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Constipation and Diarrhea - POGOe

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Constipation and Diarrhea
ElizabethWhiteman M.D.
Goals and Objectives
Diagnose GI symptoms in Palliative careAssess causes of bowel dysfunctionUnderstand bowel physiology of altered bowel movementTreatment options non pharmacologic and pharmacologicPreventionNarcotics 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 theMorphineB. Keep him NPO and place an NGtubeC. Start Metoclopramide IV around the clockD. Give him an enema and start an oral laxativeE. Call surgery to evaluate for possible obstruction
Answer D
Constipation likely due to opioidsPatients on opioids need to be on preventative treatment for constipationFull assessment of cause should be investigatedTreatment 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
ImmobilityDehydrationOpioidsElectrolyte abnormalities: hypercalcemia, hypokalemia, hypomagnesium, hypothyroid, hyperparathyroidMedications: anticholinergics, Antihistamines, TCA’s, Aluminum antacids, diureticsPoor oral intake
Bowel obstructionFecal impactionUrinary retentionTumor burdenPeritoneal diseaseTumor obstructionSpinal cord lesionsPrevious surgeries and adhesions
Secondary Side effects
PainNauseaVomitingAnorexiaBloatingDiarrhea
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 donext?
A. Order A CT scan abdomen with contrastB. Aggressively hydrateC. Check for fecal impactionD. Check a PSAE. Place NG to give lactulose
Answer A and B
Check rectal exam, rule out impactionAlso rapidly start IV fluidsCT may cause worse renal failurePSA will not add any informationAggressive 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 baselineWhat would be the next treatment to assist in his symptoms?
A. Start TPNB. Order abdominal seriesC. Start laxativesD. Hold NarcoticsE. Call surgery consult
Answer B
Order abdominal seriesPossible bowel obstruction or stool impacted higher up in colonTPN will not help symptomsLaxatives may be needed pending causeDon’t hold narcotics in a patient with history of painMay need further assessment before calling a consult
Normal Bowel function
Requires stomach and digestion, small intestinal function , colon function and defecation.
Exam
Visual- look for distentionNormal bowel soundsTenderness, Where?Fluid? AscitiesPrevious surgical scarsRectal exam
Constipation
TreatmentNon PharmacologicIncrease oral intake and fluidsIncrease mobility and activity if ableIncrease fiber and fruit juices, prunes etcPositional : commode, sitting uprightPrivacy
PharmacologicStool softenersStimulant laxativessenna, dulcolaxSaline laxativesMagnesium hydroxide, Magnesium citrate, sodium phosphateOsmotic laxativesMilk of magnesia, lactulose, sorbitol, polyethylene glycol
Bulk formingPsyllium, methylcelluloseProkinetic agentsMetoclopramideRectalSuppositories, enemas, manual disimpactionSelective mu receptor blockerMethylnaltrexone bromide
Diarrhea
More than 3-4 loose stools a dayContributes toDehydrationElectrolyte abnormalitiesMalnutritionPain and discomfortPressure ulcer risk
Causes
LaxativeBowel obstructionFecal impactionMalabsorbtionInfectionDrugs: chemo, antibioticsRadiationbleeding
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 fluidsB. Stool studiesC. Review medicationD. Rectal examE. All of the above
Answer E
All of the aboveMrs. S. symptoms are likely causing her painFinding 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
PhysiologyFluid includes PO intake, salivary, gastric, pancreatic and billiary secretionsSmall intestine absorbs about 75% fluidLarge intestine absorbs about 90% fluid
Causes
Fecal impactionIntermittent bowel obstructionTreatmentsRadiationChemotherapySurgery: gastrectomy, ileal resection, colectomyMedications: laxatives, antibiotics, sorbitolOsmotic: gtube feeding, hyperosmotic supplements
Pancreatic insufficiencyHead of pancreas tumor, post resectionMalnutritionRectal incontinence: tumor, spinal cord compression, debilityInfectionCarcinoidLactate deficiency
Treatment
GeneralStop laxativesBowel rest, bland dietTreat dehydrationReview medications, supplementsFecal impactionDisimpact
Medications
Fiber if need bulkKaopectateImmodiumTincture of opiumRadiation enteritis- usually self limitingOctreotide: chemotherapy, dumping syndrome, carcinoidPancreatic insufficiency (fatty foul smelling)Pancreatic enzymes, famotidine, loperamide
Monitor skin and perianal areaTreat any pressure ulcerZinc oxide cream to protectFrequent changing and cleaning
Summary
Constipation and diarrhea are common symptoms in palliative careAssess for patient history and review recent medications, treatmentsPrevention of constipation if on opioidsContinue ongoing monitoring throughout pt courseAvoid 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.

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Constipation and Diarrhea - POGOe