ONS PUTTING EVIDENCE INTO PRACTICE
Constipation
Definition List
Term Definition
Adequate daily Normal fluid intake is 2000 milliliters or 64 ounces per day for adults (Bisanz, 2005; Thompson, Boyd-Carson,
fluids Trainor, & Boyd, 2003).
Aromatherapy Aromatherapy is the use of fragrant essential oils distilled from plants to alter mood or improve health (American
Cancer Society [ACS], 2005a).
Aromatherapy Aromatherapy often is used as a complement to massage therapy. Aromatherapy massage involves the use of
massage fragrant essential oils combined with a carrier oil or cream during manipulation of the soft tissues of the body
(Fellowes, Barnes, & Wilkinson, 2004).
Biofeedback Biofeedback is a treatment method that uses monitoring devices and information to help people consciously control
physical processes, such as heart rate, blood pressure, temperature, sweating, and muscle tension that are usually
controlled automatically (Coulter et al., 2002; ACS, 2005b). Biofeedback therapy for constipation focuses on
training the person to relax the pelvic floor and anal sphincter. Different types of equipment can be used such as
balloons inserted into the rectum and electrical devices to determine muscle contraction (Frizelle & Barclay, 2005).
Chronic Chronic constipation is symptoms of constipation lasting at least 12 weeks, which need not be consecutive, of the
Constipation preceding year (Petticrew, Rodgers, & Booth, 2001).
Colchicine Colchicine decreases colonic transit times and increases the frequency of bowel movements over four weeks after
administration. It has been studied in chronic functional constipation (Thomas, 2007a, 2007b).
Constipation Constipation is defined as a decrease in the passage of formed stool characterized by stools that are hard and
difficult to pass. Patients have fewer than two to three stools per week and may strain to have a bowel movement.
Constipation can be accompanied by abdominal pain, nausea/vomiting, abdominal distention, loss of appetite,
headache, and dry, hard, formed stools (Petticrew et al.; Cope, 2001; Tamayo & Diaz-Zuluaga, 2004; Thompson et
al.).
Enema Injection of fluid, either plain or containing various drugs, into the rectum and colon to stimulate emptying of the
1
ONS PUTTING EVIDENCE INTO PRACTICE
Constipation
Definition List
Term Definition
lower intestines (Thorpe, 2001).
Fiber, Insoluble Insoluble fiber passes through the intestinal tract largely intact adding bulk and weight to the stool. It is non-
(nutritional bulk fermentable and helps food to pass more quickly through the stomach and intestines. Insoluble fiber can be found
forming) in wheat bran, fruit, and root vegetable skins, whole wheat, and whole grain products, as well as seeds and nuts.
Other sources include pumpernickel breads, all bran cereal, butter, lima, pinto, and white beans, split and black-
eyed peas, blackberries, boysenberries, raspberries, dried figs and prunes, artichokes, asparagus, brussel sprouts,
corn, parsnips, spinach, winter squash, and turnip greens (Griffenberg, Morris, Atkinson, & Levenback, 1997;
“Soluble vs. insoluble fiber,” 2004; Michels, 2005).
For medicinal, bulk-forming fiber, refer to Laxatives (medicinal bulk-forming fiber).
Fiber, Soluble Soluble fiber absorbs liquid to form a gel, which eases stool movement. Sources of soluble fiber include fruits,
(nutritional fiber) vegetables, beans, barley, and oat bran. Soluble fiber includes pectins, gums, starches, some hemicelluloses, and
other polysaccharides (Michels, 2005).
For medicinal soluble fiber, refer to laxatives (medicinal soluble fiber).
Fresh baker’s A fungus, most commonly used in the kitchen for raising dough. In Argentina, FBY is available in paste form that
yeast (FBY) can be mixed with liquids and/or food and then used both as a food supplement to provide vitamins and as a bowel
regulator (Wenk et al., 2000).
Herbal Herbal supplements, such as vitamins and botanics, are considered dietary supplements. Herbal supplements
supplements come in many forms, including extracts, concentrates, tablets, capsules, gel caps, liquids, and powders. Some
herbal supplements, which have been recommended as laxatives include: flaxseed, fenugreek, aloe vera, cascara
sagrada, senna pods and leaves, and psyllium seeds and husks (Nir-Paz, Cohen, & Haviv, 1999).
