Symptom Specific Services

Constipation
• Will I experience constipation during cancer treatment?
• What can I do to prevent constipation?
• How can constipation, especially narcotic-induced constipation, be treated?
• When should I call my doctor?

Will I experience constipation during cancer treatment?
Constipation is a decrease in the number of bowel movements and/or the difficult passage of hard stool. This often causes pain, discomfort and sometimes bleeding from the rectum. It can be caused by too little fluid and not enough movement in the bowel.

In patients being treated for cancer, constipation can be caused by poor food and fluid intake, decreased activity and weakness. Certain medications, especially pain medications and certain chemotherapy drugs, can also cause constipation. Sometimes the cancer itself, particularly cancers in the gastrointestinal tract, can cause constipation.

The signs and symptoms of constipation include:

• Small, hard bowel movements

• No regular bowel movement after three days

• Leakage of small amounts of soft stool (such as diarrhea) from the rectum

• Frequent and/or persistent stomachaches or cramps

• Passing large amounts of gas or frequent belching

• Blown-up or enlarged belly

• Nausea and/or vomiting

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What can I do to prevent constipation?
There are a variety of things you can do to prevent or minimize constipation, including increasing the amount of high fiber foods in your daily diet. Some examples of these foods are:

• Fresh raw vegetables

• Fresh raw fruits, especially those with skins (pears and plums) and seeds

• Bran, whole grains and cereals

• Dried fruits, especially dates, prunes and apricots

• Prune juice

Avoid or decrease your intake of foods that can cause constipation. These foods include:

• Chocolate

• Cheese

• Eggs

• Bananas

• Rice

• Apples and applesauce

Increase your fluid intake. Not only will this help prevent or minimize constipation, but it also will help prevent dehydration and malnutrition. Try to drink three quarts of fluid per day, unless your doctor or nurse tells you not to.

Your doctor may recommend over-the-counter laxatives, stool softeners, or enemas, but remember that you should not take any over-the-counter medications while receiving chemotherapy without first talking with your doctor or nurse. Specific fluids to drink include:

• Fresh fruit juices, except apple or grapefruit juice

• Warm or hot fluids, especially in the morning

Increase your physical activity as much as possible. Even short walks will help decrease constipation. It is important, however, that the level of activity does not cause you to become overly tired or physically exhausted.

Allow adequate time and privacy for using the toilet. Some patients are unable to defecate in a public bathroom and will wait until they get home. Likewise, hospitalized patients may find it difficult to defecate. Holding the stool in the large bowel can lead to water reabsorption, which causes the stool to be hard and more difficult to pass. You should plan time for bowel movements.

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How can constipation, especially narcotic-induced constipation, be treated?
For patients taking medication with narcotics, constipation is always a problem. Opiate narcotics can decrease contractions that help move the stool downward. Lack of contractions means that the stool remains in the colon, where it becomes dry and hard. Various medications, given both orally and rectally, as well as enemas, can help reduce constipation.

The treatment of narcotic-induced constipation should include, when possible, the use of preventive strategies to avoid constipation. However, preventive strategies alone will not be sufficient for patients taking opiate narcotics. The choice of treatment strategy will depend on the underlying cause of the constipation and its severity.

• Several types of medications are available for treating constipation, including:

Emollient or lubricant cathartics
Emollient or lubricant cathartics, such as docusate sodium, soften stools. Brand names of docusate sodium include Surfak and Colace. Glycerin suppositories also are a type of lubricant. Mineral oil may not be the best choice, because of its tendency to wash out fat-soluble vitamins.

Bulk cathartics
Bulk cathartics increase mass and soften stools. Several over-the-counter bulk cathartics, such as psyllium (brand name: Metamucil), are available.

Stimulant carthatics
Stimulant cathartics promote spontaneous movement of the intestines, which is the action that opiates suppress. These products are available for both oral and rectal administration. Examples include the senna-based Senokot and bisacodyl (brand name: Dulcolax). These stimulants can cause some cramping and may be unacceptable for that reason. Spreading the dose out over the day, or taking small doses with each meal and a slightly larger dose at bedtime, may diminish this effect.

Osmotic Laxatives
Two commonly used osmotic laxatives are disaccharides and saline cathartics.

Disaccharides (brand names: Lactulose and Sorbitol) exert an osmotic effect because they are not absorbed or metabolized in the small bowel. This increases bulk via fermentation in the bowel. Unfortunately, disaccharides may cause cramping, abdominal distention, and flatulence. In addition, disaccharides are usually in a liquid form and are not palatable to some people.

Saline cathartics pull fluid into the bowel to increase the weight of the stool and soften it. An example is Milk of Magnesia.

• Combination Agents
Some pharmacologic agents are available in combinations. For example, senna, a stimulant, is combined with docusate sodium, a stool softener, and sold as Senokot-S. This particular combination is recommended for narcotic-induced constipation because it helps overcome the specific problems caused by narcotics.

• Enemas
If you have impacted fecal matter, an enema may be the only way to break it up and wash it out. Once the impaction has been removed, however, enemas should be used sparingly. They tend to wash out the normal mucus in the colon, which provides lubrication for stools. Enemas should be considered as a last resort rather than part of routine treatment.

• Conclusions
Constipation is common in people with cancer, particularly among patients receiving opiate narcotics. Unfortunately, constipation is often overlooked and undermanaged, and it can become serious. Although constipation may seem like a minor complication when compared to a life-threatening disease such as cancer, it can become a major detriment to your quality of life if it is not well managed.

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When should I call my doctor?
Call your doctor if you have one or more of the following:

• No bowel movement in three days.

• Blood in or around the anal area, in the stool, on the toilet paper, or in the toilet bowl.

• No bowel movement within one day of taking a laxative prescribed by your doctor.

• Persistent, severe cramps in the lower abdomen, and/or vomiting.

• Not passing any gas from the rectum.

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