Constipation and
bowel obstruction
Constipation
• Infrequent or difficult defecation with
reduced number of bowel movements,
which may or may not be abnormally hard
with increased difficulty or discomfort
Constipation
• One of the most common complaints- in
general population 1,9-27,2%, more than
50% od patients in palliative care unit
• In pallitive care the constipation should be
defined according to patients experience
Causes of constipation
Primary causes
Intestinal abnormality
Tumor compression
Neural plexus invasion
Idiopathic constipation
Secondary causes
• Electrolyte imbalance (hypercalemia,
hyperkalemia)
• Endocrine abnormality (hypothyroidism,
diabetes mellitus)
• Neurogenic disorders (multiple sclerosis,
spinal cor injury)
• Drugs (analgetics-opioids, anticholinergic)
• Other causes (dehydratation, immobility,
decreased oral intake)
Assessment
• History of the previous normal bowel habits
• Defining pattern of change in terms of frequency,
consistency, straining, drug history, associated
symptoms
• Subjective measuresof constipation- VAS
• Physical examination: abdominal auscultation,
inspection, palpation, percussion, digital rectal
examination
• Check for correctable reasons- electrolyte
imbalance, endocrine disorders
Management-prevention
• Patient education
• Increase dietary and fluid intake
• Prophylaxis laxatives when initiating
opioids
• Increase mobility
• Confortable environment for defecation
Pharmacotherapy
Oral laxatives:
• Emollients
• Bulk-forming agents
• Osmotic agents
• Hyperosmolar agents
• Contact cathartics
• Prokinetic drugs
• Opioid antagonists
Pharmacotherapy
Rectal preparations (unpleasant, but
quick results)
• Suppositories
• Enemas
Opioid antagonists
• Opioid-induced constipation
mediated by mu receptors in GI
system
• Methylnaltrexone- restricted ability to
cross the blood-brain barrier and does
not affect opioid analgesic effects
Nonpharmacological approach
• Methodes used in prevention
• Biofeedback
Constipation
• Can present as pseudo-diarrhea-
always perform DRE!
• Discontinue constipating drugs when
possible
• Fiber supplements should be
discouraged
Bowel obstruction
• Common and distressing complication of intra-
abdominal cancer
• Mechanical obstruction or failure of normal
intestinal motility in the absence of an
obstructing lesion
• Flow: partial/complete bowel obstruction
• Intestinal ischemia: simple/strangulated
• Site: small intestine/colonic
• Once malignant bowel obstruction occurs
median survival is approximately 3 months
Causes
Clinical presentation
Depending on :
• location,
• single/multiple points of obstruction,
• mechanism,
• exacerbating medications
Clinical presentation
• Symptoms:
- Nausea
- Vomiting-early in high intestinal tract
occlusion, later in patients with large bowel
obstruction
- Intestinal colic
-Continous abdominal pain- more than 90%
of the patients
- Absence of stool and flatus passage
Diagnosis and assessment
• History and medical exam
• Laboratory and imageing data
• Differential diagnoses
Management
• Symptoms relief!!!
Surgical approach
• Disease stage
• Patients condition
• Possibility of future therapy
• More benefitial for patients with life
expectancy>2 months
• Benefitial for patients with mechanical
obstruction/limited tumor
Nonsurgical approach
• Drainage with a nasogastric tube- great
discomfort, many complications
• Drugs: analgetics, antiemetic, drugs
decreasing bowel secretion
• Also: anticholinergic, steroids, smooth
muscle relaxants
• Most patients do not tolerate oral route-
consider alternative routes
Drugs
• Opioids- most effective drugs for management of abdominal
pain, sc, td,iv
• Anticholinergic drugs like scopolamine (hioscine)- gold
standard- can be added to opioids for colicky pain, also reduce
bowel secretion sc, iv
• Corticosteroids- reducing intestinal and tumor-associated
edema
• Metoclopramide- only in partial bowel obstruction, in the
absence of colicky pain, contraindicated in complete
obstruction
• Haloperidol- first line antiemetic- central, can be added to
morphine and scopolamine butylbromide
