Constipation is the infrequent (relative to the patient’s normal bowel habits) or difficult passage of small, hard stools.
It is commonly associated with inability to defecate at will, discomfort or straining when defecating, bloating and a sensation of incomplete defecation.
This can lead to distressing complications such as pain and bleeding from haemorrhoids and anal fissure, urinary retention and infection, nausea and vomiting, and potentially bowel obstruction. Therefore, it is essential to ensure regular bowel movements to promote comfort and quality of life.
Common causes of Constipation
|Functional||Reduced mobility, decreased food intake, generalised weakness|
|Medications||Opioids (e.g. morphine, tramadol), some antidepressants and antiemetics, calcium and iron supplements|
|Pain||Haemorrhoids, anal fissures|
|Medical conditions||Dehydration and electrolyte imbalances, spinal cord compression, Parkinson's disease, hypothyroidism|
Intestinal obstruction due to intestinal/ pelvic tumours, peritoneal diseases, adhesions
Management of Constipation
- Encourage intake of fluids and high-water content foods e.g. soups, jelly, yoghurt
- Not advisable to consume high fibre foods when fluid intake is <1.5 L per day
- Encourage patient mobility
- Encourage toileting in the morning 20 minutes after breakfast due to powerful gastro-colic reflex
- Common practice to combine an osmotic laxative with a stimulant laxative to ensure regular bowel movement
- Osmotic laxatives draw fluid into intestines and soften faeces e.g. Lactulose, Macrogol (Forlax), Saline enema (Centa)
- Stimulant laxatives directly act on intestinal smooth muscle to stimulate peristalsis e.g. Senna, Bisacodyl suppository (Dulcolax)
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 of Systematic Reviews 2015; 5: CD003448.
Clemens KE, Faust M, Jaspers B, Mikus G. Pharmacological treatment of constipation in palliative care. Current Opinion in Supportive and Palliative Care 2013; 7: 183-91.
Larkin PJ, Sykes NP. The management of constipation in palliative care: Clinical practice recommendations. Palliative Medicine 2008; 22: 796-807.
Librach SL, Bouvette M. Consensus recommendations for the management of constipation in patients with advanced, progressive illness. Journal of Pain and Symptom Management 2010; 40: 761-73.
Article contributed by Palliative & Supportive Care.