Constipation
Constipation is another common symptom in palliative care both because of disease and a side effect of medications used in treatment. It is defined as a reduction in frequency in bowel motion or passing of harder stools, or both.
It can be a significant cause of abdominal pain and be further complicated by urinary retention. When not eating well it is sometimes assumed bowel movements will cease. This however is not the case due to faecal matter continuing to be formed from gut secretions, cells, and bacteria. It is preferable to anticipate and prevent constipation than to wait until the need is urgent. It is important to consider whether diarrhoea may be a presentation of constipation in overflow, and in malignant disease to always consider spinal cord compression.
Alongside non-drug treatments laxatives may be required. Generally, use softeners for hard stool and stimulants for reduced frequency Many patients on regular opioid medication will require a combination of laxatives. Opioid switches, and use of transdermal preparations may improve constipation for some. Opioid antagonists are generally reserved for resistant cases.
Causes
- Drugs - opioids, anticholinergics, ondansetron
- Inactivity/immobility
- Dehydration
- Reduced oral fibre consumption
- Spinal cord compression
- Sacral nerve root compression
- Neurological disorders such as Parkinson’s disease
Non-drug treatment
- Stop causative drugs if possible
- Encourage fluid intake
- Increase dietary fibre
- Ensure privacy when opening bowels
- Mobilisation if able
Drug treatment
- Stimulant laxatives - Senna, bisacodyl
- Osmotic laxatives - Magnesium hydroxide, lactulose
- Stool softeners - Sodium docusate, macrogols
- Rectal measures - suppositories or enemas
- Disimpaction regimes - 8 sachets Movicol a day for 3 days or sodium picosulphate
- Opioid agonists - naloxegol or methylnaltrexone SC may be considered by specialists