Annette Bisanz, MPH, RN
Advanced Practice Nurse
Nursing Administration
The University of Texas, MD Anderson Cancer Center
Hello. My name is Annette Bisanz and today we're going to talk about normal bowel function and dysfunction, related to constipation and its treatment.
The objectives for this session are that: all participants will be able to set expectations for frequency of bowel movements; normalize the constipated bowel; and assign a bowel maintenance program.
Normal bowel function, as stated in the literature, is that it can vary from three times per day to three times per week. And the most normal time to have a bowel movement is on arising in the morning from sleep or after breakfast. This is when you have a normal gastrocolic reflex.
It's important to set an expectation for frequency of bowel movements. I find that this is something that patients are not aware of. When you see patients coming into the em --- emergency center, two weeks without a bowel movement, we know we haven't taught that patient the requirements for frequency. And so, today we're going to discuss this. If a person eats three good-size meals a day, he needs a bowel movement every day. If he eats one-half his normal, he needs a bowel movement every other day. And if a person eats one-third his or her normal amount, expect a bowel movement every third day. Nobody goes more than three days without a bowel movement, even if they're in the intensive care unit, on a ventilator, and getting nothing by mouth. And the reason for this is that there is normal --- there's a normal sloughing of the gastrointestinal tract, and there are also enzymes that are pouring into the GI tract that create the need to have a bowel movement at least every three days.
To discuss the prevalence of constipation (this was surprising to me) that 10% of the general population is constipated; 20% of people over age 65, so as we age, we tend to be more constipated; 50% of people with cancer; and 78% of patients with terminal cancer. And I think it's interesting, and I always tell patients, [you know] that we're partners in this whole process of helping them with their bowel management. And I tell them that if they don't have bowel problems before they come to us, we'll give it to them with our treatments. So we need to help them to know how to manage their bowels and to help themselves with the problems of constipation and diarrhea.
Okay, so constipation from a cost perspective - it accounts for 2.5 million physician visits annually, and 400 million dollars is spent in laxative preparations every year. That's a phenomenal amount, and it shows how much people are trying to self-medicate themselves and how severe the problem really is. And so, we need to guide our patients in choosing the correct treatments, if they're going to --- and we want them to help themselves.
Okay, so for patient assessment, we want to know, when we're assessing our patients, what is the normal frequency of stools and when did they have their last bowel movement? We also want to know the consistency of the stools. We want them to describe the amount or quantity sufficient. The thing that people don't realize, if they're eating three good-size meals a day and they have a bowel movement, they should expect one every day. If they're used to going this much, and they're only going this much, they're packing up this much every day, and so our patients need to understand that quantity sufficient is really important. We also want to know accompanying symptoms - like, do they have abdominal distention, pain, any presence of nausea/vomiting? What's their appetite like? What's their fluid intake? We want to check them for an impaction. We also want to know their food, fluid, and fiber intake daily. And we want to know the medications that may be affecting their bowels.
We need to know other disease processes because we know that our cancer patients not only have can--- don't only just have cancer, they come to us with other disease processes. Some patients are diabetic. Some have neurological diseases. They may have irritable bowel syndrome, Parkinson's disease. All of these can affect the --- the GI tract. Surgical changes in the GI tract definitely can --- can affect the patient's GI motility. Treatment-causing constipation, like our opioids or chemotherapies, that cause constipation; the physical effects of disease and/or treatment, the placement of the tumor, and metastatic or advanced disease. Frequently, if the patient has a tumor or metastatic disease in the abdomen, it can press on the colon and make it difficult for the patient to have bowel movements. The patient could have obstruction from adhesions. Maybe they've had prior abdominal surgery and they have adhesions, which are constricting the colon and inhibiting the bowel function. They can have a spinal cord compression, as a complication of their cancer, and that can cause bowel problems or autonomic neuropathy. Metabolic factors, such as fluid and electrolyte imbalances, can also affect bowel function.
