恶性肠梗阻专家共识

1、 1. Anthony T, Baron T, Mercadante S, et al. Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction. J Pain Symptom Manage 2007;34:S4959 1. Ripamonti C, Bruera E. Palliative management of malignant bowel obstruction. Int J Gynecol Cancer 2002;12:1

2、3543. 2. Krouse RS. The international conference on malignant bowel obstruction: a meeting of the minds to advance palliative care research. J Pain Symptom Manage 2007;34:S16. 3。Ali sidgiqui，et al：desease and sciences 2007 52（1）276281EJC 症症 状状胃或近端小肠胃或近端小肠远端小肠或大肠远端小肠或大肠 呕吐呕吐 胆汁样，稀薄，量大，胆汁样，稀薄，量大， 无或稍有

3、气味无或稍有气味 颗粒状，体积小，恶臭，也可颗粒状，体积小，恶臭，也可 能无呕吐能无呕吐 腹痛腹痛 出现早，集中在脐周，出现早，集中在脐周， 痉挛性痛，发作间隔痉挛性痛，发作间隔 短短 出现晚，局限，深部内脏性痛，出现晚，局限，深部内脏性痛， 痉挛性痛发作间隔长，患者痉挛性痛发作间隔长，患者 多描述为绞痛多描述为绞痛 腹胀腹胀 可能不出现可能不出现出现出现 食欲减退食欲减退 经常出现经常出现可能不出现可能不出现 有肿瘤病史的患者有肿瘤病史的患者 出现肠梗阻症状出现肠梗阻症状 影像学检查影像学检查 CT/MRI 临床评估临床评估 患者因素患者因素临床决策临床决策技术因素技术因素 与患者及家属商定

4、最终治疗方案与患者及家属商定最终治疗方案 数周数日数周数日 （濒临死亡）（濒临死亡） l与手术相比，药物治与手术相比，药物治 疗是更适宜的选择疗是更适宜的选择 l评估治疗目标有助于评估治疗目标有助于 指导干预方案（例如：指导干预方案（例如： 减少恶心、呕吐，允减少恶心、呕吐，允 许患者进食，减轻疼许患者进食，减轻疼 痛，允许患者回家或痛，允许患者回家或 接受家庭护理）接受家庭护理） l药物治疗药物治疗 l静脉或者皮下补液静脉或者皮下补液 l内镜治疗鼻胃管引流内镜治疗鼻胃管引流 仅当其他措施无法减轻呕吐仅当其他措施无法减轻呕吐 时方考虑时方考虑 预计生存期预计生存期 1 .Lowe AS, Be

5、ckett CG, Jowett S, et al. Self-expandable metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre. Clin Radiol 2007;62:73844. 2. Telford JJ, Carr-Locke DL, Baron TH, et al. Palliation of patients with malignant gastric outlet obstru

6、ction with the enteral Wallstent: outcomes from a multicenter study.Gastrointest Endosc 2004;60:91620. 3. Dormann A, Meisner S, Verin N, et al. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness. Endoscopy 2004;36:54350. 4. Nassif T, Prat F

7、, Meduri B, et al. Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study. Endoscopy 2003;35:4839. 5. Espinel J, Sanz O, Vivas S, et al. Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation

8、. Surg Endosc 2006;20:10837. 6. Lillemoe KD, Cameron JL, Hardacre JM, et al. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg 1999;230:3228. discussion 328-30. 7. Jeurnink SM, Steyerberg EW, Hof GV, et al. Gastrojejunostomy v

9、ersus stent placement in patients with malignant gastricoutlet obstruction: a comparison in 95 patients. J Surg Oncol 2007. 1. Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endos

10、c 2004;60:10107 2. Jeurnink SM, Steyerberg EW, Hof GV, et al. Gastrojejunostomy versus stent placement in patients with malignant gastricoutlet obstruction: a comparison in 95 patients. J Surg Oncol 2007. 3. Wong YT, Brams DM, Munson L, et al. Gastric outletobstruction secondary to pancreatic cancer

11、: surgical vs endoscopic palliation. Surg Endosc 2002;16:3102. 1. Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc 2004;60:10107. Khot et al. 1 Sebastian et al.2 成功应用技术 551（9

12、2%）1198（94%） 临床成功 525（88%）1198（91%） 姑息治疗成功 301/336（90%）791（93%） 死亡 3（1%）7（0.6%） 穿孔 22（4%）45（3.8%） 支架移位 54（10%）132（11.8%） 再梗阻 53（10%）82（7.3%） 1. Khot UP, Wenk Lang A, Murali K, et al. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096102. 2. Sebastian S, Johnsto

13、n S, Geoghegan T, et al. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastro 2004;99:20517. 1 . Camunez F, Echenagusia A, Simo G, et al. Malignant colorectal obstruction treated by means of self-expanding metallic stents: Effec

14、tiveness before surgery and in palliation. Radiology 2000;216:4927. 2 . Law WL, Chu KW, Ho JW, et al. Self-expanding metallic stent in the treatment of colonic obstruction caused by advancedmalignancies. Dis Colon Rectum 2000;43:15227. 3. Nash CL, Markowitz AJ, Schattner M, et al. Colorectal stents

