Case Presentation: We present the case of a 66-year-old woman with metastatic plasmacytoid bladder cancer on pembrolizumab, complicated by peritoneal carcinomatosis, who was hospitalized for aspiration pneumonia in the setting of intractable nausea and vomiting. While her pneumonia responded rapidly to antibiotics, her GI symptoms progressed throughout her 4-week hospitalization. On exam, she was hemodynamically stable, but in persistent distress due to recurrent emesis. An abdominal exam revealed diffuse tenderness without peritoneal signs, and hypoactive bowel sounds. Her leukocytes, basic metabolic panel, lactate and lipase were normal. A CT revealed no retained stool nor dilated bowel, rendering constipation and small bowel or gastric outlet obstruction unlikely. Her symptoms persisted well beyond the expected timeline for pembrolizumab toxicity. An aggressive bowel regimen—to treat potential ileus and narcotic bowel—failed to improve symptoms. Ultimately, serial imaging demonstrated persistence of oral contrast in the same bowel location for over one week, concerning for severe gastroparesis. She was treated with prokinetics, all classes of antiemetic, and somatostatin analogues, without appreciable improvement. A nasogastric tube on wall suction partially controlled her symptoms but, due to high volume gastric secretion, she vomited around the tube. Initially, the patient declined corticosteroids due to incompatibility with further immunotherapy, but agreed to a dexamethasone trial when her emesis proved too severe for ongoing treatment. Her symptoms were finally managed with a combination of continuous suction and high-dose corticosteroid. We helped the patient define her goals throughout hospitalization, and she ultimately decided to pursue comfort care at home, with family support. Therefore, a venting G-tube was placed by interventional radiology and a home gastric suction machine provided, along with PCA for pain control.
Discussion: This patient’s intractable nausea and vomiting was consistent with malignant gastroparesis, an under-recognized and under-treated complication of advanced malignancy. This condition is caused by either direct metastatic invasion of the alimentary nervous system or a paraneoplastic syndrome associated with anti-neuronal antibodies (1,2). In late stages, it can render the bowel entirely static. Most often, it’s a diagnosis of exclusion, since obstruction, constipation, adverse chemotherapy effects, ileus, and narcotic bowel are common in this population. First line therapies include aggressive use of pro-kinetics and anti-emetics, but intractable cases require corticosteroids, somatostatin analogues, and continuous removal of gastric secretions (3). A large bore venting gastrostomy tube may be indicated to provide durable relief and allow for transition home under appropriate circumstances.
Conclusions: Innovative chemo- and immuno-therapy agents have transformed cancer outcomes, allowing patients to continue treatment deeper into the course of their disease. Consequently, hospitalists are managing more and more complications of end-stage malignancy, many of which are intractable and difficult to even palliate. Malignant gastroparesis is increasing amongst inpatients, and an entity that hospitalists must be able to both recognize and treat. This case highlights the importance of a multi-modal approach to the syndrome, and one that must evolve in parallel with patients’ goals of care.