Transcript S13_Constipation_Bowel_Obstruction

Seminar in Palliative Care
September 26 – October 02, 2010
Salzburg, Austria
in Collaboration with
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.
Constipation
Eugenie A.M.T. Obbens, MD PhD
Pain & Palliative Care Service
Memorial Sloan-Kettering Cancer Service
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.
Summary
Use comprehensive assessment and
pathophysiology-based therapy
to treat the cause and
improve the cancer experience
Bowel
Obstruction
Bowel obstruction . . .
• Definition: mechanical or functional
obstruction of the progress of food and
fluids through the GI tract
. . . Bowel obstruction
• Impact: misery from nausea, vomiting
and abdominal pain
. . . Bowel obstruction
Epidemiology
• Prevalence
3 % of all advanced malignancies
11 – 42 % ovarian cancer
5 – 24 % colorectal cancer
• Prognosis – poor if inoperable
64 days
Krebs HR, Goplerud DR. Am J Obstet Gynecol, 1987.
Ripamonti S, et al. J Pain Symptom Manage, 2000.
Key points
1. Pathophysiology
2. Assessment
3. Management
Pathophysiology . . .
•
•
•
•
•
•
Intraluminal mass
Direct infiltration
External compression
Carcinomatosis
Adhesions
Other
. . . Pathophysiology
• 2 liters / day orally
• 8 liters / day gastric & intestinal
secretions
• Obstruction causes accumulation
• Peristalsis causes distention, pain,
nausea, and vomiting
Assessment
• Symptoms
Continuous distension pain 92 %
Intestinal colic 72 – 76 %
Nausea / vomiting 68 – 100 %
• Abdominal radiograph
Dilated loops, air-fluid levels
• CT scan
Staging, treatment planning
Differentiating small vs.
large bowel obstruction
S / Sx
Onset
Abdominal
pain
Bowel
sounds
Bowel
movement
Vomiting
Small-high
Small-low
Large
Acute,
severe
Acute,
severe
Progressive
Variable
Variable
Mild, steady
Diminished
Hyperactive; Hyperactive;
diminished
diminished
Short-term
Short-term
Constipation
Severe
Mild /
moderate
None;
severe
Management . . .
Medical
• Opioids
Morphine – 89 % control
• Antiemetics
Prochlorperazine – 13 % control
• Steroids
Dexamethasone
. . . Management
Surgical
• Surgical evaluation
• Standard
Intravenous fluids
Nasogastric tube – intermittent suction
• Inoperable
Stent placement
Venting gastrostomy
Antisecretory agents
Drug
Dose
Notes
10 mcg / h SQ / IV
cont. infusion or
100 mcg SQ q 8 h
Minimal adverse
effects; titrate
daily
Scopolamine
( hyoscine
hydrobromide )
10 mcg / h SQ / IV
cont. infusion or
0.1 mg SQ q 6 h
Anticholinergic
effects may be
dose - limiting;
titrate daily
Glycopyrrolate
0.2 to 0.4 mg SQ
q 2 to 4 h; titrate
Anticholinergic
effects possible
Octreotide
Anticholinergics
• Antispasmodic and antisecretory
• Scopolamine
10 – 100 mcg / hr SC / IV
0.1 mg SC q 6 h and titrate
• Glycopyrrolate
0.2 - 0.4 mg SC q 2 – 4 h and titrate
Baines M, et al. Lancet, 1985.
Davis MP, Furste A. J Pain Symptom Manage, 1999.
Somatostatin
• 14 amino acid polypeptide
Serum half-life = 3 minutes
• Central action
Inhibits release of GH and thyrotropin
• Peripheral action
Inhibits glandular secretion
Pancreas, GI tract
Octreotide . . .
• Polypeptide analog of somatostatin
Serum half-life = 2 hr
• Relieves symptoms of obstruction
Ripamonti, et al. J Pain Symptom Manage, 2000.
Mercadante, et al. Supportive Care Cancer, 2000.
Fainsinger RL, et al. J Pain Symptom Manage, 1994.
. . . Octreotide
• Octreotide 10 mcg/h continuous
infusion
• Titrate to complete control of N / V
• If NG tube in place, clamp when
volume diminishes to 100 cc and
remove if no N / V
• Try convert to intermittent SC
• Continue until death
. . . Octreotide
• Side effects
Mostly none
Dry mouth
Biliary sludge / stones
• Studies in other palliative care
settings
• Subcutaneous administration
Conclusions
• Considerable symptom control
challenge
• Surgery for selected cases
• Pharmacological management
relieves symptoms in many patients
• Antisecretory agents represent a
significant advance
Summary
Use comprehensive assessment and
pathophysiology-based therapy
to treat the cause and
improve the cancer experience