ABC of palliative care: Constipation and diarrhoeaBMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7118.1293 (Published 15 November 1997) Cite this as: BMJ 1997;315:1293
- Marie Fallon,
- Bill O'Neill
Prevalence of constipation
Infrequent hard stools
Feeling of incomplete evacuation
Symptoms of complications
Nausea and vomiting
Constipation can be defined as the passage of small hard faeces infrequently and with difficulty. Constipation is more common in patients with advanced cancer than in those with other terminal diseases, and many of the associated symptoms may mimic features of the underlying disease. About half of patients admitted to specialist palliative care units report constipation, but about 80% of patients will require laxatives.
Assessment of constipation
Assessment of constipation must include establishing in what way the present pattern of bowel movements is different from the normal pattern and a physical examination, including general observation, abdominal palpation, and rectal or stomal examination
An accurate history is essential for effective management. Inquiry should be made about the frequency and consistency of stools, nausea, vomiting, abdominal pain, distention and discomfort, mobility, diet, and any other symptoms. In patients with a history of diarrhoea, care should be taken to distinguish true diarrhoea from overflow due to faecal impaction.
Careful questioning about access to a toilet or commode is important. Limited mobility may mean that using the toilet or commode is avoided. Other issues, such as lack of privacy or the need for nurses or carers to help with toileting, can exacerbate constipation.
A constipated patient may have malodorous breath, or the smell of faecal leakage may be obvious. Bacterial degradation of hard stools can result in leakage, of which the patient has no warning. General observation may reveal that a patient is in pain, confused or disorientated, or unable to reach the toilet. Abdominal distension, visible peristalsis, and borborygmi can suggest obstruction.
Palpation may reveal an easily palpable colon with indentable and mobile (and rarely tender) …