Constipation

Constipation in people with cancer — infrequent, incomplete and/or difficult bowel movements — can be caused by a number of factors. The most common causes are the cancer itself, cancer treatment, medications, diet, dehydration (loss of water or fluids), and lack of physical movement.

Constipation must be treated — and as a person with cancer, it should not be managed by you, alone. It's a task for your health care team. Now is not the time for home remedies, experiments with laxatives, or the use of an enema, unless you are specifically instructed to do so. Don't think that constipation isn't important, will go away by itself, or is not worth treating. Left unmanaged, constipation is both very painful and dangerous to your health, sometimes leading to serious complications.

Let your health care professionals know at once if you go more than three days without a bowel movement, or if your constipation is accompanied by nausea or other troubling symptoms, such as blood in your stool or in the rectal area.

Symptoms

The National Cancer Institute patient materials describe constipation symptoms this way:

• No regular bowel movement for three days
• Small, hard stools that are difficult to pass
• Urge to strain, feelings of rectal pressure, abdominal fullness, or bloating
• Stomach aches or cramps
• Vomiting and nausea
• Abdomen appears swollen or distended
• Passing an excessive amount of gas or belching frequently
• Leakage of small amounts of soft stool resembling diarrhea.

You may have one or more of these symptoms.

Prevention

The best way to avoid constipation is to take action steps to prevent it. Check with your physician or health care team about the suggestions below:

1. Drink plenty of fluids — at least 8 to10, 8-ounce glasses daily, unless your physician tells you not to do this. Fluids help keep stool soft. Some people find it helpful to drink a hot beverage about 30 minutes before the time of day you usually move your bowels.
2. Exercise helps, by keeping the intestinal tract working properly. Walking is recommended; discuss the amount of walking that would be best for you with your health care providers. If you are unable to walk, consider simple abdominal exercises in bed, or in a chair.
3. Keep a record of your daily bowel movements. Also track the times of day when you usually eat and drink, and what you consume. This information can be very useful to your health care team in analyzing and helping to relieve your constipation.
4. Use the bathroom in timely manner. It's important to respond to your body's urge for a bowel movement; don't resist this impulse. Many people experience this urge following breakfast, or after a meal. If lack of privacy is interfering with your ability to have a bowel movement, ask your health care provider to help find a private setting for you.
5. Add fiber to your diet — gradually, beginning with a few ounces, and adding a little more every few days, rather than converting your entire diet to high-fiber foods all at once. The most pleasant way to add fiber is by eating more fruit and vegetables. Consider eating whole grain cereal (including bran cereal), brown rice and nuts. If bran cereal isn't a favorite, try sprinkling some bran on other cereal, and topping it with fruit. Be sure to increase your fluid every day as you increase fiber in your diet, to keep the fiber you eat soft and easily eliminated from your body.
6. Take preventive measures if you are taking an opioid-based pain medication; ask your health care professional if you aren't sure. A bowel regimen for all patients taking opioid-based pain medications (these pain medications can slow down the action in the intestinal tract) is recommended by the National Cancer Institute.

Your health care team may recommend a variety of treatments, depending on your individual needs. Make sure to discuss your pain medications and possible constipation with your health care team, preferably before you begin taking opioid-based pain medication.

Treatment

Your health care team will talk with you about your constipation. Do not be embarrassed about discussing direct questions about your normal bowel habits, your eating habits, how much fluid you drink, your use of laxatives or enemas, exercise amounts, and what medications you are taking. You may also be given a physical examination, including a digital rectal examination. This is done to determine whether or not you have a fecal impaction (stool hardened and collected in your rectum).

The next steps will probably include all of the prevention steps listed above, and your physician may recommend medication to help, as well. These might include stool softeners, or a stool softener and a stimulant laxative, if you are taking opioid-based pain medicine. It is likely that you will be directed to take a specific amount of softener and/or laxative to start, and the dosage will be adjusted until the constipation is well-managed. In some cases, your physician may recommend the use of a rectal suppository or an enema. If the medication and treatment prescribed for you is not effective within a day or two, contact your health care professional.

