Transcript Constipation and Diarrhea

Constipation and
Diarrhea
Elizabeth Whiteman M.D.
Goals and Objectives
• Diagnose GI symptoms in Palliative care
• Assess causes of bowel dysfunction
• Understand bowel physiology of altered bowel
movement
• Treatment options non pharmacologic and
pharmacologic
• Prevention
• Narcotics and side effects
Case 1
 Mr. M is a 75 year old man with metastatic prostate
cancer is admitted with new abdominal pain and no
bowel movement for 10 days. He also has no
appetite and feels nausea.. He is on long acting
Morphine 15mg bid which controls his pain from the
cancer. His abdomen is distended and there is firm
hard stool in the rectum. He has bowel sounds and
the x-ray shows stool throughout the colon.
 What is the first thing you can do to help the
abdominal pain?
A. Stop the Morphine
B.
• .Keep him NPO and place an NG tube
C. Start Metoclopramide IV around the clock
. start an oral laxative
D. Give him an enema and
E. Call surgery to evaluate for possible
obstruction
Answer D
• Constipation likely due to opioids
• Patients on opioids need to be on preventative
treatment for constipation
• Full assessment of cause should be investigated
• Treatment of coexisting symptoms also needs to
be managed (BUT TREAT UNDERLYING
CAUSE)
• Avoid causing return of other symptoms and
keep pain treatment also in mind
Causes of Constipation
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Immobility
Dehydration
Opioids
Electrolyte abnormalities: hypercalcemia,
hypokalemia, hypomagnesium, hypothyroid,
hyperparathyroid
• Medications: anticholinergics, Antihistamines,
TCA’s, Aluminum antacids, diuretics
• Poor oral intake
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Bowel obstruction
Fecal impaction
Urinary retention
Tumor burden
▫ Peritoneal disease
▫ Tumor obstruction
▫ Spinal cord lesions
▫ Previous surgeries and adhesions
Secondary Side effects
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Pain
Nausea
Vomiting
Anorexia
Bloating
Diarrhea
Case continues
 Mr. M the 75 year old male with metastatic
prostate cancer has been home for 1 month and
receiving outpatient radiation. He is now on
Morphine sulfate SR 45mg bid and MS 15mg
q4hr prn. He has been having increasing
abdominal pain and abdominal distention, He
was admitted with N/V and AMS. On exam he
has decreased bowel sounds and tense abdomen.
Labs reveal a Ca of 13.0, BUN 65, Cr 3.5. What
do you do next?
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A. Order A CT scan abdomen with contrast
B. Aggressively hydrate
C. Check for fecal impaction
D. Check a PSA
E. Place NG to give lactulose
Answer A and B
• Check rectal exam, rule out impaction
• Also rapidly start IV fluids
• CT may cause worse renal failure
• PSA will not add any information
• Aggressive laxative may give more pain or cause
perforation is he is obstructed.
• Mr. M starts to feel better with hydration and
disimpaction. He is started back on a liquid diet
and tries to have some solids, again he has more
distention and pain. His calcium is now normal
and his renal function is at baseline
• What would be the next treatment to assist in his
symptoms?
A. Start TPN
B. Order abdominal series
C. Start laxatives
D. Hold Narcotics
E. Call surgery consult
Answer B
• Order abdominal series
▫ Possible bowel obstruction or stool impacted
higher up in colon
• TPN will not help symptoms
• Laxatives may be needed pending cause
• Don’t hold narcotics in a patient with history of
pain
• May need further assessment before calling a
consult
Normal Bowel function
• Requires stomach and digestion, small intestinal
function , colon function and defecation.
Exam
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Visual- look for distention
Normal bowel sounds
Tenderness, Where?