Hot liquids Hot liquids are not defined in the literature. For purposes of this project, hot liquids are liquids that are at a
temperature just below what would burn the mucous membranes of the mouth, in contrast to lukewarm liquids.
2
ONS PUTTING EVIDENCE INTO PRACTICE
Constipation
Definition List
Term Definition
Impaction (high) With a high impaction, the stool remains in the ascending and transverse colon causing symptoms of nausea/
vomiting, loss of appetite, abdominal distention, and cramping. In some cases, liquid stool oozes around the
impaction and can appear to be diarrhea but also can be a sign of a high impaction (Bisanz).
Impaction (low) With a low impaction, the stool is detected by digital examination in the rectum. Patients with a low impaction have
the urge to defecate but are unable to expel stool. (Bisanz, 2005)
Irritable bowel Irritable bowel syndrome (also called spastic or irritable colon) is a common disorder that can cause a number of
syndrome symptoms in any organ in the gastrointestinal tract, including the esophagus, stomach, and the small and large
intestines. The cause is unknown. The waves of muscular contraction that normally move stool through the
intestines become uncoordinated. Symptoms can be triggered or worsened by stress or a poor diet (American
Medical Association, 2004).
Laxative Laxative agents are used to treat constipation. They are classified by their mechanism of action: bulk-forming,
emollient, osmotic/saline, stimulant, and lubricant (Avila, 2004). Other pharmacologic agents used to treat
constipation include prokinetic agents and opioid antagonists.
Laxative These laxatives often are referred to as stool softeners. They function primarily as detergents, facilitating the mixing
(emollient or of aqueous and fatty substances that soften feces. Examples include docusate sodium and docusate calcium
surfactant) (Brandt et al., 2005; Avila, 2204).
Laxative These laxatives provide lubrication for the passage of feces. This laxative group includes: mineral oil and
(lubricant) magnesium hydroxide combined with mineral oil. Long-term use is contraindicated because of the risk of
malabsorption of fat-soluble vitamins (Avila,2004).
Laxative Bulking agents add water and additional solid material to stool in the intestinal lumen. The swelling of the stool
(medicinal bulk- stimulates peristalsis and decreases stool transit time (Brandt et al, 2005.; Sykes, 1994). Examples of bulking
forming fiber) agents include methylcellulose (Citrucel® GlaxoSmithKline, Philadelphia, PA ), psyllium, also known as ispaghula
husk (i.e. Metamucil® Procter and Gamble Co., Cincinnati, Ohio, Konsyl®, KONSYL® PHARMACEUTICALS, INC.
Easton, MD) and calcium polycarbophil (i.e. Konsyl® Fiber, Fibercon® Wyeth Consumer Healthcare, Richmond,
3
ONS PUTTING EVIDENCE INTO PRACTICE
Constipation
Definition List
Term Definition
VA). Most bulk laxatives need to be taken with 200-300 ml of fluid.2 CAUTION: Bulk-forming laxatives should be
avoided in patients who do not have adequate physical activity or fluid intake and/or who have severe constipation
because it may worsen manifestations of constipation (Petticrew et al, 2001.; Mancini & Bruera, 1998; Klaschik,
Nauck, & Ostgathe, 2003; Tamayo & Diaz-Zuluaga; Avila).
Laxative These laxatives are non-prescription soluble-fiber supplements available over the counter. Soluble fiber nourishes
(medicinal the normal bacteria in the gut resulting in fermentation and gas production, which stimulates laxation. Examples of
soluble fiber) this laxative type include: Partially hydrolyzed guar gum (Benefiber® Novartis, Fremont, Michigan), inulin (Fiber
Choice® GlaxoSmithKline Consumer Healthcare, L.P.), and Liquafiber® (Global Health Products, Inc., Rochester, NY).
Laxative Osmotic laxatives contain poorly absorbed ions or molecules, which create a local osmotic gradient within the
(osmotic/saline) intestinal lumen. Fluid and electrolytes are drawn osmotically from the surrounding tissue into the colon, which
creates pressure-stimulating peristalsis (Brandt et al, 2005.; Avila, 2004). Examples of this laxative type include
lactulose and sorbitol (Brandt et al., 2005). Adverse effects include electrolyte abnormalities, diarrhea, abdominal
bloating, flatulence, and colic (Brandt et al., 2005; Avila, 2004).
