1. Constipation and Diarrhea Elizabeth Whiteman M.D.

2. Goals and Objectives Diagnose GI symptoms in Palliative care Assess causes of bowel dysfunction Understand bowel physiology of altered bowel movement Treatment options non pharmacologic and pharmacologic Prevention Narcotics and side effects

3. Case 1  Mr. M is a 75 year old man with metastatic prostate cancer is admitted with new abdominal pain and no bowel movement for 10 days. He also has no appetite and feels nausea. He is on long acting Morphine 15mg bid which controls his pain from the cancer. His abdomen is distended and there is firm hard stool in the rectum. He has bowel sounds and the x-ray shows stool throughout the colon.  What is the first thing you can do to help the abdominal pain?.

4. .. A. Stop the Morphine B. Keep him NPO and place an NG tube C. Start Metoclopramide IV around the clock D. Give him an enema and start an oral laxative E. Call surgery to evaluate for possible obstruction

5. Answer D Constipation likely due to opioids Patients on opioids need to be on preventative treatment for constipation Full assessment of cause should be investigated Treatment of coexisting symptoms also needs to be managed (BUT TREAT UNDERLYING CAUSE) Avoid causing return of other symptoms and keep pain treatment also in mind

6. Causes of Constipation Immobility Dehydration Opioids Electrolyte abnormalities: hypercalcemia, hypokalemia, hypomagnesium, hypothyroid, hyperparathyroid Medications: anticholinergics, Antihistamines, TCA’s, Aluminum antacids, diuretics Poor oral intake

7. Bowel obstruction Fecal impaction Urinary retention Tumor burden ▫Peritoneal disease ▫Tumor obstruction ▫Spinal cord lesions ▫Previous surgeries and adhesions

8. Secondary Side effects Pain Nausea Vomiting Anorexia Bloating Diarrhea

9. Case continues  Mr. M the 75 year old male with metastatic prostate cancer has been home for 1 month and receiving outpatient radiation. He is now on Morphine sulfate SR 45mg bid and MS 15mg q4hr prn. He has been having increasing abdominal pain and abdominal distention, He was admitted with N/V and AMS. On exam he has decreased bowel sounds and tense abdomen. Labs reveal a Ca of 13.0, BUN 65, Cr 3.5. What do you do next?

10. A. Order A CT scan abdomen with contrast B. Aggressively hydrate C. Check for fecal impaction D. Check a PSA E. Place NG to give lactulose

11. Answer A and B Check rectal exam, rule out impaction Also rapidly start IV fluids CT may cause worse renal failure PSA will not add any information Aggressive laxative may give more pain or cause perforation is he is obstructed.

12. Mr. M starts to feel better with hydration and disimpaction. He is started back on a liquid diet and tries to have some solids, again he has more distention and pain. His calcium is now normal and his renal function is at baseline What would be the next treatment to assist in his symptoms?

13. A. Start TPN B. Order abdominal series C. Start laxatives D. Hold Narcotics E. Call surgery consult

14. Answer B Order abdominal series ▫Possible bowel obstruction or stool impacted higher up in colon TPN will not help symptoms Laxatives may be needed pending cause Don’t hold narcotics in a patient with history of pain May need further assessment before calling a consult

15. Normal Bowel function Requires stomach and digestion, small intestinal function, colon function and defecation.

16. Exam Visual- look for distention Normal bowel sounds Tenderness, Where? Fluid? Ascities Previous surgical scars Rectal exam

17. Constipation Treatment ▫Non Pharmacologic  Increase oral intake and fluids  Increase mobility and activity if able  Increase fiber and fruit juices, prunes etc  Positional : commode, sitting upright  Privacy

18. Pharmacologic ▫Stool softeners ▫Stimulant laxatives  senna, dulcolax ▫Saline laxatives  Magnesium hydroxide, Magnesium citrate, sodium phosphate ▫Osmotic laxatives  Milk of magnesia, lactulose, sorbitol, polyethylene glycol

19. ▫Bulk forming  Psyllium, methylcellulose ▫Prokinetic agents  Metoclopramide ▫Rectal  Suppositories, enemas, manual disimpaction ▫Selective mu receptor blocker  Methylnaltrexone bromide

20. Diarrhea More than 3-4 loose stools a day Contributes to ▫Dehydration ▫Electrolyte abnormalities ▫Malnutrition ▫Pain and discomfort ▫Pressure ulcer risk

21. Causes Laxative Bowel obstruction Fecal impaction Malabsorbtion Infection Drugs: chemo, antibiotics Radiation bleeding

22. Mrs. S 60 year old woman with pancreatic cancer Admitted with 5 days watery stool and abdominal pain. She has tried immodium with no help. She is dizzy and having more pain. She has a stage 2 decubitus ulcer. What would you do next?

23. A. IV fluids B. Stool studies C. Review medication D. Rectal exam E. All of the above

24. Answer E All of the above Mrs. S. symptoms are likely causing her pain Finding the cause as well as treating her for dehydration are going to help her most. C diff toxin may take 2-3 days

25. Case continues Her C diff is negative, she feels better with hydration, but still has watery loose stools. Possible causes of diarrhea?

26. Causes of Diarrhea Physiology ▫Fluid includes PO intake, salivary, gastric, pancreatic and billiary secretions ▫Small intestine absorbs about 75% fluid ▫Large intestine absorbs about 90% fluid

27. Causes Fecal impaction Intermittent bowel obstruction Treatments ▫Radiation ▫Chemotherapy ▫Surgery: gastrectomy, ileal resection, colectomy Medications: laxatives, antibiotics, sorbitol Osmotic: gtube feeding, hyperosmotic supplements

28. Pancreatic insufficiency ▫Head of pancreas tumor, post resection Malnutrition Rectal incontinence: tumor, spinal cord compression, debility Infection Carcinoid Lactate deficiency

29. Treatment General ▫Stop laxatives ▫Bowel rest, bland diet ▫Treat dehydration ▫Review medications, supplements Fecal impaction ▫Disimpact

30. Medications Fiber if need bulk Kaopectate Immodium Tincture of opium Radiation enteritis- usually self limiting Octreotide: chemotherapy, dumping syndrome, carcinoid Pancreatic insufficiency (fatty foul smelling) ▫Pancreatic enzymes, famotidine, loperamide

31. Monitor skin and perianal area ▫Treat any pressure ulcer ▫Zinc oxide cream to protect ▫Frequent changing and cleaning

32. Summary Constipation and diarrhea are common symptoms in palliative care Assess for patient history and review recent medications, treatments Prevention of constipation if on opioids Continue ongoing monitoring throughout pt course Avoid complications, perforation, vomiting, skin breakdown

33. References AAHPM, Core Curriculum, Evaluation and Management of Gastrointestinal symptoms, 1999. Cherney,N, Evaluation and Management of Treatment-Related Diarrhea in Patients with Advanced Cancer: A Review, Journal of Pain and symptom Management, Vol 36, no. 4, Oct 2008. Thomas, J, Cooney, G, Palliative Care and Pain: New Strategies for managing Opioid Bowel Dysfunction, Journal of Palliative Medicine, Vol. 11, Supplement 1, 2008. Walter A, Caroline N, Constipation, Diarrhea, Palliative care in cancer, 1996.