Bowel problems

Recognise

Constipation is one of the most common symptoms of advanced disease and can be physically uncomfortable and emotionally distressing.

Factors relating to advanced illness that can influence constipation are:

• medications especially opioid analgesics and anticholinergic medications
• limited mobility
• neurological illnesses especially dementia, stroke, depression, Multiple Sclerosis and Parkinson’s Disease
• electrolyte disturbances in advanced cancer, especially hypercalcaemia
• general disability
• low caloric or fibre intake due to reduced appetite or interest in food
• not recognising the need to defecate
• lack of assistance to access a toilet.

Approximately one-third of people taking opioids for pain will decrease or discontinue their opioids due to opioid-induced constipation.

Constipation reduces quality of life and can cause:

• pain
• delirium
• changes in behaviour
• urinary retention
• faecal impaction and/or faecal incontinence
• bowel damage.

Assess

The goal of assessment is to confirm the symptoms the person is experiencing and identify any treatable causes. Look for signs of emergencies such as bowel obstruction, spinal cord compression or gastrointestinal bleeding (see Red Flags above).

People given opioids will commonly be prescribed laxatives at the same time. Laxatives function as a:

• stool softener,
• osmotic agent (attract water to the stools),
• stimulant, or lubricant

Constipation means different things to different people, so it is important to find out what the person or their carers mean by constipation. Find out what is normal for the person and what changes they are experiencing. Ask about bowel habits, straining, bloating, pain, nausea, vomiting, diet, fluid intake, medications (regular and new), and access to a toilet.

If appropriate and the person consents, a digital rectal examination can be performed by someone who is qualified. This helps identify faecal impaction, haemorrhoids, or skin problems around the anus. If the person has a stoma, someone qualified can examine the stoma to assess for faecal impaction.

An X-ray may be requested to confirm constipation or faecal impaction, however, its usefulness in assessing these in people with advanced cancer is not supported by evidence.

Constipation can be a side effect of medicines. This includes opioids, serotonin (5HT3) blocking antiemetics like ondansetron, anticholinergics, calcium, and iron tablets. It may help to have the doctor or pharmacist review the person’s medicines.

Bristol Stool Chart is a visual aid based on seven stool types.

Manage

Ways to help the person manage constipation include:

• encouraging them to use the toilet regularly at the same time each day and to take advantage of the gastrocolic reflex that occurs after eating
• ensuring the person has adequate privacy
• ensuring the person has good fluid intake
• optimising the amount of fibre in the person's diet, if possible, e.g. drinking prune or pear juice
• encouraging general activity by good control of other symptoms, e.g. pain, dyspnoea
• treating problems such as haemorrhoids or an anal fissure.

People given opioids will commonly be prescribed laxatives at the same time. Laxatives function as a

• stool softener,
• osmotic agent (attract water to the stools),
• stimulant, or
• lubricant.

A combination of a stool softener and a stimulant laxative is the best initial choice for the management of constipation in a palliative care patient.

However, natural laxatives such as bran work by increasing fibre and stool bulk and may not relieve constipation in a palliative care patient. The increased bowel transit time and likely poor fluid intake of palliative patients often results in hard dry faeces and in this situation use of bulk-forming laxatives can even worsen constipation.

The person may require more than one type of treatment. It can take a while for them to work so reassure the person during this time.

Monitor the person's bowel habit carefully if they are taking laxatives. A dose that is too high can cause diarrhoea.

Suppositories and enemas may be given for severe constipation, especially if the person is unable to take laxatives orally.

In the case of faecal impaction, a combination of laxatives, suppositories and enemas may be needed.

Recognise

Diarrhoea can be a debilitating and embarrassing symptom for both the person and their carer(s). Recognising how diarrhoea affects the person can help in planning care to improve their quality of life.

Assess

As with constipation, the person or their carer can understand diarrhoea in different ways.

The goal of assessment is to confirm the symptoms the person is experiencing and identify any treatable causes. Also look for signs of emergencies requiring specialist treatment like faecal impaction.

Assessment questions should include:

• frequency of defecation, usual and any recent change
• nature of stools including consistency, colour, presence of mucous or blood
• current and recent medications such as laxatives, broad spectrum antibiotics.

Check:

• for dehydration (see “Assessing for dehydration in adults” in Resource)
• the person’s skin condition especially for people who are bed-bound.

Bristol Stool Chart is a visual aid based on seven stool types.

If appropriate and the person consents, a digital rectal examination can be conducted by someone who is qualified. This helps identify faecal impaction, a common cause of overflow diarrhoea. An X-ray may be requested to confirm faecal impaction, however, its usefulness in assessing constipation or faecal impaction in people with advanced cancer is not supported by evidence.

