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Constipation in the oncology patient

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Constipation is a common problem in oncology. Treatment is more aggressive than in other children due to the ongoing nature of the underlying causes and the inability of many patients to comply with basic measures such as diet, exercise and adequate fluid intake. This guideline covers the basic causes of constipation in oncology and offers a treatment schema for patients.

Enemas are contraindicated when the patient is neutropenic.

If there are concerns that the constipation is not improving or that it is related to a serious underlying pathology please contact the oncology unit.

Cause

Constipation is most likely to occur during treatment with:

  • weak or strong opioid drugs, or
  • vincristine (particularly when it is administered weekly).

Other factors such as inactivity, poor nutrition, poor fluid intake, hypercalcaemia and hypokalaemia may also be implicated. Occasionally, pressure from abdominal tumours or nerve root pressure may be the cause.

Psychological factors can also play a part in some children. Some may feel shy or uncomfortable in the hospital environment. Others may be reluctant to defecate if they have had previous pain from chemotherapy induced diarrhoea.

First take a history (including bowel habit prior to diagnosis) and examine for evidence of faecal loading. If indicated by tumour type, do lower limb neurology and anal tone. If the child complains of pain, examine the anus for fissures or infection.

Assessment

A record of bowel habit should be recorded by the parents on a bowel chart daily. If there are hard faeces or no bowel motions for > 48 hours, then a history of prior bowel habit and abdominal examination for faecal loading should be performed by the medical staff. In younger children, the visual pain scale can be utilised.

Rectal examination should not be routinely performed, but should be considered by an experienced person if there is suspicion of neurological deficit. Anal examination should be performed in children complaining of pain on defecation,or non-verbal children, to look for fissures and infection. Abdominal X-ray is not usually necessary as history and examination usually suffice, but may be needed in selected situations after discussion with the treating consultant.

Prophylaxis

Laxatives should always be prescribed prophylactically for children on opioids and those receiving weekly vincristine. They should also be considered for children on prolonged bedrest.

Families should be given advice on general measures to avoid constipation starting, such as:

  • adequate fluid intake
  • high fibre diet
  • fruit juices such as kiwicrush or prune, pear or apple with sorbitol
  • exercise.

Initially, prophylaxis for constipation can start with lactulose. If this is not effective or is not tolerated, then movicol should be added or substituted. Patients on vincristine may benefit from the addition of a stimulant laxative such as senna, but its use should be reviewed regularly, as it is not suitable for long-term use. See Doses of Laxatives below.

Treatment

If there have been no bowel motions for > 48 hours or hard faeces, then lactulose should be initiated regardless of symptoms (unless this is the child's normal bowel habit pre treatment) to prevent the development of faecal impaction (movicol should be used if lactulose is not tolerated). If there is no result in 48 hours or if there are worsening symptoms, then movicol should be added. If there is still no result, then senna or paraffin should be added or Faecal Disimpaction protocol instituted.

If the child presents constipated with colicky abdominal pain or having no bowel motions for a week, then institute the Faecal Disimpaction Protocol rather than starting with lactulose as this is usually ineffective in this setting. Start prophylactic therapy after there has been a bowel clearout.

Doses of Laxatives

Lactulose
Starting dose: 0.5 ml/kg/ dose 12 - 24 hourly. Maximum 45 ml/dose 
(please note: ensure teeth are brushed after taking this)
Movicol (polyethelene glycol, sodium bicarbonate, sodium chloride, potassium chloride) 
Starting dose 1 sachet of paediatric movicol or ½ adult sachet. Not recommended in < 2 years.  
> 12 years  1 sachet increase to bd or tds as required 
> 2 years  ½ sachet (or 1 paed sachet) increase to bd or tds as required in older children 
For faecal disimpaction see protocol below  
Docusate sodium (Coloxyl™)
oral total daily dose is 5 mg/kg 
use 1 - 3 times daily. Use in larger doses initially, then reduce. 
Bisacodyl (Dulcolax™)
  Oral  PR 
< 12 mo  2.5 mg   
1-5 yrs  5 - 10 mg  5 mg 
> 5 yrs  10 - 20 mg  0 mg 
Senna (not funded)
7.5 mg tablets. Dose is once daily.  
6 mo - 2 yr  1/2 - 1 tab 
3 - 10  1 - 2 tabs 
> 10  2 - 4 tabs 

Faecal Disimpaction Protocol

 faecal disimpaction

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Document Control

  • Date last published: 06 May 2016
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network
  • Owner: Ruellyn Cockcroft
  • Review frequency: 2 years