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TM. The EPEC-O Project Education in Palliative and End-of-life Care - Oncology. The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.
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TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPECTM-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.
EPEC– Oncology Education in Palliative and End-of-life Care – Oncology Module 3f: Symptoms -Constipation
Constipation . . . • Straining • Hard stool • Sensation of • Incomplete evacuation • Anorectal obstruction • Fewer than 3 bowel movements per week • 12 weeks duration with 2 or more 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 • Pathophysiology • Assessment • Management
Medications Opioids Calcium-channel blockers Anticholinergic Decreased motility Ileus Mechanical obstruction Metabolic abnormalities Spinal cord compression Dehydration Autonomic dysfunction Malignancy Pathophysiology
Assessment • Specifically ask about bowel function • Establish what is normal for patient
General measures Regular toileting Gastrocolic reflex Activity Specific measures Softeners Osmotics Stimulants Lubricants Large-volume enemas Management
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 fromopioids . . . • Occurs with all opioids • Pharmacologic 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 fromopioids • 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.