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Constipation- A quick thread
Often overlooked, not deliberately but if we don’t ask we will never know. First step in management is to take a good history
Often overlooked, not deliberately but if we don’t ask we will never know. First step in management is to take a good history
When did bowels last open?
What was that like?
Use the Bristol stool chart as a visual aide to ease the focus on the patient
What was that like?
Use the Bristol stool chart as a visual aide to ease the focus on the patient
Ask about associated features
Nausea, vomiting and colic may indicate obstruction.
Constipation followed by loose stools may indicate overflow
Ask about urinary retention which is commonly associated with constipation
Nausea, vomiting and colic may indicate obstruction.
Constipation followed by loose stools may indicate overflow
Ask about urinary retention which is commonly associated with constipation
Examine your patient:
Hydration status: mouth, skin turgor and BP
Immobility, Parkinsons
Abdominal exam: palpable faeces in colon. Distention and tinkling bowel sounds of obstruction.
PR: chaperone and consent always. Have suppositories to hand to avoid repeated intimate exam.
Hydration status: mouth, skin turgor and BP
Immobility, Parkinsons
Abdominal exam: palpable faeces in colon. Distention and tinkling bowel sounds of obstruction.
PR: chaperone and consent always. Have suppositories to hand to avoid repeated intimate exam.
Remember Malignant spinal cord compression and cauda equina syndrome!
New back pain (most common clue)
Sensory or motor change in lower limbs
Radicular pain around chest
Symptoms worse on coughing or straining on toilet.
Bowel and bladder disturbance is a late sign!
New back pain (most common clue)
Sensory or motor change in lower limbs
Radicular pain around chest
Symptoms worse on coughing or straining on toilet.
Bowel and bladder disturbance is a late sign!
Review the Kardex
Opioids all constipate and the effect never goes away!
Antacids
Diuretics
Iron supplements
Anticholinergics
Ondansetron (palliative care specialists will alwaysstop this more than prescribe it)
Opioids all constipate and the effect never goes away!
Antacids
Diuretics
Iron supplements
Anticholinergics
Ondansetron (palliative care specialists will alwaysstop this more than prescribe it)
Check the bloods
Hypercalcaemia: common in many cancers. Remember thirst, dehydration, confusion and in any patient who looks like they are dying when they shouldn’t really be
Hypercalcaemia: common in many cancers. Remember thirst, dehydration, confusion and in any patient who looks like they are dying when they shouldn’t really be
Diet and hydration:
Good old fashioned prunes work
Any other diet tips welcome
Hydration is key. Many laxatives rely on omsotic action or increasing water content in faeces. In hypercalcaemia several litres of hydration may be needed (possibly a separate thread)
Good old fashioned prunes work
Any other diet tips welcome
Hydration is key. Many laxatives rely on omsotic action or increasing water content in faeces. In hypercalcaemia several litres of hydration may be needed (possibly a separate thread)
Lactulose:
Sweet and sticky viscous laxative.
Sticks kardexes together and makes floors tacky.
A non-absorbable sugar that draws water into the bowel to soften stool. Drink plenty to activate.
Can cause flatulence and colicky pain.
Sweet and sticky viscous laxative.
Sticks kardexes together and makes floors tacky.
A non-absorbable sugar that draws water into the bowel to soften stool. Drink plenty to activate.
Can cause flatulence and colicky pain.
Laxido/Macrogols
Scahets that are made up with water or a little flavouring.
Again softener mainly and need hydration.
Larger doses up to 6 sachets/day can be tried for hard stool in proximal colon.
Scahets that are made up with water or a little flavouring.
Again softener mainly and need hydration.
Larger doses up to 6 sachets/day can be tried for hard stool in proximal colon.
Senna
Gentle stimulant laxative that increases the persitaltic action of the bowel. Can cause mild cramping.
Takes about 8 hours to work so can be taken at bedtime.
Larger doses of 15-30mg twice daily may be needed with opioid use.