We want to know their age. We want to know their hydration status. We want to know --- we need to be aware that the labs needed for treating and planning for patients with constipation include knowing their platelet count, their BUN, and their creatinine, and really their white cell counts, also. We may need an abdominal exam --- abdominal x-ray, like a KUB or an abdominal series. The abdominal series is much more comprehensive because you get six views on an abdominal series. And if you're really wondering what is causing the patient's abdominal distention or problems, it's probably better to order an abdominal series. Check and see if your patient had a recent CT scan with barium ingestion because many times, patients retain the barium, and we want to make sure that that barium is --- is excreted. It can cause real severe constipation. Successful self-care measures that the patient's used in the past is very important; and have they had a recent decreased --- decrease in physical activity? And then do an abdominal exam. And when you look at the abdomen and really uncover the belly and look at it, and make sure that the contour is the same on both sides, that it's --- it's equal. And then, next, take you stethoscope and assess for bowel sounds. And, frequently, if the patient is packed full of stool, you won't hear anything. Also, you won't hear anything if they have an ileus. It's something that you can use in your diagnostic tool. But the other thing is, which you want to do, is palpate the abdomen and determine: Is it firm? Is it soft? Is there any pain as you palpate the abdomen? Does the patient have additional discomfort? And then, you also might want to percuss the abdomen and that's --- to make sure how much air is in the ---the belly, because, and that goes along with the potential of increased air and Ogilvie's Syndrome, possibly, okay.
The definition for constipation, the clinical definition that I use, is hard, difficult to eliminate stool. It's not as much the frequency, but if the stool is hard and difficult to eliminate, the patient is constipated.
And if there's one thing that I want to leave you with today, it's not to ever underestimate the amount of stool that a patient can hold. I'm going to give you some --- three clinical examples of this, because it really helped me in my practice to understand how to do my job thoroughly, and well, to prevent future episodes of constipation. The first patient is a 42 --- 42-year-old Asian male. He had a colostomy and he had not had a bowel movement for 10 days. He was admitted to the hospital through the emergency room and he was miserable. His abdomen was distended. He was vomiting. He was unable to eat or drink. And so in taking his history and knowing what had happened, he had already had an x-ray; he was not obstructed. He did have stool obstruction, but he didn't have any tumor obstruction. And so, we began to irrigate the colostomy with milk and molasses. And this gentleman literally emptied a bucket of stool. I looked at him and I thought, "Where did he hold all that stool?" I mean he was of slight build, he was about 120 pounds and when you look at a person, you can't tell what's going on in their GI tract. I would like to use this next patient, too, as an example. She is a 44-year-old female. She was an entrepreneur. She had her own business. She had had colorectal surgery and six weeks later she started on radiation therapy for that same cancer. The radiation, of course, was over her GI tract. And she was two weeks into her radiation therapy, and she developed abdominal distention, severe pain and she was vomiting. And she came through the emergency center and they admitted her. And when I assessed her, I found out that she had not had a good bowel movement ever since she had her colorectal surgery; not the formed - not the nice formed stool that people normally have. And so, when she started radiation therapy, after two weeks into the radiation therapy, everybody gets diarrhea. And so, what we did is give her some Lomotil® to slow down the diarrhea. Well in essence, she was so packed full of stool, she was having runaround diarrhea from the small bowel. And she was so packed up with stool, we tried to give her milk and molasses enemas. We did four the first day. We had --- we probably cleaned out 20 cm. of her GI tract. And so, the next day, we decided, "Let's call the gastroenterologist. This lady needs help. She's absolutely in agony." The doctor took her to endoscopy, and irrigated out the stool. And I could not --- and I went with her, and I could not believe... The stool was like clay and it was chipping off the mucosa of the colon. And everything was bruised. And so it -- It just really taught me a very good lesson --- that we need to teach our patients how frequently... she obviously did not know how often she should expect a bowel movement, and also, we --- we need to fully assess and find out the pattern of stooling when patients come to us. The next patient is a 72-year-old male with progressive disease for lymphoma. This patient had been eating well. He had been having some bowel difficulties for six months. And so --- but he told me he had been having a bowel movement every other day, but he wasn't going quantity sufficient; and he was packing up every day for six months. And so we gave him four milk and molasses enemas. The first day he literally emptied a bucket of stool. The second day, we gave him another four enemas - another bucket of stool. And then, he was on the commode, pulled on his light, and asked a nurse to come in, and he was in so much pain in his rectum. The nurse put him back to bed, put on a glove, did a digital rectal exam and found an impaction. She called me and asked me to come and help her. The impaction was this big, and it was hard and it had points on it. I think, after experiencing --- feeling that, and I tried -- I put on a glove and tried to shave off those points, because I knew, if that came through the anus, it would cause bleeding, tremendous pain. And I could not budge those points. I couldn't shave them down with my finger. So, I called the gastroenterologist and he said, "You know, you've done such a good job of cleaning this patient out, now he's not nauseated anymore. I'm going to give him a gallon of GoLytely®." And this patient drank ten --- eight ounces every 10 minutes and he was very compliant. He drank the whole gallon, because there was room, he just had to get rid of this fecalith. This was a fecalith. And I didn't know what the term was until the gastroenterologist told me, and by the next day, that fecalith had dissolved. So you see, I just want to really impress upon you how much our patients hoard stool, and that we need to be very on top of bowel function of our patients because our treatments are very, very constipating.
