Constipation

KEYPOINTS

• Prevention is the most important part of treatment
• Constipation is defined as the infrequent and difficult passage of hard stools
• Constipation may be related to the disease, the treatment or may be unrelated
• The prevalence of constipation in palliative care patients is 29-86%
• Constipation can be a distressing symptom for patients and cause other problems such as abdominal pain, nausea and vomiting, or if left untreated, bowel obstruction

• Patients and families can be very distressed by even small amounts of visible bleeding
• Preventing and relieving constipation can improve quality of life
• Normal frequency of bowel movements varies between individual children
• Painful dry stools should be taken to indicate constipation

ASSESSMENT

(see Foreword)

• Taking a thorough history and performing a good clinical assessment (including rectal exam to assess for the presence of hard stool in the vault and rule out impaction) is important to try and identify the underlying cause(s) of the constipation
• Causes of constipation can include: opioids or other medications, dehydration, mechanical obstruction, immobility, emotional stress, decreased oral intake and electrolyte imbalances
• Investigations to consider may include: abdominal x-ray to assess bowel gas pattern and rule out ileus or bowel obstruction

• Mass in (L) lower quadrant may be present
• Rectal exam may show impacted faeces, fissure or tumour

MANAGEMENT

Mild Constipation

• If possible
  • Increase fluids
  • Increase fibre (if not accompanied by increase in fluids may make constipation worse)

Mild or Moderate or When Initiating Opioids

• As above + stool softener, i.e.
  • Docusate 100-200 mg bid PO as well as a peristaltic agent
  • Bisacodyl 5-15 mg bid PO or senna two tabs HS PO, increase to bid if necessary PO

No Stool for 3 Days and Stool in Rectum

• As above +
• Lactulose or sorbitol 70% 15-30 cc bid PO
• Glycerine and dulcolax suppositories
• Fleet or saline enema if suppositories not effective

Constipated Stool in Rectum

• Disimpaction if indicated

As with adults, try to prevent constipation by adding laxatives when starting opioids:

• Docusate
  • Less than 3 years: 10-40 mg/24h bid PO
  • 3-6 years: 20-60 mg/24h bid PO
  • 6-12 years: 40-120 mg/24h bid PO
• Bisacodyl
  • 6-12 years: 5-10 mg once daily PO
• Senna
  • 2-6 years: one half daily to one tab bid PO
  • 6-12 years: one tab daily to two tabs bid PO
• Lactulose
  • 1 month-1 year: 2.5 mls bid PO
  • 1-5 years: 5 mls bid PO
  • 5-10 years: 10 mls bid PO
  • 10-18 years: 15 mls bid PO
  • Adjust according to response

PITFALLS/CONCERNS

In patients in the final terminal phase, i.e. hours to days, it may be inappropriate to treat obstruction or constipation

• Do not use enemas or suppositories in children with neutropenia and thrombocytopenia
• Children with constipation may have developed rectal tears complicating the problem

PALLIATIVE TIPS

• Bowel regimens should be individualized and titrated to patient response
• A bowel regimen should be initiated at the time opioids are started and should be continued for as long as the patient takes opioids
• Urinary retention, nausea and vomiting, restlessness, and other symptoms can sometimes be relieved by treating constipation

• As with adults, encourage increased fluid intake and exercise when appropriate

SOURCES/REFERENCES

1. Dalal S, Fabbro E, Bruera E. Symptom control in palliative care - part I: Oncology as a paradigmatic example. J Palliat Med 2006;9(2):391-408. http://www.ncbi.nlm.nih.gov/pubmed/16629570
2. Downing GM, Wainwright W, editors. Medical care of the dying. 4th ed. Victoria (BC): Victoria Hospice Society; 2006. p. 341- 352.
3. Fallon MT, Hanks GW. Morphine, constipation and performance status in advanced cancer patients. Palliat Med 1999;13(2):159-160. http://www.ncbi.nlm.nih.gov/pubmed/10474699
4. Goodman M, Wilkinson S. Constipation management in palliative care: a survey of practices in the United Kingdom. J Pain Symptom Manage 2005;29(3):238-244. http://www.ncbi.nlm.nih.gov/pubmed/15781174

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