CONSTIPATION
Constipation An Overview Definition Physiology of GI tract Etiology Assessment Treatment
Definition Constipation = the infrequent passage of hard feces
Definition of Infrequent The meaning of the work infrequent (as it relates to constipation!) varies greatly Normal frequency = BM ranging from 3x/day to 3X/ week (Connell et al., 1965)
Definition /cont d Associated symptoms: Painful passage/ or straining Feeling of fullness/ pressure in rectum Sensation of incomplete emptying Abdominal distention Cramps
Symptom Prevalence Pain Fatigue/Asthenia Constipation Dyspnea Nausea Vomiting Delirium Depression/suffering 80-90% 75-90% 70+% 60% 50-60% 30% 30-90% 40-60%
Complications Abd pain, distention and discomfort Nausea, vomiting and anorexia Overflow diarrhea Hemorrhoids/ anal fissures Bowel obstruction Urinary retention Anxiety and restlessness
Physiology Coordinated effort is required 3 Areas of control: 1. Small intestinal motility 2. Colon motility 3. Defecation
Normal Bowel Functioning Promoting factors : 1. Adequate fluid intake 2. Adequate dietary fibre 3. Physical activity 4. Adequate time & privacy to defecate
Causes Of Constipation Classifications of Constipation: 1. Primary = cause is r/t compromise of the promoting factors 2. Secondary = cause is r/t pathologic changes 3. Iatrogenically-induced = cause is r/t pharmacologic interventions (Cimprich, 1985)
Constipation Other Causes: 1. Diagnosis & Treatment of Cancer 2. Opioid-Related
Disease-Related Factors Diabetes Hypothyroidism Hypokalemia Hernia Anal fissure/stenosis Hemorrhoids
Dx & Tx of Cancer Direct effects, related to: 1. Obstruction by tumor in wall 2. External compression by tumor 3. Neural damage 4. L/S spinal cord 5. Cauda equina/ pelvic plexus 6. Hypercalcemia
Neuropathy Autonomic neuropathy - diabetes - spinal cord disease - chemotherapy Parkinson s disease ALS/ MS Dementia
Iatrogenically-Induced Iatrogenically-induced = r/t pharmacologic interventions
Medications Anticholinergic activity phenothiazines tricyclic antidepressants antiparkinsonian agents Antacids
Medications cont d Diuretics Anticonvulsant Iron supplements Antihypertensives 5HT 3 Antagonists Vinca alkaloids
Opioid-Related Constipation Opioids smooth muscle receptors of bowel Inhibited propulsive peristalsis in Sm. Int. & Colon Colonic transit time fluid & lyte absorption Impaired defecation reflex: sensitivity to distension internal anal sphincter tone
Assessment Last BM? BM Frequency? Previous frequency? Stool characteristics? Defecation Painful? Urge present but no stool? No urge? Blood with stool? Nausea/vomiting?
Physical Examination Physical appearance (of the patient!) Abdomen: masses, distention bowel sounds pelvic exam X-ray Digital rectal exam Bloodwork (Ca, K, TSH)
Constipation Score Flat plate of abdomen 4 quadrants are examined: ascending, transverse, descending, rectosigmoid Scoring : 0=none 2=>50% 1=<50% 3=100% A Constipation Score > 7/12 requires treatment
Management Prevention of constipation whenever possible is the most important strategy!
Primary Treatment Prophylaxis = good symptom control activity adequate hydration recognize drug effect create a favorable environment
Treatment: Laxatives 80% pts need laxatives Little research to guide choice Softener and stimulant best May require oral/ rectal routes Enemas useful in impaction
Laxatives: Types Bulk forming agents: psyllium Surfactants: docusate Contact cathartics: senna, bisacodyl Osmotic laxatives: lactulose Saline osmotics: MgOH, Phosphasoda Enemas: oil, saline, soap suds, Fleet
Other Approaches Prokinetic agents: cisapride, domperidone, metoclopramide Antibiotics: Opioid antagonist: Chlolinergic: erythromycin naloxone pilocarpine Herbal preparations: mulberry, rhubarb, licorice
Conclusions Constipation = common problem Many causes Prevention important Assessment Key Opioid Rx + Laxative Rx Treat aggressively
References Cimprich, B. (1985). Symptom management: constipation. Cancer Nursing, 8(Suppl. 1), 39-43 Connell, A. M., Hilton, C., Irvin, E. G., Lennard- Jones, J. E. & Misiewicz, J. J. (1965). Variation in bowel habit in two population samples. BMJ, 2, 1095-1099 http://palliative.info/pages/teachingmaterial.htm
Any Questions?