There are two types of impaction. When I went to nursing school, I learned that you can put on a glove and you can do a digital rectal exam to see if the patient is impacted. And so if you see in the page - in the picture on the right, this is the - the initial development of a lower impaction. But the -- the gut can expand, and it gets much bigger than that, so the stool is so big it can't come through the anus and it has to be digitally broken up with a finger and brought down manually. The other --- on the other slide, on the left, this is a high impaction. And what happens in our cancer patients, what I am finding is, that they're coming in not having stool for five-plus days, eating well, and I do a digital rectal exam, and I feel nothing. And what I have had to come to the conclusion is that our patients, because they're not eating enough and they're not drinking enough, they are not having the massive peristaltic pushdown in their GI tract, and they're retaining fluid in the upper part of the colon, and it's actually impacted stool. So in treating these patients, we have to differentiate between a low impaction and a high impaction.
For the low impaction, we want to digitally --- digitally remove the impaction by using our finger to break it up and help to bring it out. And then following that, give the patient an enema until there is no more formed stool eliminated. When the patient has a high impaction, I recommend using milk and molasses enemas and repeat them four times a day, until there is no more formed stool eliminated. At the same time, we give oral laxatives; based on --- and the type of medication is based on their lab values.
So if you're going to give a milk and molasses enema, this is the recipe: you mix 3/4 of a cup of hot water with 3 ounces of powdered milk; add 4-1/2 ounces of molasses; and give it four times a day.
To get the best results, -- and oh, the reason I use milk and molasses is --- is because it works, and I'll tell you why. It's because we are using a low volume. That recipe is only a cup and a half, and our patients that are so full of stool, they can't tolerate a liter of fluid in an enema. The other thing is that it's a hyperosmolar solution. And because it's a very low volume, very concentrated, it will help to break up that stool and bring it down. And it's --- it's a comfortable enema for the patient. It's just food. It's not a stimulant, and I've --- I've never had a patient complain about this type of an enema. And it's very easy to administer because it's the kind of enema that is a retention enema. It's not going to be coming right back out, and I will show you how to give that enema.
This is [speaker intended to say "These are"] tips on how to get some good results from the enema that you give. First of all, you need an enema bag from the hospital. So if you're talking to a patient on the phone at home, they can't go to the drugstore and get an enema bag that will be effective for them because it's usually the red rubber, it's got the long tubing, it's got an enema tip and a douche tip connected. But with this, we want to advance the tube, and so the drugstore enema bag will not work. So for your patients to do their job, if they need to have this as a home remedy, you need to give them an enema bag from the hospital. Position the patient on the left side. Advance the enema tube up 12 inches. Then turn the patient on the right side. As you turn the patient on the right side, then the solution, when you --- when you administer it, is going to go down the transverse colon, into the ascending colon, and it's not going to come out. Remember, it's a retention enema. So after you give it, don't pull the enema tube out because if you do, they will have the immediate reflex to have a bowel movement, and you want them to hold it for 20 minutes. So you clamp off the enema tube, leave them on their right side for 20 minutes, and then remove the tube. And you'll be amazed at the results you get from giving the enema this way.
At the same time, you want to also give them magnesium citrate, one bottle p.o., and repeat it the next day, if needed, because your goal is to get everything pushed down from the top. So we work from both ends, to get rid of all that stool. If the patient has compromised kidney function, that's the only time I give lactulose, and I would give 30 cc., every four to six hours, until the patient's abdomen --- unless the patient's abdomen is distended. If the patient has a distended abdomen, I would never give lactulose, mainly because the side effect of it is gas and it --- because it ferments --- it causes a fermentation process when it hits the bowel, and it does have a side effect of gas. The other thing --- it can be dehydrating. If used in a home setting, I don't recommend it for any more than every six hours because it can dehydrate the patient if they're not getting IV fluids.
