DR. A.T.M.KAMRUL HASAN MD(Thesis) Department Of Medical Oncology Welcome to All DR. A.T.M.KAMRUL HASAN MD(Thesis) Department Of Medical Oncology

Constipation- distressing and underestimated complication of cancer patients

What is constipation ? Constipation can be defined as “unduly infrequent and difficult evacuation of the bowels” that is “reduced frequency of bowel movements than is normal for the individual concerned, which may lead to pain and discomfort”.

Etiology of Constipation Common factors of constipation in the general population include : Diet. Altered bowel habits. Inadequate fluid intake. Lack of exercise.

Cont.. Constipation can be a presenting symptom of cancer, or it can occur later as a side effect of a growing tumor or treatment of the tumor. Additional causative factors are : The tumor itself. Cancer-related problems. Effects of drug therapy for cancer or for cancer pain. Other concurrent processes such as organ failure, decreased mobility, and depression

Cont.. Physiologic factors include : Inadequate oral intake. Dehydration. Inadequate intake of dietary fiber. Organ failure. Any or all of these factors can occur because of the disease process, aging, debilitation, or treatment.

Medications Chemotherapy agents cause autonomic nervous system changes vinca alkaloids, oxaliplatins, taxanes, and thalidomide) Opioids or sedatives. Anticholinergic preparations antispasmodics, antiparkinsonism agents antidepressants

Cont… Phenothiazines. Calcium- and aluminum-based antacids. Diuretics. Vitamin supplements iron calcium Tranquilizers and sleeping medications. General anesthesia and pudendal blocks.

Cont… Altered bowel habits Repeatedly ignoring defecation reflex. Excessive use of laxatives and/or enemas. Prolonged immobility and/or inadequate exercise Spinal cord injury or compression, fractures fatigue weakness inactivity Intolerance with respiratory or cardiac problems.

Cont.. Bowel disorders Irritable colon Diverticulitis Tumor Neuromuscular disorders Neurological lesions (cerebral tumors). Spinal cord injury or compression. Paraplegia. Cerebrovascular accident with paresis. Weak abdominal muscles.

Cont.. Metabolic disorders Hypothyroidism Uremia. Dehydration. Hypercalcemia. Hypokalemia. Hyponatremia. Depression Chronic illness. Anorexia. Immobility. Antidepressants.

Cont.. Inability to increase intra-abdominal pressure Emphysema. Any neuromuscular impairment of the diaphragm or abdominal muscles. Massive abdominal mass Atony of muscles Malnutrition. Cancer Cachexia, Senility.

Cont.. Environmental factors Inability to get to the bathroom without assistance Unfamiliar or hurried environment Excess heat leading to dehydration. Change in bathroom habits (e.g., use of a bedpan) Lack of privacy

Narrowing of colon lumen Related to scarring from radiation therapy Surgical anastomosis Luminal growth Compression from extrinsic tumor.

Assessment of Constipation A normal bowel pattern is having at least three stools per week and no more than three per day; however, these criteria may be inappropriate for cancer patients.

Cont.. Comprehensive assessment include interview physical assessment (abdomen/bowel sounds/skin), medication review medical and surgical review psychosocial review, review of physical environment and appropriate diagnostics . Complete a bowel assessment and consistently reevaluate.

Cont.. The following questions may provide a useful assessment guide: What is normal for the patient (frequency, amount, and timing)? When was the last bowel movement? What was the amount, consistency, and color? Was blood passed with it? Has the patient been having any abdominal discomfort, cramping, nausea or vomiting, pain, excessive gas, or rectal fullness?

Cont.. Does the patient regularly use laxatives or enemas? What does the patient usually do to relieve constipation? Does it usually work? What type of diet does the patient follow? How much and what type of fluids are taken on a regular basis? What medication (dose and frequency) is the patient taking? Is this symptom a recent change? How many times a day is flatus passed?

Cont.. Physical assessment will determine the presence or absence of bowel sounds, flatus, or abdominal distention. Patients with colostomies are assessed for constipation. Dietary habits, fluid intake, activity levels, and use of opioids in these patients are examined.

Management Comprehensive management of constipation includes prevention (if possible), elimination of causative factors, and judicious use of laxatives.

Prevention Prevention of constipation in cancer patients Assessment Establish the patient’s normal bowel pattern and habits (time of day for normal bowel movement, consistency, color, and amount). Explore the patient’s level of understanding and compliance relating to exercise level, mobility, and diet (fluid, fruit, and fiber intake).

Determine normal or usual use of laxatives, stimulants, or enemas. Determine laboratory values, specifically looking at platelet count. Conduct a physical assessment of the rectum (or stoma) to rule out impaction

Treatment: Non pharmacological Incorporate constipation prevention strategies for as long as possible and appropriate . Attempts at defecating should be made 30 to 60 minutes following ingestion of a meal to take advantage of the gastro colic reflex. Provide a warm or hot drink approximately one-half hour before time of patient’s usual defecation.

Cont.. Bowel action should be initiated when it is “normal and convenient” for the patient in a sitting position. This can be facilitated by using; raised toilet seats, commodes and ensure adequate pain control for movement and comfort. Provide privacy and quiet time at the patient’s usual or planned time for defecation.

