GI tract obstruction, pseudo-obstruction and ileus are infrequent entities in children with cancer. Although GI obstruction from primary cancer is rare in children, it is the initial symptom of Burkitt’s lymphoma in 15% to 25% of abdominal localizations. This may be suspected in cases of intussusception in older children or its recurrence; surgical intervention is necessary in these cases. Certain drugs used in cancer patients, like vinca alkaloids and narcotics can cause bowel obstruction. Acute or sub-acute obstruction may follow chemotherapy, or abdominal surgery for tumor resection; usually conservative treatment is sufficient for its management. It may also appear in patients in palliative care with progressive abdominal tumors. Assessment includes history, physical examination, and imaging studies.
Clinical picture
Although the aetiologies differ, the manifestations suggestive of mechanical obstruction in oncology patients mimic any patient with an abdominal obstruction.
Patients may have intermittent abdominal pain, nausea or bilious emesis, constipation, haematochezia, or abdominal distension. Physical exam consistent with obstruction includes hyperactive or high-pitched bowel sounds, peritoneal signs and a palpable mass. In contrast, absent bowel sounds suggest an ileus or functional obstruction.
Due to emesis and decreased oral intake, patients often present dehydrated on exam and laboratory assessment; patients may have a relative increase in WBCs with haemoconcentration as well as hypochloremic metabolic alkalosis.
Imaging
Imaging studies include supine, upright and decubitus abdominal radiographs. Although not pathognomonic, air-fluid levels in dilated bowel loops and pneumatosis intestinalis on KUB are strongly supportive of obstruction. Dilated and contracted bowel loops may present proximal and distal to the obstruction, respectively. Abdominal CT with oral contrast will best localize the obstruction and identify the aetiology.
Gastrointestinal obstruction
Management
- History, physical ex, plain radiographs.
- Nil by mouth.
- NGT for decompression.
- Evaluation of the underlying cause.
- Stool softener and passage of a small well-lubricated rectal tube may reduce obstruction till reduction of tumor mass.
Indications for surgical intervention include: (1) persistent bleeding in the absence of neutropenia, thrombocytopenia or coagulopathy; (2) intraperitoneal perforation; (3) clinical deterioration of unknown etiology, especially if requiring blood pressure support with either colloids or vasopressors; and (4) any abdominal process that would require surgery in an immunocompetent host such as a mass lesion.
Gastrointestinal perforation
- Unresolved obstruction
- Ulcers or gastritis
- Erosion by 1ry tumor
- Infections as typhlitis
Surgical emergency managed by resection of the affected area and 2ry closure OR by 1ry re-anastomosis.
References
- Silliman CC, Haase GM, Strain JD et al (1994) Indications for surgical intervention for gastrointestinal emergencies in children receiving chemotherapy. Cancer 74:203–216
- Yip D, Goddard N (2010) Oncological emergencies: diagnosis and management. In: Robotin M, Olver I, Girgis A (eds) When cancer crosses disciplines: a physician’s handbook. Imperial College Press, London
- Fisher MJ, Rheingold SR (2011) Oncologic emergencies. In: Pizzo PA, Poplack DG (eds) Principles and practice of pediatric oncology, 6th edn. Lippincott Williams & Wilkins, Pennsylvania
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