Constipation and Serious Illness

Constipation is one of the most stressful symptoms experienced by patients with a serious illness. It occurs in at least 70% of patients. Many times, it goes unrecognized and is often undertreated.

What is constipation? 

Signs of constipation include:

• Stools are hard
• Defecation is overly difficult
• Defecation is infrequent
• Normal bowel movement pattern is disrupted

Constipation is a common and independent predictor of delirium among the cognitively impaired. It can significantly diminish the quality of life, increase stress and financial burden, and result in preventable complications, emergency room visits, hospitalizations, and death due to colonic perforation. It is preventable and treatable across the board. 

What causes constipation? 

Causes of constipation include:

• Medications: Opioids, anticholinergics, antacids, anticonvulsants, calcium channel blockers, antiemetics, antitussives, antidiarrheals, antiparkinsonians, neuroleptics, antidepressants, iron/calcium supplements, diuretics, and chemotherapeutic agents
• Diet: Anorexia, reduced food intake, reduced fluid intake, low-fiber diet, diet high in saturated fats, diet high in processed grains, chocolate
• Neurologic: Spinal cord infiltration, spinal cord impingement, rule out cord compression if back pain and cancer, cerebral tumors, autonomic dysfunction
• Metabolic: Dehydration, hypercalcemia, hypokalemia, uremia, hypothyroidism, diabetes
• Weakness/Fatigue: Proximal myopathy, central myopathy, abdominal muscle weakness
• GI Abnormalities: Structural abnormalities, pelvic tumor mass, radiation fibrosis, pelvic and/or rectal pain inhibiting defecation, IBS
• Environmental and Cultural Factors: Lack of privacy, lack of comfort or assistance with toileting, cultural sensitivities regarding defecation, use of a bedpan or commode, inability to get to the bathroom, females are more likely to suffer from chronic constipation, patients > 65 are at high risk of chronic constipation

It’s important to recognize that constipation may also lead to paradoxical or ‘overflow’ diarrhea, with leakage of fluid feces past impacted stool.

To assess whether someone is experiencing constipation, it is important to assess current bowel function including:

• Symptom onset
• Aggravating and alleviating factors
• Frequency and pattern of bowel movements
• Stool volume and appearance (consistency, color, odor, presence of blood or mucus)
• Nausea
• Abdominal discomfort
• Bloating or gas
• Tenesmus

Physical signs of constipation include:

• Distension
• Abdominal tenderness
• Fecal masses on palpation
• Abnormal bowel sounds (suggestive of bowel obstruction)
• Impaction on digital rectal exam – never give laxatives until distal impaction is cleared!

The primary goal of preventing and treating constipation should be to re-establish comfortable/regular bowel habits and to avoid constipation-related complications such as obstruction, stercoral ulceration, and perforation.

How to Manage Constipation 

In some cases, constipation can be managed and prevented without medication. Some of non-pharmacologic management tools include:

• Optimize toileting: the physical environment should be private with a good sitting position
• Fiber increases stool bulk promoting peristalsis
• Increase fluid intake – if a patient has difficulty swallowing thin liquids, improve fluid intake by using thickeners, soups, jello, and fruit
• Increase patient ambulation within patient limits
• Review medications and eliminate non-essential constipating medications
• Prunes! Studies show that prunes may be as or more effective than psyllium for treating non-opioid-induced constipation

Although preventative measures are important, they are often insufficient by themselves. Prophylactic daily laxative therapy is necessary for patients on opioids or for patients with chronic constipation.

A doctor may also prescribe medication for bowel treatment. There are several different types:

Stimulants: Stimulate fluid secretion and motility. Some examples of stimulants are Bisacodyl and Senna. Side effects include cramping pain, diarrhea, and weight loss.

Osmotic: These medications pull water into the intestine through oncotic pressure. They require adequate fluid intake to be effective. Some examples include PEG (Miralax), Lactulose, Sorbitol, Magnesium Hydroxide (Milk of Magnesia), Magnesium Citrate, and Glycerin. Side effects include cramping, flatulence, and hypermagnesemia. Glycerin, given as a suppository, may also cause rectal bleeding, blistering, burning, itching, or pain.

Enemas: Enemas cause softening of impacted stool, rectal distention, and reflex defecation. Warm tap water or warm powdered milk and molasses enemas can be performed as often as necessary to achieve results up to every two hours.

First-line laxatives include polyethylene glycol powder (osmotic) or senna (stimulant). Both an osmotic and stimulating laxative are often necessary. The laxative dose may be lowered or increased according to the patient response. The goal of this therapy is for the patient to return to a normal pattern of bowel movements.

Crossroads Hospice & Palliative Care provides care and support to patients with serious or terminal illness. To learn more about our services, please call 1-888-564-3405.

DiGi Graham, Doctor of Pharmacy
Chief Corporate Pharmacist
Crossroads Hospice & Palliative Care

Reference:
Constipation in Patients with Serious Illness. Centers for Advanced Palliative Care.