Intractable Nausea in a Patient with Metastatic Colorectal Cancer Following Insertion of a Colonic Stent
Article Outline
To the Editor:
We are writing to report the unusual development of severe nausea following insertion of a colonic stent in a patient with advanced malignancy. After several months of unsuccessful medical therapy the patient underwent surgical resection and experienced immediate and complete resolution of her nausea. To our knowledge, this is the first reported case in the literature of intractable nausea related to insertion of a colonic stent. Given the increasing use of stents in the management of gastrointestinal cancer, we believe this observation will provide guidance to other clinicians who encounter this serious, but reversible, side effect.
Case Report
A 49-year-old woman presented in January 2007 with a one-year history of intermittent, postprandial abdominal pain. Over the previous four months, the abdominal pain had increased in severity and was associated with a change in bowel habits and 40 pounds of weight loss. The patient underwent a barium enema that showed an obstructive lesion in the descending colon. Colonoscopy confirmed the presence of an obstructing mass, which was biopsy-proven adenocarcinoma. Computed tomography (CT) of the abdomen and pelvis showed multiple liver lesions scattered in both lobes measuring up to 16
mm in size, highly suggestive of metastatic disease. Due to the symptoms of impending complete bowel obstruction and the patient's poor nutritional status, it was elected to proceed with nonsurgical management of the primary tumor. The patient underwent endoscopic insertion of a metal colonic stent in February 2007. Colonoscopy to the level of the tumor (45cm from anal verge) was repeated and the obstruction bypassed using a catheter and guidewire, under endoscopic and fluoroscopic control. A colonic stent (120 mm long, 25 mm diameter Wallflex colon stent, Boston Scientific Mississauga, Ontario, Canada) was then placed across the stricture, with good resulting patency.
Following stent insertion, the abdominal pain resolved. However, within 24hours, the patient developed significant nausea and vomiting, with difficulty maintaining oral intake. She required several visits to the Emergency Department. Oral dimenhydrinate, metoclopramide, and laxatives were initiated. Due to persistent nausea and abdominal cramping, the patient returned to the endoscopy suite one week later. On repeat colonoscopy, the distal end of the stent was found to be causing inflammation at an angle in the sigmoid colon, resulting in incomplete drainage. A second colonic stent was placed overlapping the first stent, and bridging this angle. This improved the flow and reduced the inflammation.
Unfortunately, the patient continued to experience severe nausea and vomiting and was admitted several days later for further workup and management. Upper endoscopy was normal and CT of the brain did not show any overt metastasis. While in hospital, she initially responded to a regimen of intravenous metoclopramide, ondansetron, and dimenhydrinate. She tolerated a switch to oral medications and was discharged home on oral metoclopramide 15mg every six hours. However, upon discharge, her severe nausea recurred. A trial of lorazepam for anticipatory nausea and dexamethasone did not provide any symptomatic relief. The patient continued to lose weight, and within a month of the stent placement, had lost an additional 25 pounds. The palliative care service was consulted. At the time, she rated her nausea as 6–10/10 on the Edmonton Symptom Assessment System.1 She thought she had benefit from metoclopramide but had experienced some restlessness and so was switched to domperidone 20mg every four hours.
The patient's symptoms persisted, and in March 2007, it was decided to initiate palliative chemotherapy (infusional 5-FU and irinotecan, FOLFIRI). The patient tolerated chemotherapy well, with no increase in the severity of her nausea. A variety of antiemetic agents targeting different receptors and pathways for nausea and vomiting2, 3 was initiated by the palliative care service. These agents targeted: the vagus and sympathetic afferent nerves' D2 and 5-HT3 receptor antagonists (metoclopramide, domperidone, and ondansetron); the chemoreceptor trigger zone's D2 and 5-HT3 receptors (prochlorpromazine, haloperidol, metoclopramide, domperidone, and ondansetron); the vomiting center's 5-HT3, muscarinic-cholinergic, and histamine receptors (ondansetron, scopolamine, meclizine, and dimenhydrinate); and cortical receptors (nabilone and drabilone). The patient did not have any significant improvement in her symptoms, with the exception of temporary relief with acupuncture.
Two months after colonic stenting (April 2007), she had lost a total of 35 pounds and became severely debilitated, requiring enteral feeding support through a percutaneous gastrojejunal feeding tube. The underlying cause of her nausea remained unclear, although it did relate temporally to insertion of the colonic stents. Therefore, in discussion with the patient and her surgeon, resection of the primary tumor and the stents was planned. The patient tolerated five cycles of FOLFIRI remarkably well and her preoperative CT scan showed an excellent radiographic response to treatment.
