Constipation

What is constipation?

• Infrequent or difficult passage of stools, which may be (but not always) small and; hard
• May be associated with inability to defecate at will, discomfort when defecating, unproductive urges and straining, bloating and a sensation of incomplete evacuation
• Implies a significant variation from the normal bowel habit of an individual patient

Non-pharmacological measures

• Ensure adequate fluid intake – Increase intake of high water content foods such as soups, yoghurt and jelly
• Encourage patient mobility
• Encourage toileting in the morning 20min after breakfast because of the powerful gastro-colic reflex
• Maintain privacy and avoid bedpans, if possible

Laxatives for constipation

• Stimulant laxatives
  (e.g. Senna, Bisacodyl)

• Osmotic laxatives
  (e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG))

• Bulk-forming laxatives
  (e.g. Fybogel)
  • Not usually used in palliative care as most patients struggle to drink the required 1.5litres/day.

Rectal interventions for constipation

• Is the rectum impacted or empty?
  
  • If impacted, is the stool hard or soft?
    
    • If stool is hard – Lubricate using glycerine suppositories or soften with olive oil enema followed by phosphate enema once softened.
    • If stool is soft – Use rectal stimulant (e.g. Bisacodyl suppositories, phosphate enema)
  • If empty, is the rectum dilated or not?
    
    • If dilated or “ballooned” – This often suggests constipation higher up. Give high fleet enema or high centa enema over a few days until constipation resolves.

What can be done for constipation in patients who are incontinent?
(e.g. spinal cord compression)

• PO Senna 2 tablets every other night, with Bisacodyl suppository 10mg every other day (the day after Senna is given)
• Avoid lactulose as it results in “acidic” stools that may cause skin irritation.
• Aim for well-formed stools every 2-3 days

If symptoms are not controlled with measures outlined here, please consult your local palliative care service.

• Candy B, Jones L, Larkin PJ, Vickerstaff V, Tookman A, Stone P. Laxatives for the management of constipation in people receiving palliative care. Cochrane Database Syst Rev. 2015 May;5.
• Clemens KE, Faust M, Jaspers B, Mikus G. Pharmacological treatment of constipation in palliative care. Curr Opin Support Palliat Care.2013 Jun;7(2):183-191.
• Clark K, Currow DC. Constipation in palliative care: what do we use as definitions and outcome measures? J Pain Symptom Manage. 2013 Apr;45(4):753-762.