[19] Constipation Flashcards
Why is constipation difficult to define?
As it is a subjective experience
What generally suggests constipation?
Defecation less than 3x per week
What are the possible features of constipation?
- Straining
- Lumpy or hard stools
- Sensation of complete evacuation
- Sensation of anorectal obstruction/blockage
- Less than 3 defecations per week
Are loose stools a common feature of constipation?
Not without laxatives
Why is constipation an important symptom to consider?
Without treatment, can cause unnecessary suffering
What can cause constipation in cancer?
- Cancer treatments
- The cancer itself
- Side effects from other medications
- Insufficient fibre
- Insufficient fluids
- Lack of exercise
- Long term use of laxatives
- Ignoring the call to stool
- Depression and anxiety
- Other medical conditions
What aspects of cancer treatment can cause constipation?
- Chemotherapy or targeted drugs
- Abdominal surgery
Why can chemotherapy/targeted drugs cause constipation?
They affect the nerve supply to the bowel
What factors can cause constipation after abdominal surgery?
- Muscles may be too weak to expel stool
- Pain may make patient unable to expel stool
- Drugs for anaesthetic or for pain
- NBM
- Major pelvic operations can damage nerves that help bowel work properly
How can the cancer itself cause constipation?
- Press on nerves of spinal cord, slowing down or stopping movement of bowel
- Abdominal tumours can distort the bowel
- Tumour in lining of bowel can affect nerve supply to muscles
What are the most common medications that have constipation as a side effect in cancer?
- Painkillers, especially opioids
- Anti-emetics
What other medications can cause constipation?
- Some BP medications
- Antidepressants
- Vitamin supplements, such as iron and calcium
- Anti-convulsants
- Drugs for Parkinsons disease
- Diuretics
- Antacids
What medical conditions can cause constipation?
- Bowel obstruction
- Parkinson’s disease
- Spinal cord injiry
- Diabetes
- Hyper calcaemia
- Multiple sclerosis
- Thyroid problems
- Stroke
- Hypokalaemia
What should the history for constipation in cancer include?
- Full assessment of pre-disease and current bowel pattern
- Experience of defecation - difficulty, effort, outcome
- Stool itself
What information about the stool should be obtained in constipation?
- Type
- Consistency
- Colour
- Odour
What may be useful in the assessment of constipation?
An assessment scale or the Bristol Stool Chart
What examination should be done in constipation?
Abdominal examination with DRE
Why do opiates cause constipation?
Their impact on interstitial smooth muscle tone and fluid absorption prevents the forward peristalsis of faecal matter in the colon, and results in a dry hard stool
How should constipation caused by opiates be prevented?
A laxative should be titrated against the dose of opiates, and increased accordingly
What are the principles for management of constipation?
- Re-establishment of comfortable bowel pattern
- Promotion of independence and personal preference
- Management distressing side effects of treatment
What are the distressing side effects of treatment of constipation?
- Discomfort
- Flatulence
- Pain
Describe the role of natural methods of constipation management in cancer patients?
Natural methods alone are unlikely to be successful in a debilitated patient
What route of administration is preferred for laxatives in constipation?
Oral
What is the first line management for constipation?
Combine laxative stimulant and softner
What is the second line management for constipation?
Use rectal suppository and/or enema
What can be used for opioid-dependant patients with constipation who do not respond to suppositories and/or enema?
Peripherally specific opioid antagonist such as methylnaltrexone administered SC
What happens towards the end of life, regarding the management of constipation?
The overall priority of constipation in terms of symptom burden may be less important
What might indicate the need for assessment and intervention for constipation at the end fo life?
Restlessness
