When constipation becomes an emergency for cancer patients

MD Anderson Cancer Center
Date: 9-10-12


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Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas M. D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today, our guest is Dr. Knox Todd. He is Professor and Chair of the Department of Emergency Medicine here at M. D. Anderson and our subject is somewhat delicate, but very important. We're going to talk about constipation. So Dr. Todd, constipation is a big deal with cancer patients.

Dr. Todd: It is a big deal Lisa, and cancer patients don't want to talk about it. In fact, the number one advice I would give to cancer patients is to talk to their doctors and communicate all of the symptoms that they have including constipation.

Lisa Garvin: Now constipation I know opiates, which a lot of cancer patients take for pain management opiates are a big cause of constipation, but there are others.

Dr. Todd: Certainly, cancer itself is a cause of constipation, many of our treatments for cancer cause constipation, and particularly, opiates or what people refer to as narcotics will routinely cause constipation particularly if they're taken continually for more than a few days.

Lisa Garvin: Now typically, in a cancer patient setting at least, aren't the doctors kind of anticipating this and trying to get medications to help them before constipation occurs?

Dr. Todd: I would like to think that M. D. Anderson is better than most places in terms of anticipating the consequences of all forms of treatment including opiates and I would say that our track record for anticipating problems and dealing with them proactively is actually much better than the general medical population. That being said, what I've seen as an emergency physician is patients tend not to share a lot of these things with their oncologist. I had a patient who presented to me at the Emory Emergency Department years ago and she was suffering a variety of symptoms including pain and constipation and she presented to our emergency department in great distress, I only realized at the end of the visit that she had just come from her oncologist's office. I asked if she'd shared that with her oncologist and she said, no doctor, my cancer is fine.

Lisa Garvin: So they don't think of constipation as, they think it's something they have to tough out or it's just...

Dr. Todd: Well, I think when you and I talk about constipation it's thought of as a trivial problem. We all have constipation from time to time, and I think in the cancer population, constipation means something different. It may mean that our treatments are causing some symptoms. It may mean that our cancer is getting worse and these are things that patients don't necessarily want to bring up with their oncologist in particular. If, if again, I think there is a, one of the take homes I'd love for our patients to get from this message is to do everything you can to communicate your experience to your physician. What we see in the emergency department is patients who arrive with significant others, those who care for them and are there for them in the emergency department 24x7, those aren't necessarily the same people who come in to see the oncologist in his or her office, and that difference that contrast between the messages I receive in the emergency department and those I hear my patients have told their doctors about in the office, those differences are really striking. All of us experience better health outcomes when we have social connections, that's why it's true that those with partners or married persons tend to have better health outcomes than those who are more socially isolated. In part, that's because our loved ones will help us communicate messages to doctors when they really need to get through, they'll stand up for us.

Lisa Garvin: Well now, how do people with constipation end up in the emergency room?

Dr. Todd: There are some symptoms that get so bad one cannot ignore. One of the more common reasons people come to the emergency department is because of pain, pain just too severe to ignore. Constipation can be quite painful and it can gradually progress over time to the point at which you really can't ignore it and either you or your loved one will bring you into the emergency department. I think cancer patients tend to have a heightened understanding of what progression of symptoms might mean. So whereas you and I might think of constipation as a trivial problem, it may pass, it's, so to speak, but for a cancer patient it certainly may mean that a cancer is progressing, it may be a sign of cancer progression, particularly those with colorectal cancer where the growth of a tumor in a localized area may directly lead to constipation. Those patients are going to be more cognizant of what those symptoms might mean and come to an emergency department earlier.

Lisa Garvin: But constipation can actually get to the point where it totally blocks a GI tract?

Dr. Todd: Unfortunately that's true. Constipation when it's severe can have bad outcomes. We actually see the rare, but we do see deaths related to constipation.

Lisa Garvin: And that comes from perforating the colon, I guess, an infection or?

Dr. Todd: It certainly can come from just the direct pressure in the bowel that causes poor blood flow to parts of the bowel and then a perforation. It can also, constipation can cause a variety of other problems. It can result in nausea and vomiting, vomiting associated complications can, can lead to pneumonias and other issues that can bring one to the emergency department.

Lisa Garvin: Now you wrote an article for emergency medicine where you talked about, you know, the different stages of dealing with constipation. Apparently, and I did not know this, and probably the general public doesn't, but there are actually four different kinds of laxatives that can be used to help, you know, ease constipation.

Dr. Todd: Right, there are the over-the-counter laxatives I think that people are familiar with, stool softeners, drugs like Colace that help soften the stool and make it easier to pass. There are also osmotic laxatives things like MiraLax is a commonly sold over-the-counter osmotic laxative that can be used. There are also stimulant laxatives and these include medications like Senna, that contain Senna, Senokot is one of the trade names, and then salt laxatives magnesium phosphate, magnesium citrate.