Some people who have been using laxatives very often for many years may not respond well to the standard treatments for constipation. This can also be true for patients whose illness has made them bed-ridden. Your health care team will use more aggressive treatments if you fit either of these descriptions.

Caution: cancer patients should never use an enema or suppository without specific instructions from your health care provider.

There are also some new medication possibilities being tested now that have the potential to help. Ask your physician about these.

Impaction. Fecal, or stool, impaction occurs when all of the stool does not leave the body during a bowel movement, or when bowel movements are not occurring regularly. Hardened stool in the rectum continues to absorb water, becoming even larger and more difficult to pass.

Impaction can be caused by many of the things that cause constipation, and also by the overuse of laxatives, which can make the colon less and less sensitive to the stimulus for a bowel movement.

Symptoms of impaction can be the same as symptoms for constipation, and include others as well:

• Back pain (the impaction may be pressing on a nerve)
• Increased or decreased urge to urinate (the impaction is pressing on the bladder)
• Shortness of breath can occur if a bloated abdomen presses on the lungs

Treating impaction. Again, this is not to be treated with home remedies. A possible impaction should always be verified and then treated by a health care professional. Don't attempt enemas or other remedies unless told to do so by your physician. Self-use of enemas can further injure an already-irritated bowel and rectum.

If impaction is present, your health care team will work to soften your stool so that it can be more easily removed or passed out of your body. This may be done with water, oil or other materials, possibly in the form of an enema or suppository. Additionally, you may be asked to use bowel-softening medications to help soften stool higher up in the colon.

Questions for Your Doctor

In treating constipation, your health care team may include an oncologist, registered dietician and nurse.

1. What other information from me will be helpful to you in managing my constipation?
2. Might any of the medications prescribed for me possibly cause constipation? (Consider medications used in chemotherapy, pain management, sleep aids, tranquillizers, some forms of calcium, anti-nausea medications, antidepressants, antacids and diuretics.) What is the best way to manage this?
3. Are there exercises that you would recommend for me?
4. How much dietary fiber is right for me? What foods are high in fiber? And should I consider supplements?
5. If I must take a stool softener and/or a laxative because of some of the mediations I already take, what are your specific recommendations?
6. Are there any symptoms or reactions to treatment for my constipation that should prompt me to call you immediately?
7. How long is my constipation likely to last?

More Information

Commonly Used Medical Agents for Constipation

• Bulk Producers — include dietary fiber, bran and methyl cellulose. They work with the body's natural processes to hold water in the intestinal tract, soften stool, and increase the frequency of the passage of stool. Bulk laxatives (such as Fiber-Malt, Maltsupex, and Metamucil) are not recommended for use in a bowel regimen to counteract the bowel effects of opioids.
  • Bulk laxatives may take as long as 72 hours to begin working.
  • Bulk laxatives always must be taken with two 8-ounce glasses of water to avoid the development of a bowel obstruction.

• Saline laxatives — these agents, such as milk of magnesia and magnesium citrate, draw fluid into the intestines, which in turn alters stool consistency, expands the bowel, and triggers the urge to pass stool.
  • These can begin working within a half hour to three hours.
  • Repeated use can cause electrolyte imbalance in the body. They should not be used in patients with kidney dysfunction, edema, congestive heart failure, megacolon (extreme dilation and enlargement of the colon), or high blood pressure.

• Stimulant laxatives — these impact the intestines directly, and may cause cramping.
  • They become effective within 6 to 10 hours.
  • Prolonged, repeated use of these medications can cause laxative dependence and reduction or loss of normal bowel function.
  • These are generally taken on an empty stomach at bedtime, and are sometimes used to help ease bowel movements in patients who should not strain to move their bowels.

• Lubricant laxatives, usually mineral oil, lubricate the lining of the intestine and soften stool. This kind of laxative is usually taken on an empty stomach, at bedtime.
• Stool softeners, such as Coalace, promote water retention in the stool, and soften the stool.
  • They are slow to work — several days may pass before an effect is seen.
  • Softeners are often used in combination with stimulant laxatives
• Laculose (such as Chronulac) soften stool in the colon by increasing the amount of water in the stool.
  • Takes 24-48 hours to begin working
  • Laculose should not be given if impaction or obstruction is suspected.

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James & Marcia Foley

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