Waikato DHB Palliative Care Guidelines

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4. Constipation

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Constipation is common in advanced disease and can cause many distressing symptoms – colicky abdominal pain, anorexia, nausea, vomiting, urinary retention, anxiety and in some elderly patients may cause confusion.

Prevention is the key, and the need to treat constipation is usually due to a failure of prevention.

It should be anticipated when patients are taking opioids or anticholinergic drugs and it is imperative in these patients to prescribe prophylactic laxatives. “The hand that charts the morphine, charts the laxatives”.

Don’t forget to discuss dietary and fluid management.

A rectal examination is recommended on all patients with constipation to decide on appropriate treatment required.

4.1 Laxatives

1. Stimulant/Softener combinations

Commonly used in Palliative Care Laxsol™ 1-2 tabs bd. (can be increased up to 3 TDS).

2. Iso-osmotic Laxative

Movicol™ (macrogol and electrolytes) 2 sachet dissolved in250 mls of water once daily. Particularly useful for faecal impaction – can be increased to 2-3 sachets daily if needed. This requires a specialist subsidy application.

Lactulose – NOT recommended for palliative care patients as large quantities of oral fluid needed and can cause severe bloating and flatulence.

Other medications used include Coloxyl (softener) and bisacodyl (stimulant).

Note:

Stimulants are contraindicated for patients with complete bowel obstruction.
Assess bowel action daily and adjust laxatives accordingly.
Bulking agents and high fibre diets are not well tolerated by terminally ill patients.

4.2 Enemas

These will not often be required if a good bowel regime has been started.

A rectal examination should be carried out on all patients to decide on appropriate treatment required.

Use suppositories or microlax first (1- 2 bisacodyl and if very hard 1-2 glycerine). If these are ineffective then try an oil retention enema, left overnight if possible.

A Fleet™ enema (sodium phosphate) is useful once or twice but prolonged use may cause electrolyte imbalance. Care needs to be taken in administration – do not apply too much pressure.

Constipation can be an extremely distressing symptom. Please seek advice from Palliative Care service if it remains unresolved.

4.3 Severe constipation

Movicol™ first line – see above. Can use up to 4-8 sachets /day for severe faecal impaction.

Oral Fleet ™ may be required - can cause abdominal cramping and severe diarrhoea and is unpleasant for the patient to take. Start with 5 – 15mls and repeat or increase as appropriate.

Should not be used repeatedly due to risk of electrolyte imbalance (maximum of once a week is the recommended dose in conjunction with serum electrolyte monitoring).

Manual removal may be required.

Seek advice from Palliative Care service.

Information last reviewed: March 2012	Please foward any enquiries about this document to Sandra.Haggar@waikatodhb.health.nz
Next review date: March 2014	For Palliative Care advice, please call (07) 839 8691 or the specialist on-call.