Al-Sadeel SocietyPalliative Care for Cancer Patients

Constipation

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Constipation

Amal Dweib Khleif RN, BSN, ON, Palliative care Specialist

Constipation

• Straining• Hard stool• Sensation of

– Incomplete evacuation– Anorectal obstruction

• Fewer than 3 BM / week • 12 weeks duration > 2 symptoms

. . . Constipation

Epidemiology• Impact: abdominal discomfort / pain,

nausea and vomiting• Prevalence: up to 90% among cancer

patients treated with opioids• Prognosis: can limit prognosis if

untreated– Management always possible

Pathophysiology

• Medications– Opioids– Calcium-

channel blockers

– Anticholinergic

• Decreased motility

• Ileus• Mechanical

obstruction

• Metabolic abnormalities

• Spinal cord compression

• Dehydration• Autonomic

dysfunction• Malignancy

Chemotherapeutic agents associated with constipation• Cyclophosphamide• Mechlorethamine• Chlorambucil• Melphalan• Carmustine (BCNU)• Lomustine (CCNU)• Semustine (Methyl-CCNU)• Thiotepa• Triethylenemelamine• Busulfan• Procarbazine• Dacarbazine• Hexamethylmelamine• Cisplatin• Vinblastine• Vincristine• Vinorelbine

Assessment

• History and examinationfull clinical assessment of constipation

includes the following:

◗the pattern of recent bowel movements;

◗the pattern of pre-illness bowel movements;

◗past history of use of laxatives;

full clinical assessment of constipation includes the following:

◗ the use of potentially constipating drugs;◗ food intake (especially fibre content);◗ fluid intake;◗ presence or absence of faeces in the rectum;◗ consistency of faeces—soft or hard;◗ presence of anal tone and reflex;◗ evidence of normal or abnormal sacral nerve root

sensation;◗ presence of predisposing factors for constipation;◗ overall disease status and prognosis.

◗ assessment of the mouth for possible causes of reduced intake of food and

fluids (such as ulceration or ill-fitting dentures); ◗ inspection of the abdomen for distension; ◗ abdominal palpation, which might reveal a

palpable colon and faecal mass; ◗ assessment of bowel sounds, which might be

diminished, slow, or absent; ◗ inspection of the anus for haemorrhoids, fissure,

or faecal fluid leakage ◗ rectal examination,

Summary of assessment

An effective bowel care plan is based on a thorough assessment which includes:

◗ obtaining a comprehensive history including the person’s preferences for

bowel management; ◗ assessment of the impact of constipation

on quality of life; ◗ physical assessment; ◗ identification of risk factors; ◗ accurate documentation;

INTERVENTION

• General measures– Regular toileting– Gastrocolic reflex– Activity

• Specific measures– Softeners– Osmotics– Stimulants– Lubricants– Large volume enemas

Stool softeners (detergent laxatives)

• Sodium docusate• Calcium docusate• Phospho-soda enema PRN

Stimulant laxatives

• Prune juice • Senna • Casanthranol • Bisacodyl

Osmotic laxatives

• Lactulose or sorbitol • Milk of magnesia (other Mg salts) • Magnesium citrate• Polyethylene glycol

Lubricants / enemas

• Glycerin suppositories• Phosphate enema• Oil retention enema• Tap water, 500 – 1,000 ml

Constipation from opioids . . .• Occurs with all opioids• Pharmacological tolerance develops

slowly, or not at all• Dietary interventions alone usually

not sufficient• Avoid bulk-forming agents in

debilitated patients

. . . Constipation fromopioids• Combination stimulant / softeners

are useful first-line medications– Casanthranol + docusate sodium– Senna + docusate sodium

• Prokinetic agents• Opioid antagonists

Prophylaxis of constipation

• Maintain good general symptom control • Encourage activity• Maintain adequate oral fluid intake• Maximize the fibre content of the diet• Anticipate constipating effects of drugs • altering treatment or starting a laxative

prophylactically • Create a favourable environment

Summary

• Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience