Buku Medicine

Bowel obstruction

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Bowel obstr. flowchart

Major Haemorrhage

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Malignant hypercalcaemia

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Spinal cord compression

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Malignant SVCO

Quick Tip: 95% of cases of superior vena cava obstruction (SVCO) are caused by malignant tumour in the mediastinum preventing venous drainage from the head, arms and upper trunk. 



  • Commonest in lung cancer. Can also occur in lymphoma and some other cancers. 
  • Onset usually over weeks or months, but occasionally occurs rapidly over days. 


Clinical Presentation

  • Facial swelling, redness, headache, periorbital oedema, engorged conjunctivae. 
  • Swelling of the arms, prominent distended veins on neck and chest wall. 
  • Breathlessness, cough, chest pain, stridor, cyanosis. 
  • Visual disturbance. 


Immediate action

  • Steroids may be helpful.  Give dexamethasone 16mg stat (oral or equivalent dose IV or SC) and continue 16mg daily as morning dose; also prescribe PPI for gastric protection. 
  • Give oxygen if available & required and manage other symptoms (see guidelines on breathlessness and agitation). 
  • Discuss URGENTLY with the local Acute Oncology Team and arrange appropriate imaging.  
  • Anticoagulation may need to be considered if evidence of thrombus. 


Follow up

  • If the obstruction is resolved by stent insertion or other intervention, the dexamethasone should be reduced gradually and possibly stopped. Consider ongoing prophylactic anticoagulation. Ongoing care should be provided and guided by team managing the malignancy.
  • If the obstruction cannot be resolved with intervention, the dexamethasone should be gradually reduced to the lowest dose that manages symptoms. 


If SVCO suspected in patient at end of life/too unwell for/unwilling to have investigations: 

  • Manage symptoms in patient’s preferred care setting. Agree an Emergency Health Care Plan. 
  • Consider steroids (as above), anticoagulation with treatment dose low molecular weight heparin, symptomatic measures and nursing at 45 degrees for comfort.  


NCA Handbook