Cont.. Cancer patients are encouraged to eat more high-fiber foods such as fruits , vegetables and 100% whole- grain cereals, breads, and bran. Increased fiber intake must be accompanied by increased fluid intake. High fiber intake is contraindicated in patients at increased risk for bowel obstruction, such as those with a history of bowel obstruction or status postcolostomy.

Cont.. Provide toilet or bedside commode and appropriate assistive devices; avoid bedpan use whenever possible. Avoid excessive straining (this can complicate some medical conditions). Encourage activity.

Cont.. Encourage patient to increase fluid intake, with a goal of drinking eight 8-oz (240-mL) glasses of fluid daily unless contraindicated. Encourage regular exercise, including abdominal exercises in bed or moving from bed to chair if the patient is not ambulatory.

Cont.. Encourage adequate fiber intake. Healthy adults consume 20 g to 35 g of fiber per day (average consumption is 11 g). Children and adolescents consume the number of grams of fiber equal to their age plus 5—for example, a 10-year-old consumes 15 g of fiber per day (10 + 5). This guideline applies until age 18 years; at that time, the adult recommendations are followed.

Treatment: Pharmacological Constipation is a common side effect of all opioids. Patients often stop opioid therapy because of opioid induced constipation. Opioid induced constipation is much easier to prevent than treat. Opioids cause decreased motility (by suppression of intestinal peristalsis) and increased water and electrolyte re-absorption in the small intestine and colon. Transdermal fentanyl and methadone have been shown to produce less constipation. Consider opioid rotation for severe refractory constipation.

Cont.. Tolerance will not develop to the constipating effects of opioids. The constipating effect of opioids are not dose dependant. Consider patient preferences when determining bowel regime. Senna is preferred secondary to a favorable toxicity profile and cost advantage. The sweet taste of lactulose can cause problems with compliance. Sorbitol has been found to be less nauseating.

Cont.. • Start laxatives on a regular basis for all patients taking opioids • Based on the bowel pattern, time since last bowel movement and bowel medication previously being used, determine the level of the bowel protocol for medications. • Use a step wise approach, titrate the laxatives according to the bowel protocol to ensure regular bowel movements. Aim for soft formed stool at least once every 2 to 3 days. • Three days without a bowel movement requires intervention.

Cont.. Rectal laxative should never accompany an inadequate prescription of oral laxative. Avoid use of bulk forming agents (fiber) in patients with poor oral fluid intake. They may worsen with an incipient obstruction. The patient must be able to tolerate 1.5 to 2 litres of fluid per day.

Cont.. Osmotic laxatives should be accompanied by an increase in fluid intake. Metoclopramide inhibits dopamine centrally and peripherally, therefore increasing peristalsis in the digestive tract as well as combating nausea and vomiting. Metoclopramide 10 to 20 mg PO q6h. Polyethylene glycol can use as a laxative for opioid induced constipation. Polyethylene glycol 10 to 30 g PO daily to b.i.d. or 60 to 240 g for evacuation.

Laxatives Oral laxatives Type Action Sodium docusate Predominantly softening - surfactant Detergent, increase water penetration Lactulose Predominantly softening – osmotic laxative Retain water in small gut Sorbitol Predominantly softening – osmotic cathartic Methyl cellulose Predominantly softening – bulk forming agent Normalize stool volume

Oral laxatives Type Action Magnesium sulphate Predominantly softening – saline laxative Retain water and strong purgative action Polyethylene glycol Predominantly softening – osmotic cathartic Increases fluid and purgative action Sennosides Peristalsis stimulating - anthracenes Reduces water and electrolyte absorption and purgative action Bisacodyl Peristalsis stimulating - polyphenolic

Rectal laxatives Type Action Bisacodyl suppository Peristalsis stimulating - polyphenolic Evacuates stools from rectum or stoma: for colonic inertia Glycerin Predominantly softening - osmotic laxative Softens stools in rectum or stoma Phosphate enema Peristalsis stimulating – saline laxative Evacuates stools from lower bowel Oil enema Predominantly softening – lubricant laxative Softens hard impacted stool

Preferred characteristics of a laxative Oral formulation Palatable Minimal side effects at recommended doses – in particular colic pain Potent enough to have an effect but not so potent as to carry a high risk of inducing diarrhoea Total number of pills or total volume of liquid medication at an acceptable level for the patient

Recommendations Even in the absence of oral intake, the body continues to produce 1 to 2 ounces of stool per day. It is not necessary to have a bowel movement every day. As long as stools are soft and easy to pass, every 2 to 3 days is acceptable. “Normal” bowel movements vary from person to person. If appetite is small, try to incorporate nutritious liquids such as milkshakes, cream soups, fruit juice.

Cont.. Rectal agents should be avoided in cancer patients at risk of thrombocytopenia, leukopenia, and/or mucositis from cancer and its treatment. In the immunocompromised patient, manipulation of the rectum and anus should be avoided (i.e., no rectal examinations, no suppositories, and no enemas). These actions can lead to the development of anal fissures or abscesses, which are portals of entry for infection. Also, the stoma of a patient with neutropenia should not be manipulated unnecessarily.

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