Managing The Tough Times

For the past few days, Chang has been eating little and not sleeping well. Besides pain, he is also struggling with severe constipation. He has not had a bowel movement for the past 14 days.

(Before writing about this topic, I asked him if he really wants me to post about his constipation problems and he said yes, so here goes....)

Constipation is a common and frequently troublesome symptom in patients with advanced cancer. Despite its prevalence, constipation can still be an overlooked symptom, which often receives little attention until significant problems occur. Often, multiple causative factors are present:-

o Reduced food (including fibre) and fluid intake

Patients with advanced cancer often have a reduced appetite for a variety of reasons, with fibre in particular being difficult to tolerate: 

-  Some tumours produce chemical substances that suppress appetite.

- The slowdown of many bodily functions including gastric emptying, which results in early satiety and decreased hunger;

- Nausea and/or vomiting are associated with an aversion to food;

- Oral pain when attempting to eat and drink. Possible causes include oral thrush, mouth ulcers, mucositis;

- Only able to tolerate a low residue diet and are too weak to chew for any length of time

o Reduced abdominal and pelvic muscle power

Patients with advanced malignancy who are too weak to give the push necessary for defecation. 

o Reduced mobility

  

o Constipating drugs
(e.g. opioids, drugs with anticholinergic action, antagonist anti-emetics, iron). Opioid use is strongly associated with constipation in patients with advanced cancer. Opioids have a constipating effect whether given orally, sub-cutaneously or transdermally, although the incidence of constipation may be reduced with non-oral administration

 o The cancer itself

 If a tumour is pressing on the nerves in the spinal cord, it can slow down or stop the movement of the bowel and so cause constipation. Tumours in the abdomen can compress, squeeze, or narrow the bowel and rectum making it difficult to have a bowel motion. Or a tumour in the lining of the bowel can affect the nerve supply to the muscles and cause constipation

 

o Environmental factors

Environmental factors should not be overlooked. Patients unable to get to the toilet unaided may be reluctant to ask for assistance due to embarrassment or a desire not to bother their caregivers.

Treatment of Constipation

Oral measures such as laxative therapy are usually the firstline treatment of constipation. However, rectal measures such as suppositories and enemas can bring about quick results. An enema is a liquid that is squirted into the rectum and colon via the anus whereas a suppository is an easily melted pill or capsule inserted in the rectum.

In  Chang's case however, laxatives have not worked. In cases of constipation it is important not to wait if there is no bowel movement for a few days. He told me that he was too embarassed to accept help during an earlier visit to the hospital. (when a nurse asked him if he wanted an enema administered). So, during his recent stay at the hospital last week,  he asked for assistance and this time, the nurse administered the enema for him but it was unsuccessful. Back home, he has tried what he calls the "tin mining approach" ie using water to spray up the anus but has still not been successful.

The Hospis Malaysia nurse will be visiting tomorrow. Hopefully, there will be a breakthrough.

(Updated by Chang's friend)