Constipation – in Palliative care

Constipation in palliative care –One of the most frequently encountered symptoms in palliative care ( particularly those with advanced cancer ) Potential to significantly impair quality of life 
( unpleasant physical symptoms and psychological preoccupation ) About 80 % of people with cancer will require treatment at some time Poorly recognized under-treated and there is uncertainty about the best management of constipation and variation in practice between palliative care settings

definition- Definition is highly subject
 Infrequent ( relative to patients normal bowel habit ) difficult passage of small hard faeces
 It is possible to be constipated and have normal or even soft stools –> eg failure if propulsion by the bowel 
(opioid induced or neuropathic constipation )
 Constipation can lead to

○ nausea
○ vomiting
○ anorexia
○ overflow diarrhoea

Causes – cancer related –Bowel obstruction Compression or infiltration of lumbosacral spinal cord , cauda equina or pelvic plexus Hypercalcemia caused by cancer Painful defecation Autonomic neuropathy  Drugs -Opioids 
90 % will need laxatives Drugs with antimuscarinic 
○ cyclizine
○ hyoscine
○ phenothiazines
○ tricyclics Ondansetron / granisetron
tropisetron Diuretics Iron Anti-parkinsons , antacids , anti-convulsants , anati-diarrhoeals , neuroleptics , antidepressants functional factors -Inadequate fluid intake Dehydration Weakness or dyspnoea Confusion Immobility Anorexia Low fibre diet Lack of privacy Comfort assistance with toileting eg bedpan metabolic-Hypercalcaemia Hyperkalaemia Uraemia Hypothyroidism Diabetes

History-Bowel history
○ what is normal for the patient ? frequency , amount timing
○ stool consistency , colour , odour , blood . mucous
○ when did patient last open bowel
○ enquire about
 abdominal pain / discomfort
 nausea / vomiting
 excessive gas / rectal fullness
 bloating Urinary frequency / retention Drug history Diet Functional status Assess severity and impact of constipation and any faecal incontinence Effectiveness of management till date
constipation assessment scales to assess the presence and severity are 
available An abdominal
 XR can be a useful to confirm 

Examination-General observation Malodrous breath or smell of faecal leakage
 Abdominal examination- note

○ distention
○ visible peristalsis
○ tenderness
○ faecal mass
○ bowel sounds
 Digital rectal examination- note
○ anal fissure or tears
○ haemorrhoids
○ anal sphincter tone
○ rectal dilatation
○ presence/ absence of stool
○ stool consistency
○ rectal mass Digital rectal examination or not-DRE or not ? Be guided by individual circumstances
 to exclude faecal impaction if it is more than 3 days since the last bowel movement ( 98 % of faecal impaction occurs in the rectum ) pt c/o incomplete evacuation normal state of rectum is empty ie absence of faecal matter on DRE does not necessarily exclude constipation DRE should not be routinely conducted in actively dying patients

non-pharmacological measures –Education Alleviate contributing factors Optimized toileting
○ positioning ( use toilets / commodes in preference to bedpan)
○ timing ( most powerful gastro-colic reflex happens in morning )
 encourage to use toilet 20 mins after breakfast Fluid and fibre intake Mobility- correlation between exercise and improved bowel transit time Abdominal massage – may be beneficial in some patients
remains unproven

Preventing constipation-When starting opioids or any other constipating drug
advice about risk of constipation

Prescribe a stimulant laxative as Senna at the first prescription
and aim for regular bowel movements 
without straining every 1-3 days

In opioid induced constipation laxative therapy should be regular and no PRN Treatment is based on inadequate experimental evidence There persists and uncertainty about the best management of constipation in this group of patients No good evidence to guide choice of laxatives

Manage any reversible cause if possible Re-establish comfortable bowel habits Ease pain and discomfort and improve sense of well being Restore satisfactory level of independence in relation to bowel habits Take into account individual patient preference Use softeners if stool is hard , stimulants if soft stool is not expelled A combination of a softener and a stimulant often needed (eg co-danthramer ) A higher and more frequent doses than specified by product license may be needed Titrate the dose daily or alternate days as needed If faecal leakage happens consider reducing the dose of softener and ↑ the stimulant If bowel colic occurs the dose of the softening laxative should be ↑ relative to stimulant dose Use oral laxatives in preference to rectal measures Consider adding a pro-kinetic agent as metoclopramide , domperidone or erythromycin 
( avoid if symptoms of colic )

enema-Avoid phosphate enemas if possible
○ especially people > 65
○ can cause water and electrolyte disturbances Opioid induced constipation –> avoid bulk forming laxative
( eg bran , isphagula ) Paraffin Avoid rectal interventions as enemas , suppositories or manual evacuation in people who
○ are on chemotherapy ( ↑ risk infection if neutropenic )
○ thrombocytopenic ( platelet count < 20 ) ↑ risk bleeding
○ underlying rectal or anal disease Bisacodyl supp –> evacuates stool from rectum or stoma Gylcerine supp–> softens stool in rectum or stoma Phsophate enema –> evacuates from lower bowel Arachis oil enema –> softens hard impacted stool

Bowel obstruction-Absence of passage of flatus per rectum Colicky abdominal pain and abdominal distension Anorexia , nausea or vomiting ( may be faeculent ) Abdominal tenderness without guarding or rebound Active , tinkling bowel sounds ; or quiet or absent bowel sounds ( late signs )

faecal impaction-Stools hard and lumpy Large and infrequent ( every 7-10 days ) or small and relatively infrequent 
( eg every 2-3 days ) Straining ineffective Manual methods needed to extract faeces Overflow faecal incontinence or loose stools are present Faecal masses are palpable abdominally or peri-anally or on internal rectal examination
○ avoid DRE – those receiving chemotherapy , are thrombocytopenic or have rectal or anal disease