Manage

In the case of frequent diarrhoea, arrange access to a toilet or equipment such as bedside commode or bedpan.

It is important for the person with diarrhoea to stay well hydrated. Provide frequent sips of clear liquids, oral rehydration solutions with sodium chloride and sugars, like sports drinks or soups. Intravenous (IV) or subcutaneous fluids may be needed with severe diarrhoea.

Teaching and assisting in good skin care is important. The skin should be clean and dry to limit skin irritation related to moisture. Barrier products can be used to reduce skin breakdown but care should be taken to avoid products that are difficult to remove.

Provide the person and their carer with information about causes and treatments for diarrhoea.
Common foods to avoid include dairy products, caffeine and alcohol, foods with high sugar or sorbitol, high-fibre legumes (raw vegetables), high-fat foods, spicy meals. If appropriate recommend the person eats frequent, small meals rather than few large meals.

Medication may be used to reduce bowel motility (peristalsis) and/or improve stool consistency.

Recognise

There are several types of faecal incontinence:

• Urge incontinence, the person gets the urge to empty their bowels but with little warning
• Wind (flatus) incontinence, the person cannot tell whether they need to pass wind or stool
• Passive incontinence, the person does not know when they need to empty their bowel or that they have emptied their bowel
• Anal and rectal incontinence – when the muscles or nerves in the rectum and anus are damaged, causing leaks
• Overflow incontinence, if the person is constipated and the bowel is blocked with hard stool, watery stool can leak around the blockage. This can be mistaken for diarrhoea.

Assess

The goal of assessment is to confirm the symptoms the person is experiencing and identify any treatable causes. Also look for signs of emergencies requiring specialist treatment like faecal impaction.

Assessment questions should include:

• frequency of incontinence
• urgency suggests a diarrhoeal illness
• constant passive leakage suggests overflow incontinence from faecal impaction or faecal incontinence because of defaecatory dysfunction
• nature of stools including consistency, colour, presence of mucous or blood - use the Bristol Stool Chart 
• associated symptoms (e.g. constipation, pain or straining, rectal bleeding)
• effect on lifestyle (e.g. distress, withdrawing from social interactions) and hygiene
• cognitive status, mobility, visual acuity, manual dexterity, access to toilet and carer assistance.

A skin assessment is important as faecal incontinence can compromise skin integrity especially in those with impaired mobility.

If appropriate and the person consents, a digital rectal examination can be conducted by someone who is qualified. This helps identify faecal impaction. It can also assess anal sphincter tone (i.e. resting and squeeze pressure). This may be difficult or impossible in older people with cognitive impairment or in those who are unable to squeeze on demand.

Manage

Speak to the person, and the people close to them if they wish, about how they would like to manage their symptoms.

Options for managing bowel incontinence include:

• disposable absorbent pads worn inside underwear
• disposable bed pads
• anal plugs, if tolerated, to help prevent leaks
• medicines to treat diarrhoea or laxatives to treat constipation.

Recognise

Bowel obstruction is common in people with cancer particularly of the ovary or bowel. Malignant bowel obstruction can be from an intrinsic cause (e.g. colon disease), extrinsic compression (e. g. tumour mass, post-surgical adhesions), or from peristaltic dysfunction (e.g. due to ovarian cancer). It may be a combination of these.

It is responsible for symptoms including nausea, vomiting, abdominal distension, colic, pain, and constipation. Consequently, it has a profound impact on quality of life of the person and their carers. It often requires hospitalisation.

A malignant bowel obstruction has a poor prognosis.

Assess

Assessment should include a careful discussion of symptoms particularly pain, nausea, vomiting and bloating (onset, frequency, quality, and intensity), bowel movements and whether the person can still eat or drink.

Abdominal examination will focus on abdominal distention, palpable mass(es), localised tenderness and bowel sounds. (see video in Resources)

A suppository or enema may be used to empty the rectum before confirming a diagnosis of bowel obstruction.

A plain X-ray can be used to differentiate between high and low bowel obstruction.

Manage

If the obstruction is single and localised and the person’s health is good enough, surgery may be performed to remove a tumour. This option is considered along with a person’s quality of life and prognosis.

Steroids may be used to reduce tumour oedema and therefore reduce compression.

With a short prognosis, nurses may be involved in helping the person come to terms with their prognosis and options for care. This may include a referral to palliative care.

Medicines might be prescribed to reduce pain, colic, nausea, and vomiting. Oral medications may not be feasible or absorbed, so syringe driver or medication patches may be used.