Sherlock – “I fear this is no mere fancy of the bowels, but a most grievous obstruction—tragically real, and cruel in its consequence. A certain cause of death. ”

I have been struggling with the fact that my patients with malignant bowel obstruction have an extremely poor survival, and this combined with the damning realization that their finite existence might be defined by the complete absence of the experience of eating, serves as a continued reminder of the egregious devastation brought about by advanced cancer. Infact it serves as a heady reminder that the experience of eating has been so undervalued and neglected in medical teaching, that the debasement of it, is not even considered a symptom – ever heard of “dis-eatopathy or mal-eatexperience”.

The rapid phase of decline, witnessed when starvation sets in, often compounded by the absence of parenteral nutrition, makes for a frighteningly real experience for all concerned.

A patient with secondary peritoneal carcinomatosis with delirium, was advised consultation liaison. Prompt evaluation was initiated. Analgesia was optimised. She had symptoms of Constipation with large biliuous vomitus, following which symptom-directed treatment was started.
Timely transfer of care was sought, and goal-concordant, maximal ward-based management, including but not limited to, therepeutic paracentesis, multiple anti-emetics and anti-secretory agents, typically used in this setting was instituted after witnessing the churnings on POCUS (*that octreotide and hyoscine are to be used together might be an important note to aspiring specialists, so would the maximal-advisable dosing).

This post has been conceptualized as an acknowledgement of the fact that her life has recently, crossed the threshold of 2 weeks and that her diet plan has been able to progress up another step (hitherto unseen in this patient population) – the difficult transition from full liquids to the introduction of low-fiber diet has been accomplished. These developments were also accompanied by the first bowel movement (duly acknowledged by the dietary team who promptly responded with the addition of a diet chart to existing patient records as a token gesture).

Watson, though the situation remains precarious there has been some forward movement (if you know what I mean!!). Again, though the outcome was known to all, we did witness this experience together.

Disclaimer – Every attempt has been made to safeguard the identity of patients referred to in the vignettes and any circumstances arising out of this moral treatise are completely unintended on the part of the author. The author does not intend to cause any harm to another individual’s or organization’s reputation and has tried his level best to ensure that identities are fiercely protected.