 66.
(22) Twycross RG. Pain relief in advanced cancer. 2nd ed. Edinburgh: Churchill Livingstone, 1994. p. 425-53.
(23) Ripamonti C. Malignant bowel obstruction in advanced and terminal cancer patients. Eur J Palliat Care 1994; 1(1):16-9.
(24) Hardy J, Ling J, Mansi J, Isaacs R, Bliss J, A'Hern R, et al. Pitfalls in placebo controlled trials in palliative care: dexamethasone for the palliation of malignant bowel obstruction. Palliat Med 1998, 12(6): 437-42.
(25) Laval G, Girardier J, Lassaunière JM, Leduc B, Haond C, Schaerer R. The use of steroids in the management of inoperable intestinal obstruction in terminal cancer patients: do they remove the obstruction? Palliat Med 2000; 14(1): 3-10.
(26) Feuer DJ, Broadley KE. Systematic review and meta-analysis of corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancers: Systematic Review Steering Committee. Annals of Oncology 1999; 10(9): 1035-41.
(27) De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg 2009; 96(3): 229-39.
(28) Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of the acute colonic pseudo-obstruction. N Engl J Med 1999; 341(3): 137-41.
(29) Amaro R, Rogers AI. Neostigmine infusion: new standard of care for acute colonic pseudo-obstruction? Am J Gastroenterol 2000; 95(1): 304-5.
(30) van der Spoel JI, Oudemans-van Straaten HM, Stoutenbeek CP, Bosman RJ, Zandstra DF. Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure: a prospective, double-blind, placebo-controlled trial. Intensive Care Med 2001; 27(5): 822-7.
(31) Organización Médica Colegial. Sociedad Española de Cuidados Paliativos. Declaración sobre la atención médica al final de la vida. Madrid: Sociedad Española de Cuidados Paliativos, 2002.
(32) World Health Organization. Cancer pain relief and palliative care: report of a WHO expert committee. Technical reports, 804. Geneva: WHO, 1990.
(33) Ripamonti C, Mercadante S, Groff L, Zecca E, De Conno F, Casuccio A. Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial. J Pain Symptom Manage 2000; 19(1): 23-34.
(34) Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Support Care Cancer 2000; 8(3): 188-91.
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2012-07-31
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Della Valle A, Wolaj M, Santos D, Mesa F, Treglia A. Manejo terapéutico actual de la oclusión intestinal maligna no quirúrgica. Rev. Méd. Urug. [Internet]. 31 de julio de 2012 [citado 27 de diciembre de 2024];28(2):108-14. Disponible en: https://revista.rmu.org.uy/index.php/rmu/article/view/349
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