An iso-osmotic laxative is physiologically inert and, therefore, is not absorbed or metabolized in the gut (Arora &
Srinivasan, 2005). Polyethylene glycol (PEG) is an example of this type of laxative. In the United States,
standard-dose PEG, with electrolytes is known as Golytely® (PEG-3350 and electrolytes for oral solution)
(Braintree Laboratories, Inc., Braintree, MA and Colytely® (Schwartz Pharma, Inc., Milwaukee, WI). Low-dose
PEG, referred to as PEG 3350, is available in the United States without electrolytes and is marketed as Miralax ®
(Schering-Plough HealthCare Products, Inc., Kenilworth, N.J.). In the United Kingdom and the Netherlands, it
is available with or without electrolytes. Nulytely® (Braintree Laboratories, Inc., Braintree, MA) is a sodium-free
mixture for specific patient populations. Regardless of the ingredients, PEG acts by opposing water absorption from
stool in the large bowel, increasing the water content and volume of the stools, thus making them softer and easier
to pass (Avila, 2004).
Hyper-osmotic laxatives have a more rapid onset of action compared to other osmotic laxatives. An example of
this type of laxative is a glycerin suppository, which also has lubricating properties (Avila,2004).
4
ONS PUTTING EVIDENCE INTO PRACTICE
Constipation
Definition List
Term Definition
Saline laxatives or magnesium salts: These salt mixtures contain magnesium or sulfate ions. They act by
drawing fluid into the gut osmotically; softening the stool and causing increased intraluminal pressure and
stimulation of peristalsis (Avila). “Dehydration can occur with repeated use of saline laxatives, so they should not be
prescribed in patients who cannot tolerate fluid loss” 88 or in patients who cannot maintain adequate daily fluid
intake (see definition above). Examples of this laxative group include sodium phosphate enemas (Fleet Enema®
C. B. Fleet, Inc., Lynchburg, VA)., magnesium citrate, and magnesium hydroxide (Milk of Magnesia®
GlaxoSmithKline, Philadelphia, PA).
Laxative Stimulant laxatives irritate the nerve endings in the colonic mucosa stimulating peristalsis. They also may limit
(stimulant) water absorption by altering fluid and electrolyte transportation within the intestinal mucosa (Brandt et al.). Side
effects of these agents include abdominal discomfort, electrolyte imbalances, allergic reactions, and hepatotoxicity.
Melanosis coli (a benign pigmentation disorder of the colon) also has been reported with senna-containing
compounds (Brandt et al.; Sykes). Examples of this laxative group include senna (Senokot® Purdue Products L.P.
Stamford, CT, ExLax® NOVARTIS CONSUMER HEALTH., East Hanover, NJ) and bisacodyl (Dulcolax® Boehringer
Ingelheim Corporation, Ridgefield, CT, Correctol® Schering-Plough HealthCare Products, Consumer Relations,
Memphis, TN) (Brandt et al.).
Lubiprostone Lubiprostone is a locally acting chloride channel activator with a similar mechanism of action on intestinal fluid to
bulking agents and osmotic laxatives. It increases intestinal fluid volume and motility, resulting in stool softening
and an ease of passage. Although the U.S. Food and Drug Administration approved it in January 2006 for chronic
idiopathic constipation, no studies in patients with cancer have been published (Thomas, 2007a, 2007b).
Massage Massage involves the manipulation of muscles and soft tissues of the body by the hands for the purpose of
Therapy producing an effect on the vascular, muscular, and nervous systems of the body (Fellowes et al., 2004).
Milk and The sugar in milk and molasses enemas irritates the intestinal lining and produces gas, which distends the
Molasses Enema intestines, causes pressure, peristalsis, and subsequent evacuation. A low-volume enema <300cc, when given
high (12”) and held for 20 minutes, produces the best results. Caution: Evaluate intravascular volume status before
using enemas with hypertonic solutions (Walker, Warner, Brilli, & Jacobs, 2003).
