• Seek specialist advice early, as management can be complex.
• A syringe driver may be needed because the oral route is often unreliable.

Peristaltic failure:

• If possible stop drugs which decrease peristalsis (e.g. cyclizine, tricyclic antidepressants, opioids).
• Advise small, frequent meals with avoidance of high-fibre foods.
• If there is no colic: start a prokinetic anti-emetic (e.g. metoclopramide, 30–100 mg/24 hours) via continuous subcutaneous infusion (CSCI).
• If colic develops: stop use of the prokinetic anti-emetic and treat as for mechanical bowel obstruction.

Mechanical bowel obstruction:

• Exclude constipation, or treat if present:
• To relieve and prevent constipation, docusate or Movicol^® should be titrated to produce a comfortable stool without colic.
• Treat nausea with cyclizine, 50–150 mg/24 hours via CSCI:
• If nausea persists, add haloperidol, 2.5–10 mg/24 hours or as a single night-time dose, or levomepromazine, 5–25 mg/24 hours or as a single night-time dose.
• Avoid prokinetics.
• Treat colic with an antimuscarinic (e.g. hyoscine butylbromide, 20 mg immediately by subcutaneous injection, then 60–120 mg/24 hours via CSCI).
• Large-volume vomiting: start an antisecretory drug (e.g. hyoscine butylbromide or octreotide):
• If colic is present:
• Hyoscine will reduce secretions and treat colic, but its full antisecretory effect is achieved only after about 3 days.
• If large volume vomiting persists, consider using octreotide if a more rapid or profound antisecretory effect is required. This may require admission, depending on the experience of the primary healthcare professional and the availability of octreotide in the community.

• These recommendations are consistent with specialist palliative care guidelines on the management of bowel obstruction [Lothian Palliative Care Guidelines Group, 2004b] and with specialist palliative care guidelines for the management of nausea and vomiting [Fife Area Drug & Therapeutics Committee, 2004; Lothian Palliative Care Guidelines Group, 2004a].