In June 2007, she was taken to the operating room for a palliative left hemicolectomy. During the surgical resection, it was noted that the large mass in the sigmoid colon had become adherent to the left fallopian tube and ovary as well as the pelvic sidewall, but the remainder of the colon was palpably free of disease. The stent was palpable through the bowel wall and seemed intact. There was no evidence of omental disease and the liver had a few small palpable metastatic deposits that were previously identified on CT imaging. Resection en-bloc of the entire primary tumor and the fallopian tube and ovary was accomplished and the specimen was sent fresh to the pathologist. A primary anastomosis was developed and the patient was allowed to recover on the surgical ward. In the postanesthetic recovery room, the patient experienced immediate postoperative resolution of her intractable nausea. Her performance status, appetite, and weight improved within days of being discharged from hospital.
Pathologic examination of the resected left colon specimen showed moderately differentiated adenocarcinoma with transmural invasion into subserosal fat (Fig. 1e–g) and negative resection margins. Regional lymph nodes were negative for malignancy. The endoluminal colonic stents spanning an 18 cm segment (Fig. 1a) were surrounded by acute and chronic mucosal and mural inflammation with areas of deep ulceration, mural suppurative necrosis (Fig. 1b,c), and diffuse pseudopolyp formation (Fig. 1d).
Fig. 1
Colon segmental resection specimen opened with endoluminal stents in situ (a). The stented segment showed severe inflammatory disease with extensive ulceration and mural inflammation (b; original magnification 2×), mucosal acute and chronic inflammation with crypt distortion (c; original magnification 200×), and pseudopolyp formation (d; original magnification 2×). An invasive adenocarcinoma (T3 lesion), which was difficult to clearly identify on the mucosal aspect, was present at the distal portion of the stented segment (e; original magnification 2×; f, original magnification 50×; g, original magnification 250×).
Comment
Enteral stents are used increasingly as a nonsurgical alternative for the palliation of obstructive colorectal cancer and provide an important minimally invasive treatment option for patients with advanced cancer.4, 5, 6, 7, 8 Major complications related to stent placement include perforation (3%), stent migration (11%), and reobstruction (7%), as well as bleeding, tenesmus, and abdominal pain.4, 5, 6, 7, 8 Although this patient experienced immediate resolution of her severe abdominal pain with stent insertion, she subsequently developed intractable nausea refractory to all medical therapy. Her symptoms led to considerable weight loss and decline in functional status, ultimately leading to palliative surgical resection with complete resolution of symptoms following surgical resection of the stent. Postulated mechanisms for the development of nausea following colonic stent insertion include vagal or sympathetic afferent stimulation because of irritation, distention of the stenosed colon wall (which would be unusual, as these pathways usually exist only in the small bowel and proximally) or a motility disorder secondary to the placement of the stent.9, 10 It is also possible that the patient's nausea was secondary to a systemic reaction to an unknown compound in the stent. To our knowledge this is the first reported case of severe nausea related to a colonic stent.
The management of advanced colorectal cancer involves close collaboration between members of a multidisciplinary team. Minimally invasive management of the primary tumor in advanced cancer has led to considerable improvements in the treatment of patients with advanced malignancy. This case report highlights a rare but potentially serious toxicity of colonic stents. Clinicians should consider removal of colonic stents in a patient with severe unexplained nausea, which is refractory to medical management.
References
- The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 1991;7(2):6–9
- . Treatment of nausea and vomiting in advanced cancer. Support Care Cancer. 2000;8:444–452
- American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol. 2006;24(18):2932–2947
- Systematic review of the efficacy and safety of colorectal stents. Br J Surg. 2002;89(9):1096–1102
- Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol. 2004;99(10):2051–2057
- Colorectal stenting for colonic obstruction: the indications, complications, effectiveness and outcome—5-year review. Eur J Radiol. 2006;60:91–94
- . Metallic stenting for colorectal obstruction. Gastrointest Endosc Clin N Am. 1999;9(3):459–477
- . Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology. 2000;215(3):659–669
- . Nausea and vomiting. Gastroenterology. 2003;125:1860–1867
- . AGA technical review on nausea and vomiting. Gastroenterology. 2001;120:263–286
PII: S0885-3924(08)00207-8
doi:10.1016/j.jpainsymman.2008.02.003
© 2008 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
