Constipation is the decreased frequency or absence of bowel movements. Common causes include medications such as opiates and anticholinergic drugs; certain illnesses that can cause delayed emptying such as multiple sclerosis and Parkinson’s; chemical imbalances such as hypercalcemia and hypokalemia; or reduced oral intake and reduced activity.
- Assessment Constipation can be subjectively assessed, like all symptoms, by using the PQRSTU mnemonic (see Symptom Assessment) or other numeric scales such as the ESAS (see Symptom Assessment). Further assessment should include questions about usual bowel pattern and frequency that is acceptable to the patient. The presence of nausea and/or vomiting is also an important assessment. Questioning about whether stool is hard to pass or whether bowels are moving at all can guide the clinician in treatment.
- Treatment The goal in the treatment of constipation is prevention. As not all persons with serious illness may be able to manage based on the extent of disease, a patient-centric approach to encouraging adequate activity, fluids and oral intake may be helpful. Other nonpharmacologic interventions include warm fluids such as coffee or tea. A small glass of warmed prune juice mixed with apple juice works for many people. There are many different types of laxatives; selection of which laxative or combination of laxatives to use should be based on assessment. Consult an evidence-based guideline for further information in the palliative treatment of constipation.
Due to the action opiates exert on mu receptors in the intestinal tract, constipation is a common and unrelenting side effect. Because of this, all those started on opiate therapy should be concomitantly started on a bowel regimen and closely monitored. The exception would be for those who are experiencing too-frequent bowel movements. For the patient with refractory constipation despite an aggressive bowel regimen, consideration should be given to opioid rotation. Morphine is known to cause difficulties in managing constipation. As well, there is a newer class of medications that target the mu receptors in the intestinal tract while maintaining the desired analgesic action of the centrally acting mu receptors; these medications include methylnaltrexone and naloxegol. Referral to a palliative care specialist is recommended for the management of refractory constipation in thosewith serious illness on opiate therapy.
Clinical Practice Guidelines
- Fast Facts
- Fraser Health
- Agency for Healthcare Research and Quality
- Consensus recommendations for the treatment of constipation in patients with advanced, progressive illness
- National Comprehensive Cancer Network (requires free registration)
- Erichsen, E., Milberg, A., Jaarsma, T., and Friedrichsen, M.J. “Constipation in Specialized Palliative Care: Prevalence, Definition and Patient-Perceived Symptom Distress.” Journal of Palliative Medicine 18 no. 7 (2015): 585-592.
- Kuebler, K. K., Heidrich, D. E., and Esper, P. Palliative and End-of-Life Care: Clinical Practice Guidelines, 2nd ed. (St. Louis, MO; Saunders, 2007).
- Webster, L. R. “Opioid-Induced Constipation.” Pain Medicine 16 S1 (2015): S16-21
- Wrede-Seaman, L. Symptom Management Algorithms: A Handbook for Palliative Care, 3rd ed. (Yakima, Washington: Intellicard, Inc, 2009).