You can continue the enemas and the oral medications until there is no more formed stool in the colon.
After the colon is free of stool, then, and this is what we call normalizing the bowel. And after that, then a main --- bowel maintenance program will work for the patient. Too often a patient comes in constipated, and we hit them with all these stimulant laxatives. That is not the time to give stimulant laxatives because it makes the patient miserable. We need to help them get rid of the stool first, and then --- the bowel maintenance program can include the --- the other bowel medications.
The bowel maintenance program then should include - they need adequate fluids; so they need two quarts of fluid per day. They need 25 to 40 grams of fiber per day. And if they can't take it in their diet, it's important that they get it medicinally. If your patient is on tube feeding, make sure that the dietitian gives a formula with fiber in it. And make sure your patients know that they can't put Metamucil® in the feeding tube. It will block it. And eat --- and have the patient should eat three well-balanced, good-sized meals per day if possible. This is important for good bowel function. The one thing that I notice that people --- that patients who are getting liquid feedings or getting feedings through a tube think that because they are just eating --- taking liquids, they don't have to have a bowel movement every day, and that's a myth. If they're taking all of their nutrition in liquid form, they need to have a bowel movement every day. If they're eating half their norm in liquid form, every other day, and so forth, okay. So make sure that your patients understand that. Provide bowel medications to offset side effects of opioids and other medications on the GI tract. And include physical activity in the patient's daily regimen and then if the patient needs bowel training, we need to assist them with that.
Front-line therapy for constipation is adequate fluid (2 quarts per day) and fiber, nutritional or medicinal. If they're going to take it nutritionally, one of the things I have found very effective is Fiber One® cereal. It's the noodle type, and what the box states is it has 28 grams of fiber in one cup. If they put fruit on top of that, they've got their daily allotment of fiber. And for a society where we don't eat enough fiber, this is a great thing to teach the patient to get some -- a lot of fiber in this way. We've added it to our menu for the patients and they can choose it for breakfast each day. If they can't take nutritional fiber or can't get enough that way, I would recommend medicinal fiber where they take 1 tablespoon or 6.8 grams of psyllium, or 1 tablespoon of methylcellulose in 8 ounces of water. And make sure they follow it immediately by 8 ounces of water because it's the amount of fluid that they take with it that will dictate how it's going to work in the GI tract. If they can't drink that much at one time, what I recommend is a heaping teaspoon in 4 ounces of fluid, plus 4 more ounces of fluid, twice a day.
Okay, if front-line therapy of fu --- fiber and fluid is not effective, then you can add milk of magnesia and things like MiraLax®, stool softeners, and lubricants if needed. What we tell our patients to prevent constipation, if you're expecting a bowel movement every two days based upon you're eating half your norm, by 4:00 in the afternoon, if you haven't had a bowel movement, drink 4 ounces of prune juice. If you don't have a bowel movement by bed time, take milk of magnesia.
So here we go, just to reiterate: if no bowel movement by 4:00 p.m. on the expected day, take 4 ounces of prune juice followed by a hot liquid. If no bowel movement by bed time, take 2 tablespoons, or some people don't like the taste of milk of magnesia, they can take 2 caplets; and if no bowel movement after breakfast the next day, repeat the milk of magnesia every 6 hours until they have a bowel movement. If the patient needs to take repeatedly milk of magnesia, their bowel maintenance program is not strong enough. So remember, if they're on opiates and constipating medications, they can take up to 8 Senna-S a day. So if they're only on 2 Senna-S twice a day, you can up it to 3 twice a day. If they're on 4 Senna-S twice a day, which is the optimum dose, and that's not working, add MiraLax® once a day. If that's not working, they can have MiraLax® twice a day.
OK so we can take up to 8 Senna-S per day, and if laxation doesn't occur, add the MiraLax®, and increase it to two doses if needed. And if no relief from the above regimen, consider giving subcutaneous Relistor®. This is a new drug on the market for opioid-induced constipation. It won't have any effect on any other causative factor of constipation, only opioids.
