Constipation and malignant bowel obstruction in palliative care


Constipation and malignant bowel obstruction in palliative care download

Jason W Boland
Elaine G Boland


ConstipationConstipation is a decreased frequency of and/or difficulty withdefecation, although this depends on an individual’s perceptionof their normal bowel habit. Constipation can include straining,hard dry stool, abdominal discomfort and a sensation ofincomplete evacuation. It is common in patients being givenpalliative care, affecting about 50% with advanced illness and upto 87% of terminally ill patients given opioids.1,2Constipation often leads to considerable distress, being associ-ated with abdominal pain and distension, anorexia, nausea andvomiting. It can result in faecal impaction, intestinal obstruction,urinary retention or incontinence. Overflow diarrhoea resultingfrom constipation can wrongly be interpreted as overuse of laxa-tives, leading to reduced laxative use and worsening of constipation.AssessmentAssessment involves a thorough history, examination andappropriate investigations to diagnose and ascertain the under-lying cause of the constipation. Digital rectal examination formspart of the examination, especially if the person is complaining ofincomplete evacuation or overflow diarrhoea, or if faecalimpaction needs to be excluded. Digital rectal examinationshould not be carried out in immunocompromised or severelythrombocytopenic patients. Plain abdominal radiography isgenerally unhelpful to diagnose constipation.Assessment aims to diagnose the constipation, assess itsseverity, associated symptoms and impact, and find its cause. Itshould elucidate whether the constipation pre-dates the illnessrequiring palliative care, the role (and potential for modification)of contributing factors including medications, fluid intake and anydirect effects of the underlying disease that could cause con-stipation. The effectiveness of previous management, includingself-care, non-drug and drug measures, should also be evaluated.3


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