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Constipation and the Cancer Patient
Constipation Definition Physiology of GI tract Etiology Assessment Treatment
Constipation Assessment methods Etiology Concomitant disease Pharmacologic treatment Preventative strategies
Definition Passage of small, hard stools Painful passage (straining) Prolonged interval N range: 1 in 3d to 3 in 1d
Physiology Coordinated effort: motility (peristalsis) intact ANS hormonal activity mucosal transport defecation reflex
Symptom Prevalence Pain Fatigue/Asthenia Constipation Dyspnea Nausea Vomiting Delirium Depression/suffering % % 70% 60% % 30% % %
Etiology Malignancy Medications Concurrent Disease
Malignancy Effects Direct obstruction by tumor in wall external compression by tumor neural damage L/S spinal cord cauda equina/pelvic plexus hypercalcemia
Malignancy Effects Secondary effects poor po intake dehydration weakness/inactivity confusion depression unfamiliar toilet arrangements
Medications Opioids Anticholinergic activity phenothiazines tricyclic antidepressants antiparkinsonian agents Antacids
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
Medications Diuretics Anticonvulsant Iron supplements Antihypertensive Rx 5HT 3 Antagonists Vinca alkaloids
Concurrent Disease Diabetes Hypothyroidism Hypokalemia Hernia Anal fissure/stenosis Hemorrhoids
Neuropathy & Constipation Autonomic neuropathy diabetes spinal cord disease chemotherapy Parkinsons disease ALS/MS Dementia
Complications Hemorrhoids Rectal prolapse Fecal impaction Obstruction Perforation Nausea/vomiting Urinary retention
Assessment Hx/PE Digital rectal exam Abd X-ray Blood work (Ca, K, TSH)
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?
Physical Exam Physical appearance Abdomen: masses, distention bowel sounds DRE Pelvic exam
Constipation Score Flat plate of abdomen 4 quadrants ascending, transverse descending, rectosigmoid 0=none, 1= 50%, 3=100% CS>7/12 requires treatment
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 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: erythromycin Opioid antagonist: naloxone Chlolinergic: pilocarpine Herbal preparations: mulberry, rhubarb, licorice
Conclusions Constipation common problem Many causes Prevention important Assessment key Opioid Rx+laxative Rx Treat aggressively
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