Abstract
Case Study
A 48-year-old female with recent diagnosis of adenocarcinoma of unknown origin and metastatic disease to the peritoneum initially presented to a nearby academic hospital with abdominal pain. She underwent exploratory laparotomy with tumor debulking surgery at that time. Shortly thereafter, she was readmitted to the same hospital with evidence of partial small bowel obstruction and treated conservatively with bowel rest, nasogastric (NG) tube placement, and intravenous (IV) fluid administration. Eventually the NG tube was removed, and she was discharged home. The following day, she received cycle one of palliative chemotherapy with cisplatin and gemcitabine at her local outpatient oncology clinic. She experienced persistent nausea and intermittent vomiting throughout the night and presented to our local community hospital for evaluation.
At the time of admission, she was passing minimal flatus and had passed only a small bowel movement that morning. She had experienced nausea, vomiting, and poor oral intake for over a week. Other presenting symptoms included mild to moderate abdominal pain involving the upper abdomen. Upon evaluation, abdominal x-ray revealed dilated loops of small bowel, consistent with partial small bowel obstruction. An NG tube was placed, and the patient’s symptoms were initially improved with bowel rest.
Her medical history was significant for pulmonary embolism detected at the time of her adenocarcinoma diagnosis, and she was on oral anticoagulation and home oxygen. She also had a history of depression and total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAH/BSO) due to fibroids. Her social history revealed she was an office worker and married with two sons, ages 18 and 24. The 18-year-old son lived at home with the patient and her husband. The patient was eagerly awaiting the birth of a granddaughter, due in a few weeks’ time. Her mother and father were also present daily during her hospitalization and were a major source of support for her and her family.
At the time of hospital admission, a surgical team consultation concluded she was not a candidate for palliative surgery due to extensive disease burden. She was seen in consultation by medical oncology, who recommended resuming chemotherapy once the acute partial small- bowel obstruction resolved.
Palliative Care Consult
A palliative care consultation was requested to assist with symptom management, including pain and nausea relief. At the time of consultation, the patient appeared in mild distress due to abdominal pain and distention. Vital signs were stable. Physical exam was significant for absent bowel sounds and a mildly distended but nontender abdomen. The NG tube was in place, draining bilious gastric fluid. She had mild nonpitting edema involving the bilateral lower extremities. Discussion with the patient revealed values consistent with improving symptoms and extending life expectancy as long as possible. The patient expressed wishes for “aggressive treatment,” which she defined as continuation of chemotherapy and full resuscitation.
The palliative care team discussed symptom management options with the patient. Nonsurgical management of partial bowel obstruction was continued, including bowel rest, NG tube decompression, and IV fluids. Pain was controlled initially with IV morphine as needed. After symptom improvement and evidence of bowel function recovery, the NG tube was removed. However, after a short time, she required NG tube replacement due to recurrent nausea and vomiting. Discussion was initiated with the patient, who opted for placement of a venting gastrostomy tube (G-tube) and total parenteral nutrition (TPN), with the goal of symptom relief and administration of nutrition, which would allow for continuation of chemotherapy.
During placement of the venting G-tube, the gastroenterology (GI) team noted extensive tumor involving the stomach, which made placement of the tube difficult. Additionally, anticoagulation was held during G-tube placement, and postoperatively, the patient experienced acute, right-sided chest pain and shortness of breath. Computed tomography (CT) scan with pulmonary embolus (PE) protocol revealed a new PE, and anticoagulation was changed to enoxaparin. Shortly thereafter, she became febrile and developed leukocytosis. Blood cultures revealed coagulase-negative staphylococcus from a Port-a-Cath source. She was treated with appropriate antibiotic therapy; however, follow-up blood cultures revealed persistent coagulase-negative staphylococcus bacteremia. Her indwelling Port-a-Cath was removed. After appropriate antibiotic therapy, a peripherally inserted central catheter line was inserted and TPN restarted.
Reinstituting Palliative Chemotherapy
Palliative care discussion with the patient confirmed her desire to reinstitute palliative chemotherapy, with the goal of restoring bowel function and returning home. Chemotherapy was resumed on day 15, despite concerns and even objections from several nursing staff members. The patient experienced treatment side effects, including prolonged thrombocytopenia. A platelet function antibody returned positive, consistent with heparin-induced thrombocytopenia. Enoxaparin was discontinued, and fondaparinux (Arixtra) was initiated. Platelet count recovered shortly thereafter.
The patient required intense symptom management due to intractable abdominal pain and nausea and vomiting despite adequate venting G-tube decompression. Medical management was maximized with antiemetics, antisecretory agents, steroids, and antipsychotic agents, and symptoms eventually improved after cycle 2 of chemotherapy. Thereafter, the patient was discharged home. At the time of discharge, her symptoms were well controlled on minimal pain medications. She was still experiencing intermittent nausea but was passing flatus.
By reducing the tumor burden, chemotherapy significantly improved her quality of life. She spent a total of 7 weeks in the hospital. During that time, she received two cycles of chemotherapy plus best supportive care and symptom management. Despite intermittent nausea and vomiting, administration of palliative chemotherapy allowed this patient to achieve her primary goals, which included returning home to her family and regaining some bowel function. Over the next several months, she received several more cycles of outpatient palliative chemotherapy. She experienced mild to moderate nausea and intermittent vomiting despite G-tube venting. Eventually, her disease progressed, and the patient chose to forgo any further intervention or chemotherapy. She was enrolled in hospice care and died comfortably at home surrounded by her family.