Fluid? Ascities
Previous surgical scars
Rectal exam
Constipation
• Treatment
▫ Non Pharmacologic
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Increase oral intake and fluids
Increase mobility and activity if able
Increase fiber and fruit juices, prunes etc
Positional : commode, sitting upright
Privacy
• Pharmacologic
▫ Stool softeners
▫ Stimulant laxatives
 senna, dulcolax
▫ Saline laxatives
 Magnesium hydroxide, Magnesium citrate, sodium
phosphate
▫ Osmotic laxatives
 Milk of magnesia, lactulose, sorbitol, polyethylene
glycol
▫ Bulk forming
 Psyllium, methylcellulose
▫ Prokinetic agents
 Metoclopramide
▫ Rectal
 Suppositories, enemas, manual disimpaction
▫ Selective mu receptor blocker
 Methylnaltrexone bromide
Diarrhea
• More than 3-4 loose stools a day
• Contributes to
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Dehydration
Electrolyte abnormalities
Malnutrition
Pain and discomfort
Pressure ulcer risk
Causes
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Laxative
Bowel obstruction
Fecal impaction
Malabsorbtion
Infection
Drugs: chemo, antibiotics
Radiation
bleeding
Mrs. S
• 60 year old woman with pancreatic cancer
Admitted with 5 days watery stool and
abdominal pain. She has tried immodium with
no help. She is dizzy and having more pain. She
has a stage 2 decubitus ulcer.
• What would you do next?
A. IV fluids
B. Stool studies
C. Review medication
D. Rectal exam
E. All of the above
Answer E
• All of the above
• Mrs. S. symptoms are likely causing her pain
• Finding the cause as well as treating her for
dehydration are going to help her most.
• C diff toxin may take 2-3 days
Case continues
• Her C diff is negative, she feels better with
hydration, but still has watery loose stools.
• Possible causes of diarrhea?
Causes of Diarrhea
• Physiology
▫ Fluid includes PO intake, salivary, gastric,
pancreatic and billiary secretions
▫ Small intestine absorbs about 75% fluid
▫ Large intestine absorbs about 90% fluid
Causes
• Fecal impaction
• Intermittent bowel obstruction
• Treatments
▫ Radiation
▫ Chemotherapy
▫ Surgery: gastrectomy, ileal resection, colectomy
• Medications: laxatives, antibiotics, sorbitol
• Osmotic: gtube feeding, hyperosmotic
supplements
• Pancreatic insufficiency
▫ Head of pancreas tumor, post resection
• Malnutrition
• Rectal incontinence: tumor, spinal cord
compression, debility
• Infection
• Carcinoid
• Lactate deficiency
Treatment
• General
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Stop laxatives
Bowel rest, bland diet
Treat dehydration
Review medications, supplements
• Fecal impaction
▫ Disimpact
Medications
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Fiber if need bulk
Kaopectate
Immodium
Tincture of opium
Radiation enteritis- usually self limiting
Octreotide: chemotherapy, dumping syndrome,
carcinoid
• Pancreatic insufficiency (fatty foul smelling)
▫ Pancreatic enzymes, famotidine, loperamide
• Monitor skin and perianal area
▫ Treat any pressure ulcer
▫ Zinc oxide cream to protect
▫ Frequent changing and cleaning
Summary
• Constipation and diarrhea are common
symptoms in palliative care
• Assess for patient history and review recent
medications, treatments
• Prevention of constipation if on opioids
• Continue ongoing monitoring throughout pt
course
• Avoid complications, perforation, vomiting, skin
breakdown
References
• AAHPM, Core Curriculum, Evaluation and Management of
Gastrointestinal symptoms, 1999.
• Cherney,N, Evaluation and Management of Treatment-Related Diarrhea
in Patients with Advanced Cancer: A Review, Journal of Pain and
symptom Management, Vol 36, no. 4, Oct 2008.
• Thomas, J, Cooney, G, Palliative Care and Pain: New Strategies for
managing Opioid Bowel Dysfunction, Journal of Palliative Medicine, Vol.
11, Supplement 1, 2008.
• Walter A, Caroline N, Constipation, Diarrhea, Palliative care in cancer,
1996.