Dexamethasone and metoclopramide in the management of patients with inoperable partial malignant bowel obstruction: A prospective, single-arm interventional multicentric trial.

Malignant bowel obstruction (MBO) is a serious complication in patients with ovarian and gastrointestinal malignancies with an incidence of 10-51percent. The patients suffer from a poor quality of life due to an increased symptoms such as pain, nausea and vomiting, and constipation. Further, the intolerance to orals adds to the necessity of   hospitalization. In the setting of an inoperable bowel obstruction, not amenable to stenting, medical management remains the only option.

Octreotide is among the drugs frequently used in the medical management of MBO, by virtue of its ability to reduce gut wall edema and gastric and pancreatic secretions. However, a double-blind, placebo controlled, RCT involving 87 patients did not demonstrate a statistically significant reduction in the number of days free from vomiting despite addition of octreotide. Dexamethasone and metoclopramide are two other drugs which have been consistently used in partial bowel obstruction and found to relieve pain, nausea, vomiting, and improve motility. While dexamethasone has anti-inflammatory effects that reduce gut wall edema, it is also a centrally acting antiemetic. Metoclopramide is a prokinetic with antiemetic properties. NCCN recommends both drugs in the management of patients with partial IMBO. A recent study among patients with partial IMBO, supports the safety and efficacy of triple therapy with dexamethasone, metoclopramide and octreotide in reducing pain, nausea, constipation and resumption of oral intake. However, the sample size in this study was 15 patients and further studies are needed to confirm the findings. A retrospective cohort study examining the effect of the triple therapy on rate of de-obstruction was not significantly different from patients who did not receive all 3 drugs. While guidelines recommend the use of octreotide as an antiemetic, the evidence is not strong and its cost high in developing countries precluding its use in all settings. Further, our unpublished data shows that the majority of the patients achieve symptom control with metoclopramide and dexamethasone without the addition of octreotide. Hence, this study aims to explore the efficacy of the combination of dexamethasone with metoclopramide in reducing symptoms among patients with inoperable partial, bowel obstruction.