Constipation

Question 1

Why is constipation difficult to define?

Answer 1

As it is a subjective experience

Question 2

What generally suggests constipation?

Answer 2

Defecation less than 3x per week

Question 3

What are the possible features of constipation?

Answer 3

• Straining
• Lumpy or hard stools
• Sensation of complete evacuation
• Sensation of anorectal obstruction/blockage
• Less than 3 defecations per week

Question 4

Are loose stools a common feature of constipation?

Answer 4

Not without laxatives

Question 5

Why is constipation an important symptom to consider?

Answer 5

Without treatment, can cause unnecessary suffering

Question 6

What can cause constipation in cancer?

Answer 6

• 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

Question 7

What aspects of cancer treatment can cause constipation?

Answer 7

• Chemotherapy or targeted drugs

- Abdominal surgery

Question 8

Why can chemotherapy/targeted drugs cause constipation?

Answer 8

They affect the nerve supply to the bowel

Question 9

What factors can cause constipation after abdominal surgery?

Answer 9

• 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

Question 10

How can the cancer itself cause constipation?

Answer 10

• 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

Question 11

What are the most common medications that have constipation as a side effect in cancer?

Answer 11

• Painkillers, especially opioids

- Anti-emetics

Question 12

What other medications can cause constipation?

Answer 12

• Some BP medications
• Antidepressants
• Vitamin supplements, such as iron and calcium
• Anti-convulsants
• Drugs for Parkinsons disease
• Diuretics
• Antacids

Question 13

What medical conditions can cause constipation?

Answer 13

• Bowel obstruction
• Parkinson’s disease
• Spinal cord injiry
• Diabetes
• Hyper calcaemia
• Multiple sclerosis
• Thyroid problems
• Stroke
• Hypokalaemia

Question 14

What should the history for constipation in cancer include?

Answer 14

• Full assessment of pre-disease and current bowel pattern
• Experience of defecation - difficulty, effort, outcome
• Stool itself

Question 15

What information about the stool should be obtained in constipation?

Answer 15

• Type
• Consistency
• Colour
• Odour

Question 16

What may be useful in the assessment of constipation?

Answer 16

An assessment scale or the Bristol Stool Chart

Question 17

What examination should be done in constipation?

Answer 17

Abdominal examination with DRE

Question 18

Why do opiates cause constipation?

Answer 18

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

Question 19

How should constipation caused by opiates be prevented?

Answer 19

A laxative should be titrated against the dose of opiates, and increased accordingly

Question 20

What are the principles for management of constipation?

Answer 20

• Re-establishment of comfortable bowel pattern
• Promotion of independence and personal preference
• Management distressing side effects of treatment

Question 21

What are the distressing side effects of treatment of constipation?

Answer 21

• Discomfort
• Flatulence
• Pain

Question 22

Describe the role of natural methods of constipation management in cancer patients?

Answer 22

Natural methods alone are unlikely to be successful in a debilitated patient

Question 23

What route of administration is preferred for laxatives in constipation?

Answer 23

Oral

Question 24

What is the first line management for constipation?

Answer 24

Combine laxative stimulant and softner

Question 25

What is the second line management for constipation?

Answer 25

Use rectal suppository and/or enema

Question 26

What can be used for opioid-dependant patients with constipation who do not respond to suppositories and/or enema?

Answer 26

Peripherally specific opioid antagonist such as methylnaltrexone administered SC

Question 27

What happens towards the end of life, regarding the management of constipation?

Answer 27

The overall priority of constipation in terms of symptom burden may be less important

Question 28

What might indicate the need for assessment and intervention for constipation at the end fo life?

Answer 28

Restlessness