It's also indicated for the treatment of opioid-induced constipation in patients with advanced illness or who are receiving palliative care when response to laxative therapy has not been sufficient. It decreases the constipating effects of opioids because what it does is it lifts off the opioid from the mu-receptors in the colon and allows for normal laxation. It does not diminish central analgesia effect of opioids, so it's a very nice drug to give because they still get the benefits of their opioids and get --- get the pain relief.
Because it talks about giving it to palliative care patients, I --- I just wanted to review with you the continuum of curative and palliative care. And as you're first diagnosed usually with cancer, you're in the curative mode and the acute care mode. And so you see, on the left-hand side of the screen here, your whole focus is primarily on curative. And as you get --- have progressive disease, the curative form of treatment gets less and less. As you're in the palliative care mode, really when you're in the curative care --- care mode, you still get some palliative treatments like symptom management, pain management. And so most of our patients that have cancer have a continuum of curative and symptom management along the continuum of care.
The contraindications for Relistor® is patients with known or suspected mechanical gastrointestinal obstruction, so it's very important to realize that this is not a magic drug that can be just given; give them a shot and they'll have a bowel movement. If they're impacted with stool, that stool has to be removed because that, in a sense, is a suspected mechanical obstruction by stool, so it's not safe to give if they are full of stool. It's a great --- it is very good for maintenance dose, also. Relistor® has not been studied in pregnant or breastfeeding women, children, or patients with severe hepatic impairment.
The dosage of Relistor® is based on the patient's weight. It's given subcutaneously. It's usually given every other day but no more frequently than every 24 hours. And it does cause laxation within half an hour to four hours. Dose reductions are --- are --- are done with severe renal impairment.
Okay, now if your patient needs bowel training for constipation, this is the method to use. Have the patient drink 4 ounces of prune juice before a big meal of choice. It makes no difference which meal, although I do prefer breakfast because that's when they have the normal gastrocolic reflex. But for some people, they can't do it until evening because of their home situation. So they have to pick a meal where they have a big meal and center their bowel training around that. So they drink 4 ounces of prune juice before the meal of choice, eat a --- the big meal, drink a hot liquid, and then immediately insert a bisacodyl suppository. Repeat that step for 14 days, and on day 15, insert a glycerin suppository in place of the bisacodyl. And sometimes that ---, by putting them through this training for two weeks, the bowel has learned to respond to the stimulus of the prune juice, big meal, and hot liquid, and they may no longer need a Dulcolax® suppository. But if they don't have results with --- with the glycerin suppository, insert the bisacodyl suppository for another week and then try it again.
Sometimes, people need digital stimulation in order to have a bowel movement. And this is --- digital stimulation is used when regular bowel training is not successful for patients with neurological bowel --- or with a neurogenic bowel. All patients with S2 and below nerve involvement will need digital stimulation. And when the anal sphincter is very tight and the stool can't pass through without relaxing the external and internal anal sphincters, digital stimulation would be needed for them.
So how do you do digital stimulation? All right, the process is: put a glove on and lubricate your index finger. Insert your gloved, lubricated finger into the anus one-half inch and do a circular rotation, very gently because you want to relax the external sphincter. Then you advance the finger to 1 inch and you continue the circular rotation until you relax the internal sphincter. And once that is felt, the stool will begin to pass, and that can be repeated until no more stool is eliminated. You repeat this daily as part of the bowel regimen, the bowel training that we just mentioned.
Okay, bowel training with digital stimulation, if you need to combine the bowel training with the digital stimulation, here's how you do it. You bowel train with the prune juice, the big meal, the hot liquid, and immediately do digital stimulation to empty the stool in the rectal vault. Then you're going to insert the rectal bisacodyl suppository, and 30 minutes --- and 30 minutes later you're going to repeat the digital stimulation until all the stool is eliminated. Teach the patient to do this daily as the patient's only means of eliminating stool. And many of our patients, because of a neurogenic bowel and nerve involvement are involved in doing this on a daily basis and are very successful.
So in summary, you have learned: the importance of normalizing the bowel before giving the patient a bowel maintenance program. You have learned the way to administer milk and molasses enemas to get the best outcome. You have learned about a new medication effective for opioid-induced constipation that has been refractory to normal laxative therapy. And you have learned when digital stimulation is needed for bowel training. I thank you for your attention.
Normal Bowel Function and Dysfunction Related to Constipation video
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