Name:
Harrison's Podclass - Episode 83- A 72-Year-Old with Constipation
Description:
Harrison's Podclass - Episode 83- A 72-Year-Old with Constipation
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Duration:
T00H05M36S
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https://cadmoreoriginalmedia.blob.core.windows.net/5e0eed30-7fc1-4775-863b-914412a7f559/Harrison%27s Podclass - Episode 83- A 72-Year-Old with Constip.mp3?sv=2019-02-02&sr=c&sig=bEav1XKGI7XzDEkOBEdSd5Y0ufZ5WDlpjqDJfFC24lg%3D&st=2024-05-04T14%3A09%3A41Z&se=2024-05-04T16%3A14%3A41Z&sp=r
Upload Date:
2022-06-12T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music] [Dr. Handy] Hi, welcome to Harrison's PodClass, where we discuss important concepts in internal medicine. I'm Cathy Handy. [Dr. Wiener] And I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine. [Dr. Handy] Hi, everyone. Today's episode is a 72-year-old with constipation. [Dr. Wiener] Cathy, today we have a case that's relevant to both of our clinical activities.
[Dr. Handy] All right. [Dr. Wiener] So a 72-year-old woman has stage 4 ovarian cancer and she has known diffuse peritoneal study. She's developing increasing pain in her abdomen and is admitted to the hospital for pain control. She previously has been treated with oxycodone 10 mg orally every six hours as needed, and she's on no other home meds. On admission, she's initiated on intravenous morphine via a PCA or patient-controlled analgesia.
She begins to complain about increasing bloating and constipation over the next day or two since starting the increased doses of narcotics. [Dr. Handy] Okay. Just to summarize, a patient with stage 4 ovarian cancer who has new abdominal complaints and is receiving narcotics. [Dr. Wiener] So what's your general approach in these types of patients? [Dr. Handy] Well, I often find these difficult, because as we know narcotics can cause constipation or even functional bowel obstruction, but patients, especially with advanced cancer, can also develop acute abdominal issues either related to their tumor, their therapy, their history of surgery.
And she's been receiving narcotics for a while but these symptoms are new, so before just ascribing any new clinical complaint to constipation, I do want to make sure that I'm not missing something that requires another intervention. So in this woman I'd want to know more about her vitals, especially her physical exam, labs, and since she's an inpatient, maybe some imaging.
[Dr. Wiener] Okay, well on exam she has no fever, hypotension or tachycardia. She reports that she feels full and does feel like she feels constipated. Overall, her vitals are normal. Her abdominal examination shows no overt distension, but she does have a little bit of reduced bowel sounds, but they're present. She's not tender focally and has no rebound tenderness.
Her labs reveal no change in her hemoglobin, and her white blood cell count is unchanged. [Dr. Handy] Well, that's all reassuring. Did she get any imaging, abdominal X-ray? [Dr. Wiener] In fact, she did. It shows no free air nor abnormal air fluid levels. It does, in fact, show extensive stool throughout the colon. [Dr. Handy] Okay, so certainly this could be narcotic-induced constipation.
[Dr. Wiener] So let's talk more about that. [Dr. Handy] Well, constipation is reported in up to 70-100% of patients requiring palliative care. Although hypercalcemia and other factors can cause constipation, it is most frequently a predictable consequence of the use of opioids for pain and dyspnea relief. It can also be related to the anticholinergic effects of medicines like tricyclic antidepressants, as well as other factors like inactivity and poor diet, which are common among seriously ill patients.
At a minimum, it can be uncomfortable for the patient, and if left untreated, constipation can cause substantial pain and vomiting, essentially bowel obstruction. It is also associated with confusion and delirium, which we know is a negative prognostic factor in all patients, but particularly the elderly. [Dr. Wiener] Okay, so let's get to the question. The question asks, all of the following are reasonable treatment options for this patient's constipation, except?
So four true and one false, and the options are, A. bisacodyl; option B. is docusate; option C. is fiber; option D. is magnesium citrate; and option E. is prune juice. [Dr. Handy] The answer is C. You should not use a fiber supplement such as psyllium to treat constipation in patients receiving opiates.
They do not relieve constipation and may make it worse. Fiber agents are used to increase stool bulk, which is meant to promote peristalsis by distending the colon. However, narcotics inhibit peristalsis, and fiber agents can worsen distension and pain. Furthermore, fiber agents can also exacerbate symptoms in the presence of dehydration, which can be present in these patients.
[Dr. Wiener] Okay, so what should be the clinician's approach? [Dr. Handy] Whenever opioids and other medications known to cause constipation are used, preemptive treatment for constipation should be instituted at the same time. Although physical activity and adequate hydration can be helpful, each is limited in its effectiveness for the most seriously ill patients.
So stimulant and osmotic laxative stool softeners, fluids and enemas are the mainstays of therapy. [Dr. Wiener] The question lists some specific examples. Can you run through them? [Dr. Handy] Sure. So prune juice and bisacodyl are stimulants to promote peristalsis and inhibit water reabsorption from the colon. Magnesium citrate or polyethylene glycol are non-absorbed osmotic agents, they promote retention of water in the colon.
Docusate is a stool softener, it works as a detergent to increase water content of the stool. Now all of these may be helpful in patients receiving narcotics. [Dr. Wiener] Okay, so the teaching point in this case is that patients receiving narcotics are very likely to develop substantial constipation that can be notably symptomatic. It's worth treating patients receiving regular doses of narcotics, however fiber supplementing agents should not be used.
Also, in a patient with new symptoms, make sure to rule out other causes of abdominal pathology before simply ascribing everything to constipation. [Dr. Handy] And you can read more about this in Harrison's chapter on diarrhea and constipation. [upbeat outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's PodClass is brought to you by McGraw Hill's AccessMedicine, the online medical resource that delivers the latest trusted content from the best minds in medicine.
Go to accessmedicine.com to learn more.