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