Clinical Review

ABC of palliative care: Constipation and diarrhoea

BMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7118.1293 (Published 15 November 1997) Cite this as: BMJ 1997;315:1293
  1. Marie Fallon,
  2. Bill O'Neill

    Prevalence of constipation

    Constipation

    Definition
    • Infrequent hard stools

    Associated symptoms
    • Flatulence

    • Bloating

    • Abdominal pain

    • Feeling of incomplete evacuation

    Symptoms of complications
    • Anorexia

    • Overflow diarrhoea

    • Confusion

    • Nausea and vomiting

    • Urinary dysfunction

    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

    History

    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.

    Examination

    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.

    Radiograph of constipated patient showing stool masses and trapped gas

    Palpation may reveal an easily palpable colon with indentable and mobile (and rarely tender) …

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