Constipation is the passage of small, hard faeces infrequently or with difficulty, and they use their bowels less often than is normal for the person.
Diarrhoea can mean either very loose, wet stools, or more frequent bowel movements.
Faecal incontinence is the inability to control bowel movements which leads to unexpected leakage of liquid and/or solid stool.
Intestinal obstruction or bowel obstruction occurs when the movement of gastrointestinal contents is blocked. This can be due to poor bowel function or a malignant tumour. It occurs in 20–50% of people with ovarian cancer and 10–29% of people with colon cancers.
Nurses have an important role in recognising, assessing, and managing symptoms related to bowel function. They can also help patients and families with sensitive and culturally appropriate education and support.
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:
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:
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:
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.
Ways to help the person manage constipation include:
People given opioids will commonly be prescribed laxatives at the same time. Laxatives function as a
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
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.
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.
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:
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.
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.
There are several types of faecal incontinence:
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
Assessment questions should
A skin assessment is important as
faecal incontinence can compromise skin integrity especially in those with
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.
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:
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.
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.
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.
A dietitian can provide dietary recommendations for the person and their family and the care team.
This information was drawn from the following resources:
Watch Bowel care and intestinal obstruction in end-of-life care from the Palliative Care Bridge
Go to Constipation on the Marie Curie website
Access more Bowel Problems resources
Page created 26 April 2023