constipation
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Al-Sadeel SocietyPalliative Care for Cancer Patients
Constipation
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Constipation
Amal Dweib Khleif RN, BSN, ON, Palliative care Specialist
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Constipation
• Straining• Hard stool• Sensation of
– Incomplete evacuation– Anorectal obstruction
• Fewer than 3 BM / week • 12 weeks duration > 2 symptoms
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. . . 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
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Pathophysiology
• Medications– Opioids– Calcium-
channel blockers
– Anticholinergic
• Decreased motility
• Ileus• Mechanical
obstruction
• Metabolic abnormalities
• Spinal cord compression
• Dehydration• Autonomic
dysfunction• Malignancy
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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
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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;
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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.
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◗ 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,
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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;
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INTERVENTION
• General measures– Regular toileting– Gastrocolic reflex– Activity
• Specific measures– Softeners– Osmotics– Stimulants– Lubricants– Large volume enemas
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Stool softeners (detergent laxatives)
• Sodium docusate• Calcium docusate• Phospho-soda enema PRN
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Stimulant laxatives
• Prune juice • Senna • Casanthranol • Bisacodyl
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Osmotic laxatives
• Lactulose or sorbitol • Milk of magnesia (other Mg salts) • Magnesium citrate• Polyethylene glycol
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Lubricants / enemas
• Glycerin suppositories• Phosphate enema• Oil retention enema• Tap water, 500 – 1,000 ml
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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
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. . . Constipation fromopioids• Combination stimulant / softeners
are useful first-line medications– Casanthranol + docusate sodium– Senna + docusate sodium
• Prokinetic agents• Opioid antagonists
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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
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Summary
• Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience