What happened, in summary

A man in his 20s had been diagnosed 5 months earlier with stage IV metastatic gastric adenocarcinoma after presenting with bowel obstruction. Exploratory surgery found tumor at the splenic flexure, leading to partial colectomy. Biopsy confirmed gastric adenocarcinoma involving the splenic flexure and a perineal nodule. After surgery, he continued to experience abdominal pain, nausea, vomiting, constipation, and repeated partial small-bowel obstructions.

He returned 1 day after a 10-day hospitalization with severe abdominal and back pain, tense distention, nausea, and inability to tolerate food. Initial treatment included bowel rest, intravenous fluids, nasogastric decompression, laxatives, anti-nausea medication, and escalating opioids. Parenteral nutrition began on hospital day 8. By day 10, imaging showed small-bowel dilation up to 6 cm and a transition point, while high opioid requirements were also worsening bowel function.

On day 11, a thoracic epidural at T7–T8 delivered ropivacaine and eliminated the need for hydromorphone through the pain pump. With dexamethasone and octreotide, he passed 3 large bowel movements and his pain improved. The epidural was removed on day 14 when blood cultures showed bacteremia. After antibiotics, his pain was controlled with methadone and oxycodone, and he tolerated liquids. He was discharged on day 24 with palliative-care follow-up. More than 6 months later, he remained on palliative treatment after 3 additional nonoperative admissions for recurrent obstruction.