Bowels

Constipation is a frequent complaint in the general community, and more common in palliative care patients. Opioid induced constipation should be considered during the assessment of constipation.

Key points

• Constipation is a common problem in palliative care patients and is frequently multifactorial. Prevalence and severity of constipation increases as patients become more functionally dependent.
• Symptoms should be assessed in relation to the person’s previous bowel habit.
• The goal of management is prevention. Always ask about the symptom and manage pre-emptively.
• Failure to manage constipation can lead to reduced adherence to medications, avoidable admissions, and is very distressing.

Assessment

• Always consider the possibility of bowel obstruction – especially in high risk patients (ovarian or bowel cancer, or those with peritoneal disease). They may present with symptoms of incomplete or intermittent obstruction.
• The main role for an abdominal x-ray (AXR) is to exclude obstruction.
• Faecal impaction may present with spurious diarrhoea, called ‘overflow’ diarrhoea.
• Rectal examination should include an assessment of pelvic floor and sphincter functioning, checking for anal pathology, and looking for sources of pain on defecation.
• Exclude metabolic causes eg, hypothyroidism, hypercalcemia.
• Many medicines contribute to constipation. Review the drug chart. Some of the medications associated with constipation include opioids, serotonin (5HT3) blocking antiemetics like ondansetron, anticholinergics, calcium and iron tablets.
• Assess hydration.

Approach to management

• The person will generally require the use of aperients to manage constipation
• Patient education.
• Address any reversible contributors including pain, fluid intake, mobility and activity levels, toileting arrangements.
• Reduce polypharmacy, and select less constipating opioids where appropriate.