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Constipation and the Cancer Patient

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Presentation on theme: "Constipation and the Cancer Patient"— Presentation transcript:

1 Constipation and the Cancer Patient

2 Constipation Definition Physiology of GI tract Etiology Assessment

3 Constipation Assessment methods Etiology Concomitant disease
Pharmacologic treatment Preventative strategies

4 Definition Passage of small, hard stools Painful passage (straining)
Prolonged interval N range: 1 in 3d to 3 in 1d

5 Physiology Coordinated effort: motility (peristalsis) intact ANS
hormonal activity mucosal transport defecation reflex Coordination of motility, mucosal transport and reflexes. Motility needs CNS and ANS activity both para- and sympathetic systems and the function of hormones. 3 types of motility: segmental (non-propulsive) short-segment propulsive and long-segment propulsive. Segmental movement churn and mix, peristalsis moves forward. Incr. in segmental, nonpropulsive movements ass’d with constipation

6 Symptom Prevalence Pain Fatigue/Asthenia Constipation Dyspnea Nausea
Vomiting Delirium Depression/suffering % % 70% 60% % 30% % %

7 Etiology Malignancy Medications Concurrent Disease

8 Malignancy Effects Direct obstruction by tumor in wall
external compression by tumor neural damage L/S spinal cord cauda equina/pelvic plexus hypercalcemia

9 Malignancy Effects Secondary effects poor po intake dehydration
weakness/inactivity confusion depression unfamiliar toilet arrangements

10 Medications Opioids Anticholinergic activity phenothiazines
tricyclic antidepressants antiparkinsonian agents Antacids

11 Opioid effects Ileocecal & anal sphincter tone
Peristaltic activity in SI & C Impaired defecation reflex sensitivity to distension internal anal sphincter tone ‘lyte & water absorption in SI & C

12 Medications Diuretics Anticonvulsant Iron supplements
Antihypertensive Rx 5HT3 Antagonists Vinca alkaloids

13 Concurrent Disease Diabetes Hypothyroidism Hypokalemia Hernia
Anal fissure/stenosis Hemorrhoids

14 Neuropathy & Constipation
Autonomic neuropathy diabetes spinal cord disease chemotherapy Parkinson’s disease ALS/MS Dementia

15 Complications Hemorrhoids Rectal prolapse Fecal impaction Obstruction
Perforation Nausea/vomiting Urinary retention

16 Assessment Hx/PE Digital rectal exam Abd X-ray Blood work (Ca, K, TSH)

17 History Last BM? BM freq? Previous freq? Stool characteristics?
Defecation painful? Urge present but no stool? No urge to defecate? Blood with stool? Nausea/vomiting? Stool frequency NB for Dx Characteristics like ribbons, pencil, pellets Painful BM suggests tumor, hemorrhoids No BM (+ urge) suggests neurologic damage or obstruction No urge suggests colonic inertia Bloody stools = hemorrhoids, colitis, tumor bleeding

18 Physical Exam Physical appearance Abdomen: masses, distention
bowel sounds DRE Pelvic exam

19 Constipation Score Flat plate of abdomen 4 quadrants
ascending, transverse descending, rectosigmoid 0=none, 1=<50%, 2=>50%, 3=100% CS>7/12 requires treatment

20 Treatment Prophylaxis good symptom control activity adequate hydration
recognize drug effect create a favorable environment

21 Treatment: Laxatives 80% pts need laxatives
Little research to guide choice Softener and stimulant best May require oral/rectal routes Enemas useful in impaction

22 Laxatives Bulk forming agents: psyllium Surfactants: docusate
Contact cathartics: senna, bisacodyl Osmotic laxatives: lactulose Saline osmotics: MgOH, Phosphasoda Enemas: oil, saline, soap suds, Fleet

23 Other Approaches Prokinetic agents: cisapride, domperidone, metoclopramide Antibiotics: erythromycin Opioid antagonist: naloxone Chlolinergic: pilocarpine Herbal preparations: mulberry, rhubarb, licorice

24 Conclusions Constipation common problem Many causes
Prevention important Assessment key Opioid Rx+laxative Rx Treat aggressively

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