Gentle stimulant laxative that increases the persitaltic action of the bowel. Can cause mild cramping.
Takes about 8 hours to work so can be taken at bedtime.
Larger doses of 15-30mg twice daily may be needed with opioid use.
Bisacodyl
Dynamite stimulant. Usually works but warn about colicky pains and diarrhoea if constipation has been present for a few days.
Start with low doses of 5-10mg once a day.
Often best used with a softener.
Dynamite stimulant. Usually works but warn about colicky pains and diarrhoea if constipation has been present for a few days.
Start with low doses of 5-10mg once a day.
Often best used with a softener.
Docusate
Another gentle laxative. Acts to increase stool water and fat content via a surfactant effect.
Generally requires generous dosing up to 100-200mg twice daily before effects seen.
Another gentle laxative. Acts to increase stool water and fat content via a surfactant effect.
Generally requires generous dosing up to 100-200mg twice daily before effects seen.
Co-Danthramer
Palliative care use mainly
Combined softener and stimulant which also comes in liquid form. Useful to reduce medication burden.
Avoid in those with incontinence as can be irritant if left in contact with skin.
Palliative care use mainly
Combined softener and stimulant which also comes in liquid form. Useful to reduce medication burden.
Avoid in those with incontinence as can be irritant if left in contact with skin.
Suppositories
Soft/medium hard stool on PR
Glycerine and/or bisacodyl suppositories. Work by causing rectal evacuation.
Soft/medium hard stool on PR
Glycerine and/or bisacodyl suppositories. Work by causing rectal evacuation.
Enemas
If stool very hard consider an Arachis oil enema in the evening (caution in nut allergy) followed by a phosphate enema in the morning. Hint: tilt the bed to help patient retain enemas.
If stool very hard consider an Arachis oil enema in the evening (caution in nut allergy) followed by a phosphate enema in the morning. Hint: tilt the bed to help patient retain enemas.
Remember: prevention of constipation is easier and kinder than treatment (enemas/supps)
Think ahead!
When starting opioids: start a softener and stimulant at the same time but you need to explain why to patients. Laxatives are for the most part very gentle in action.
Think ahead!
When starting opioids: start a softener and stimulant at the same time but you need to explain why to patients. Laxatives are for the most part very gentle in action.
New opioids?
Could try:
Senna 15mg at night and lactulose 10mls twice daily. Drink plenty.
Alternatively laxido 1 sachet twice daily plus plenty water.
Remember: the colon is the only opioid target that NEVER develops tolerance to opioid drugs. Think long term
Could try:
Senna 15mg at night and lactulose 10mls twice daily. Drink plenty.
Alternatively laxido 1 sachet twice daily plus plenty water.
Remember: the colon is the only opioid target that NEVER develops tolerance to opioid drugs. Think long term
Naloxegol
Peripheral opioid receptor antagoist than acts on colon but doesn’t cross blood brain barrier as its Pegylated.
Use when first line laxatives not working. Don’t stop other laxatives.
Colicky pain common with first doses. Avoid in bowel obstruction.
Peripheral opioid receptor antagoist than acts on colon but doesn’t cross blood brain barrier as its Pegylated.
Use when first line laxatives not working. Don’t stop other laxatives.
Colicky pain common with first doses. Avoid in bowel obstruction.
Methyl naltrexone
Naloxegol’s more potent cousin.
Subcutaneous injection. Effects can be quick and marked.
Advise discussion with palliative care specialist and ward pharmacist before use. Exclude obstruction before use.
Naloxegol’s more potent cousin.
Subcutaneous injection. Effects can be quick and marked.
Advise discussion with palliative care specialist and ward pharmacist before use. Exclude obstruction before use.
For more info:
https://cks.nice.org.uk/topics/palliative-care-constipation/prescribing-information/how-laxatives-work/
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Constipation.aspx
https://cks.nice.org.uk/topics/palliative-care-constipation/prescribing-information/how-laxatives-work/
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Constipation.aspx