15、for the management of malignant large bowel obstruction. Gastrointest Endo 2002;55:AB216. 4. Pothuri B, Guiguis A, Gerdes H, et al. The use of colorectal stents for palliation of large bowel obstruction due to recurrent gynecologic cancer. Gynecol Oncol 2004;95:5137. 1. Campagnutta E, Cannizzaro R,

16、Gallo A, Zarrelli A, Valentini M, De Cicco M, et al. Palliative Treatment of Upper Intestinal Obstruction by Gynecological Malignancy: The Usefulness of Percutaneous Endoscopic Gastrostomy. Gynecologic Oncology 1996;62:1035. 2. Pothuri B, Montemarano M, Gerardi M, Shike M, Ben-Porat L, Sabbatinin P,

17、 et al. Percutaneous endoscopic gastrostomy tube placement in patients with malignant bowel obstruction due to ovarian carcinoma. Gynecologic Oncology 2005;96:3304. 镇痛药 根据WHO指南 强烈推荐 抗胆碱能药物 丁溴东莨菪碱 氢溴酸东莨菪碱 持续疼痛 绞痛 给药方式 n持续皮下给药（CSI） l持续静脉给药CIV） l经皮肤给药 减少胃肠道分泌 1、抗胆碱能药物 丁溴东莨菪碱（40-120mg/d） 甘罗溴铵（，tid，sc或iv

18、） 氢溴酸东莨菪碱（） 和/或 2、生长抑素类似物 奥曲肽0.2-0.9 mg/d，civ或csi 止吐治疗 l胃复安（仅用于不全肠梗阻及没有绞痛的患者） 氟哌啶醇（5-15mg/dCSI） 甲氧异丁嗪 （50-150mg/dCSI） l镇静药 氯吡嗪（25-75mg/d直肠给药） 氯丙嗪 （50-100mg/d直肠给药/皮下） l抗组胺药盐酸吗嗪（100-150mg/d皮下或直肠 给药） 恶心呕吐 1. World Health Organization. Cancer Pain Relief. Second ed. Geneve: WHO; 1996. 2. Hofmann B, Hahe

19、im LL, Soreide JA. Ethics of palliative surgery in patients with cancer. Br J Surg 2005;92:8029. 3. Pothuri B, Guiguis A, Gerdes H, et al. The use of colorectal stents for palliation of large bowel obstruction due torecurrent gynecologic cancer. Gynecol Oncol 2004;95:5137. 4.Fainsinger RL, Spachynsk

20、i K, Hanson J, et al. Symptom control in terminally ill patients with malignant bowel obstruction. J Pain Symptom Manage 1994;9:128. 5. Ventafridda V, Ripamonti C, Caraceni A, et al. The management of inoperable gastrointestinal obstruction in terminal cancer patients. Tumouri 1990;76:38993. 6. Merc

21、adante S. Pain in inoperable bowel obstruction. Pain Digest 1995;5:913. 7. 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 Sympt Manage 1991;6:4846. Ventafridd

22、a V, Ripamonti C, Caraceni A, et al. The management of inoperable gastrointestinal obstruction in terminal cancer patients. Tumouri 1990;76:38993. 2. De Conno F, Caraceni A, Zecca E, Spoldi E, Ventafridda V. Continuous subcutaneous infusion of hyoscine butylbromide reduces secretions in patients wit

23、h gastrointestinal obstruction. J Pain Sympt Manage 1991;6:4846. 3. 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 having a nasogastric tube. A prospectiv

24、e, randomized clinical trial. J Pain Symptom Manage 2000;19:2334. 4. 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. Supportive Care in Cancer 2000;8:18

25、891. 1. Ripamonti C, Panzeri C, Groff L, Galeazzi G, Boffi R. The role of somatostatin and octreotide in bowel obstruction: pre-clinical and clinical results. Tumouri 2001;87:19. 2. Anthone GJ, Bastidas JA, Orlandle MS, Yeo CJ. Direct proabsorptive effect of octreotide on ionic transport in the smal

26、l intestine. Surgery 1990;108:113642. 1. 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 having a nasogastric tube. A prospective, randomized clinical tria

27、l. J Pain Symptom Manage 2000;19:2334. 2. 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. Supportive Care in Cancer 2000;8:18891. 1. Mercadante S, Avola

28、 G, Maddaloni S, et al. Octreotide prevents the pathological alterations of bowel obstruction in cancer patients. Support Care Cancer 1996;4:3934. Mercadante S, Kargar J, Nicolosi G. Octreotide may prevent definitive intestinal obstruction. J Pain Symptom Manage 1997;13:3525. 3. Sun X, Li X, Li H. M

29、anagement of intestinal obstruction in advanced ovarian cancer: an analysis of 57 cases in Chinese. Zhonghua Zhong Liu Za Zhi 1995;17:3942. 1. Cozzaglio L et al. Outcome of cancer patients receiving home parenteral nutrition. J Parenteral Enteral Nutrition 1997;21:33942. 2. Hoda D, Jatoi A, Burnes J, Loprinzi C, Kelly D. Should patients with advanced, incurable cancers ever be sent home with Total parenteral nutrition? Cancer 2005;103:8638. 1. Ripamonti C, Twycross R,