Directions: Mix 3 ounces powdered milk in ¾ cup warm water, add 4 ounces of molasses, and mix. Insert enema
5
ONS PUTTING EVIDENCE INTO PRACTICE
Constipation
Definition List
Term Definition
tube approximately 12 inches into the rectum or until resistance is met and administer less than 300cc. After
solution is given, clamp the enema tube and leave it in place while the patient lies on his or her right side for 20
minutes to allow solution to go into the transverse and ascending colon. Repeat up to four times per day until the
impaction is relieved (Bisanz, 2005).
Misoprostol Misoprostol is a synthetic oral prostaglandin E analog that has been studied in patients with chronic functional
constipation. It has been shown to decrease colonic transit time and increase stool weight in a one-week period
after administration (Thomas, 2007a, 2007b).
Opioid Opioids are peptides that act as potent analgesics. They are located centrally, in the brain, and peripherally, for
example, in the gut. When used, these agents block receptors in all locations. When blocking the receptors in the
gut, intestinal propulsion slows, increasing the potential for constipation (Choi & Billings, 2002).
Opioid This group of medications has been used for the treatment of opioid-induced constipation. They reverse the opioid
Antagonists action at opioid receptor sites located in both the central and/or peripheral nervous systems (i.e., the gut) (Choi &
Billings,2002). Each of the medications has varying affinities for the different opioid receptors.
Central and peripheral opioid antagonists: These tertiary opioid antagonists act on both central and peripheral
opioid receptors. They are relatively lipid-soluble and readily cross the blood-brain barrier with the potential to block
the beneficial analgesic effects, as well as the adverse effects of opioids (Choi & Billings,2002). Because of their
affinity for central nervous system opioid receptors, opioid withdrawal symptoms may occur after administration
especially in opioid- dependent patients (Friedman & Dello Buono, 2001; Choi & Billings,2002). Examples of these
drugs include: Naloxone (Narcan®), which is an injectable opioid antagonist; Naltrexone, which is an oral
antagonist; and Nalmefene, which is similar to naltrexone but is more potent in antagonizing Mu and Kappa
receptors and has a longer half-life. These agents are used primarily to reverse sedation and respiratory
depression in suspected narcotic overdose or in the treatment of alcohol and opioid dependence; however, they
also have been studied in reversing opioid-induced suppression of bowel motility (Friedman & Dello Buono; Choi &
Billings,2001).
Peripheral opioid antagonists: These quaternary opioid antagonists do not cross the blood-brain barrier in
humans, and they are believed to reverse opioid side effects mediated by receptors located in the periphery (i.e.,
6
ONS PUTTING EVIDENCE INTO PRACTICE
Constipation
Definition List
Term Definition
the gastrointestinal tract) without interfering with pain relief or precipitating opioid withdrawal (Choi & Billings; Yuan,
& Israel, 2006). Some opioid-induced adverse events that these drugs may potentially target include constipation,
nausea/vomiting, cough suppression, and urinary retention (Choi & Billings, 2002; Foss, 2001).
Examples of these agents are: Alvimopam (ADL 8-2698), which is an orally administered selective (peripheral)
opioid antagonist; and Methylnaltrexone, which is available in a parenteral and oral formulation. Both of these
agents currently are being investigated for the treatment of opioid-induced adverse effects including
constipation(Choi & Billings,2002; Neary & Delaney, 2005; Yuan, & Israel, 2006). Alvimopam is awaiting FDA
approval for this indication (Choi & Billings,2002; Webster et al., 2006).
Palliative Care The purpose of palliative care is management of symptoms such as pain, nausea and vomiting, The focus is not
curative but to improve the patient’s quality of life. Palliative care has developed into an integral part of (rather than
the antithesis of) comprehensive cancer care and is starting to be integrated earlier into the continuum of cancer
care (National Comprehensive Cancer Network, 2006a).
Soy Milk Milk that is nondairy and made from soy (Iacono et al., 1998).
Tegaserod This drug is a selective agonist of the 5-HT4 receptors in the enteric nervous system. It increases small-bowel
transit time by stimulating the peristaltic reflex, facilitating intestinal secretion, and inhibiting visceral afferent
responses (Brandt et al.,2005; Kamm et al., 2005).
7