Transcript Module 11 - IPCRC.NET
The
TM
EPEC-O
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.
E P E C O EPEC – Oncology Education in Palliative and End-of-life Care – Oncology
Module 3f Symptoms – Constipation
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
Key points
1.
Pathophysiology 2.
Assessment 3.
Management
Pathophysiology
Medications Opioids Calcium-channel blockers Anticholinergic
Decreased motility
Ileus
Mechanical obstruction
Metabolic abnormalities
Spinal cord compression
Dehydration
Autonomic dysfunction
Malignancy
Assessment
Specifically ask about bowel function
Establish what is normal for patient
Management
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
Lederle FA, et al.
Am J Med
, 1990.
Attar A, et al.
Gut
, 1999.
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
Bagnol D, et al.
Neuroscience
, 1997.
. . . Constipation from opioids
Combination stimulant / softeners are useful first-line medications Casanthranol + docusate sodium Senna + docusate sodium
Prokinetic agents
Opioid antagonists
Sykes NP.
Palliat Med
, 2000.
E P E C O
Summary
Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience