Constipation

Short Answer

A. Incorrect. You don't need to stop her pain medication to treat her constipation. An enema followed by a daily regimen should help the problem.

B. Incorrect. While using these agents long-term is appropriate, she requires more immediate intervention. An enema would help more quickly.

C. Correct! It is appropriate to start with an enema to clear the stool, then continue a daily regimen to prevent the problem from recurring.

D. Incorrect. Metoclopramide may be helpful in some cases, especially where concomitant nausea and vomiting are present. However, when acute constipation is present, a treatment such as an enema is more appropriate.

Long Answer

The correct answer is C. Water or soap suds enema, followed by regular senna plus docusate 1 tab po bid.

Constipation is important to anticipate, prevent and control in the chronically and terminally ill, especially when giving opioids. This is a common symptom in palliative care, particularly in those treated with opioids and in the elderly. It is much easier to prevent and treat early, and consequences of untreated constipation can be difficult to manage.

The approach to the patient with constipation begins with assessment of what the patient/family considers a "normal" bowel pattern and consideration of potential underlying causes. Common causes in palliative care include opioids and other medications, such as anticholinergics and diuretics. Dehydration, decreased food intake, immobility, and abdominal pathology such as malignancy and ascites are also common contributors. Examination for hypo/hyperactive bowel sounds, the presence of a mass, and fecal impaction may be important. An X-ray may be helpful if the diagnosis of constipation is unclear or if bowel obstruction is suspected [^] ask specifically for the volume of stool on the requisition. When considering the causes of constipation, it is useful to understand the four components affecting the production of a normal bowel movement.

Solid waste: An intermediate amount is best. If diet is fiber-poor, psyllium fiber may help.

Motility: low activity levels, the presence of ascites or cancer in the abdomen, and drugs contribute to this. Since this is usually a common etiology in the severely ill, drugs that increase motility are usually the first choice. Senna comes in tablets or liquid; start at 1 tablet (8.6 mg) qhs, up to a maximum dose of 4 tablets bid. For patients with current constipation, evacuate existing stool with an enema first to avoid cramping.

Water content: Increasing water intake is often helpful, if possible. Can also give osmotically active particles that retain water, such as magnesium salts or non-absorbable sugars like sorbitol and lactulose. However, sorbitol and lactulose may be difficult to tolerate. Hyperosmolar solutions may worsen dehydration, are contraindicated in renal failure, and may also be difficult to tolerate. These should be a second step or be used in more difficult cases.

Lubrication: eases passage of stool and minimizes pain with excretion. Mineral oil enemas or glycerin suppositories may be helpful. Docusate sodium only softens stool, but may make passing more comfortable.

Nonpharmacologic treatments may also help. Have the patient sit upright when trying to defecate. Take advantage of gastrocolic reflex that occurs after eating. Increase mobility and fluid intake if these are contributing.

In order of preference in patients with advanced illness, poor mobility, and decreased oral intake:

Stimulants: prune juice, senna (up to 8 or more tablets per day), bisacodyl 10 mg pr
Osmotics: lactulose 30-45 ml qd, milk of magnesia 30[^]60 ml po qd-bid, magnesium citrate 8 oz po
Detergents (stool softeners): docusate 100 mg po qd-bid, phosphosoda enema
Prokinetic: metoclopramide 10 mg po qid
Lubricant: glycerin suppository, mineral oil enema
Large-volume enemas: warm H20 or soap suds

Difficult cases may require disimpaction in conjunction with softening with a glycerin suppository or mineral oil enema, or the help of a gastroenterologist to mechanically disimpact the colon.

Last update: 7/13/02; 4:05:55 PM.