Lisa Garvin: So how do those work, I mean, do they, they're not stool softeners per se, do they like purge the bowel or how do these work?

Dr. Todd: Well, the, the stool softeners do just that. They soften stool and make hard stool easier to pass. What happens is that the longer stool remains in the colon the more water is drawn out of it and it becomes dry and hard and ultimately leads to obstruction and impaction. So stool softeners will help with that. The osmotic laxatives really do purge. Any one who has ever done a gastrointestinal prep for a colonoscopy may remember that large gallon container in the refrigerator that one takes to get ready for that procedure and so that is a, a purging laxative and salt laxatives do much the same thing. Stimulant laxatives actually stimulate the bowel to contract and help move through a stool.

Lisa Garvin: So what about home treatment, I mean, if you're an active cancer patient should, and you're having constipation, should you just go to the drugstore and get something or should you talk to your oncologist?

Dr. Todd: Well, I think it's important to talk to the oncologist to get a sense of why constipation might occur, what the cause is that may be related to cancer or its treatment what you might expect in terms of the likelihood of constipation and the underlying reasons for constipation, and these are going to be different for people with different cancers. Just as an example, someone with a lower colorectal malignancy who experiences progressive constipation that may be the first sign that the cancer is present at all or perhaps that it recurred. Patients who have had surgery in the past are at risk for scarring in the abdomen and that can cause constipation, but it can also cause bowel obstruction, which is a much more serious issue and one of the first questions we try to answer in the emergency department and in particular those who take opioids or opiates or narcotics are if they take them continuously bound to get some form of constipation and that should be anticipated. There are specific treatments for opioid induced constipation that differ from some of the other laxatives we talked about.

Lisa Garvin: What was the summary of the article that you had in emergency medicine? I know in your conclusions you were saying that there should be a lot of proactivity involved in managing constipation.

Dr. Todd: Well, I think the important thing is to anticipate constipation either caused by the cancer or caused by its treatment. Over-the-counter remedies can be used, but in the setting of cancer and its treatment, it's important to let the physician know, let the oncologist, medical oncologist or surgical oncologist, know that you're experiencing the problem. If you're on opioids or narcotic medications, all of those patients should be taking some form of laxative. The usual bowel regimen that's included with a narcotic prescription is a stool softener and a stimulant laxative. In the particular case of opioid induced constipation, there are new drugs that are being developed that have a specific action on the bowel to reduce or eliminate the influence of opioids that slow down the bowel and those have become much more useful to us. In fact, those may be used in the emergency department to relieve constipation or they may be used as an, on an outpatient basis to prevent recurrent constipation.

Lisa Garvin: Are these currently on the market?

Dr. Todd: There is one drug methylnaltrexone that is administered subcutaneously through a small needle under the skin that is the most commonly used drugs. There are a number of drugs that are entering the market that are specific antagonists. They counteract the actions of opioids on the gut and we'll see more of those as they are developed.

Lisa Garvin: And as far as dietary restrictions, people may think that you know, they can cure their constipation with diet, is that true in the cancer patient population?

Dr. Todd: Well, it's certainly true that one can make that symptom less likely. One of the common reasons for constipation is simply dehydration - not taking enough fluids. The other may be inactivity. If we don't move around, if we don't walk, if we are in bed most of the time, predictably constipation will result. So it's important to keep up your fluid intake, keep up your physical activity to prevent constipation. And the reasons for physical inactivity are not just related to the cancer per se, many patients have depression or anxiety that is comes along with a serious disease like cancer and both depression and anxiety can lead to inactivity and increased rates of constipation.

Lisa Garvin: So the take-home message, you know, and you've stated a couple of times, but to wrap up so we want to be proactive, we want to do some sort of preventative measures, and so kind of, you know, give us like a nutshell for patients.

Dr. Todd: Well, I think the most important take-home messages are: Talk to your doctor about your symptoms. If you're hesitant to bring those up with you doctor, bring someone with you to the doctor's visit, who will advocate for you. Number two, I think if you're taking narcotics or opioid medication, you should expect to be on some sort of bowel regimen, and if your doctor doesn't prescribe that for you, ask him or her why not. And I think it's important to realize that constipation can result from mood disorders that are common with cancer and those should be recognized and treated when present. And if one experiences increased abdominal pain, particularly with abdominal distention or swelling and decreased bowel movements that maybe a sign you need to see the doctor right away and if you cant get in to see your oncologist, in the emergency department, we're there 24 hours, 7 days a week to take care of you.

Lisa Garvin: Great! Thank you very much Dr. Todd.

Dr. Todd: Thank you.

Lisa Garvin: If you have questions about anything you've heard today on Cancer Newsline, contact Ask M. D. Anderson at 1877-MDA-6789 or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.

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