Palliation in colorectal cancer: obstruction, stents, stomas and liver capsule pain

A substantial minority of colorectal cancers present as an emergency with obstruction, and others obstruct as the disease advances. A self-expanding metal stent placed at colonoscopy relieves a left-sided obstruction within a day or two and can be used as a bridge to elective surgery, so the patient is resected without a stoma and with a lower complication rate, or as definitive palliation in incurable disease; perforation, migration and re-obstruction are its risks and stenting is avoided while bevacizumab is being given because of the perforation rate. A defunctioning or end colostomy is the alternative and is often better for right-sided or multi-level obstruction, for peritoneal disease and where the prognosis is longer. Right-sided obstruction is usually resected with primary anastomosis. For inoperable malignant bowel obstruction from peritoneal disease, treatment is medical: a subcutaneous syringe driver with an anti-emetic, an anti-secretory drug such as hyoscine butylbromide or octreotide, dexamethasone, and opioid analgesia, with a venting gastrostomy if vomiting persists. Liver capsule pain from bulky metastases is a distinct, position-dependent right upper quadrant pain that responds to dexamethasone and, when it does not, to a short course of palliative radiotherapy to the liver. Pelvic pain, bleeding and discharge from an unresectable rectal tumour respond to hypofractionated palliative radiotherapy; tenesmus is the hardest symptom and may need a nerve block or a stoma. Early integrated palliative care alongside oncology is recommended from diagnosis of incurable disease, and NICE NG151 covers the management of obstruction and the ongoing care of people with advanced colorectal cancer.