Small bowel

Malignant small bowel obstruction is frequently seen in patients suffering from peritoneal carcinomatosis. Primary cancers of the small bowel are rare but due to late diagnosis also can present with obstruction. In the case of peritoneal carcinomatosis, the primary cancer usually is not localized within the small bowel. Primary lesions in these patients most commonly are in the large bowel, stomach, ovaries or pancreas. Surgery is the treatment of choice for the cure as well as palliation of small bowel cancers. In a palliative situation, treatment most of all must follow the principle to first do no harm, and decisions must be based on the patient's wishes, fitness for surgery, oncologic treatment options and prognosis. If the patient is considered fit for surgery, only a short conservative treatment attempt should be made followed by surgery. If possible, enteroenteric bypass should be preferred over stoma formation. Peritoneal carcinomatosis should be assessed using the Peritoneal Cancer Index prior to treatment planning. In patients unfit for surgery, stent insertion (endoscopic or radiological), venting gastrostomy and feeding jejunostomy should be considered depending on symptoms. Medical treatment of nausea and vomiting as well as analgesia must be provided in close cooperation with the palliative care team.