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The
EPEC-O
TM
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
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EPEC – Oncology
Education in Palliative and End-of-life Care – Oncology
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Module 3f
Symptoms –
Constipation
Constipation . . .

Straining

Hard stool

Sensation of
Incomplete evacuation
Anorectal obstruction

Fewer than 3 BM / week

12 weeks duration > 2 symptoms
. . . Constipation
Epidemiology

Impact: abdominal discomfort / pain,
nausea and vomiting

Prevalence: up to 90 % among
cancer patients treated with opioids

Prognosis: can limit prognosis if
untreated
Management always possible
Key points
1. Pathophysiology
2. Assessment
3. Management
Pathophysiology

Medications
Opioids
Calcium-channel
blockers
Anticholinergic



Decreased
motility
Ileus
Mechanical
obstruction





Metabolic
abnormalities
Spinal cord
compression
Dehydration
Autonomic
dysfunction
Malignancy
Assessment

Specifically ask about bowel function

Establish what is normal for patient
Management

General measures

Specific measures
Regular toileting
Softeners
Gastrocolic reflex
Osmotics
Activity
Stimulants
Lubricants
Large volume
enemas
Stool softeners
(detergent laxatives)

Sodium docusate

Calcium docusate

Phospho-soda enema PRN
Stimulant laxatives

Prune juice

Senna

Casanthranol

Bisacodyl
Osmotic laxatives

Lactulose or sorbitol

Milk of magnesia (other Mg salts)

Magnesium citrate

Polyethylene glycol
Lederle FA, et al. Am J Med, 1990.
Attar A, et al. Gut, 1999.
Lubricants / enemas

Glycerin suppositories

Phosphate enema

Oil retention enema

Tap water, 500 – 1,000 ml
Constipation from
opioids . . .

Occurs with all opioids

Pharmacological tolerance develops
slowly, or not at all

Dietary interventions alone usually
not sufficient

Avoid bulk-forming agents in
debilitated patients
Bagnol D, et al. Neuroscience, 1997.
. . . Constipation from
opioids

Combination stimulant / softeners
are useful first-line medications
Casanthranol + docusate sodium
Senna + docusate sodium

Prokinetic agents

Opioid antagonists
Sykes NP. Palliat Med, 2000.
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Summary
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Use comprehensive
assessment and
pathophysiology-based therapy
to treat the cause and improve
the cancer experience