Consensus Recommendations for the Management of Constipation in Patients with Advanced, Progressive Illness

Abstract

Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.

Butyric acid in functional constipation

“…Moreover, keeping a stool diary and bowel training may help. Furthermore, it is well documented that adding osmotic laxatives such as polyethylene glycol or lactulose can increase stool frequency and improve symptoms of constipation [12]. Sometimes prokinetic drugs are recommended; however, their effect is limited to the upper gastrointestinal tract [13].…”

Managing Constipation in Adults With Cancer

“…A patient's self-report of constipation, which can be gained by a reliable and valid screening tool (see "Assessment of Constipation in Patients With Cancer" in the May/June 2016 issue of JADPRO), should be incorporated into a more thorough focused history and physical examination to confirm constipation (and rule out bowel obstruction; Librach et al, 2010;Selby & Corte, 2010). Assessment parameters include:…”

“…Auscultation will distinguish among normal, hyperactive, and absent bowel sounds. Palpable masses-particularly left-sided (descending colon)-must be examined by deep palpation to distinguish stool (which indent) from tumors (which do not; Clemens et al, 2013;Librach et al, 2010). A fecal mass with gas trapped in the bowel may feel like crepitus, and percussion may differentiate ascites and a gas-filled bowel.…”

“…Patients who have sharp, knifelike pain during the examination may have mucosal injury (Costilla & Foxx-Orenstein, 2014). A dilated rectum or no palpable stool in the rectal vault may indicate higher constipation in the sigmoid colon (Hussain et al, 2014;Librach et al, 2010). Hard, dry stool in the rectum with fecal impaction directs the first management step: elimination of impacted stool before starting oral laxative therapy (Clemens et al, 2013).…”

Opioid Induced Constipation Part I: Established Management Strategies #294

“…8 However, there is no specific evidence in favor of any of these interventions to treat OIC, and adherence may be challenging for chronically ill patients.…”