Today my blog is about a subject dear to any nurse’s heart. In my early career, student nurses had the task of going round the ward with the ‘bowel book’ and asking each patient if they had had a bowel movement. If they hadn’t, fairly dire consequences followed, with an increase in prunes on the menu, and some brewing of potent enemas. Fortunately, bowel care has become a little more scientific over the years, with many more medications and solutions to help ease the sluggish gut.
Constipation can be one of the most uncomfortable sensations people experience, and yet is often underestimated. It’s a common symptom in cancer, particularly during treatment, but also at virtually any point in the cancer trajectory.
What is constipation?
Simply put, constipation is when the bowel is not emptied regularly, and passing stools becomes uncomfortable. The stool itself can become hard and lumpy, and on the Bristol Stool Chart,( a pictorial view of poop) it would be definitely a One or Two! In severe constipation, you may feel nauseous, loss of appetite, and pain and cramping. In the elderly, it can sometimes lead to confusion too. It can even cause difficulty passing urine.
How regular is regular? Each one of us is different, but it’s more about what is the normal pattern for you. A bowel movement 1 -3 times a day, or three times a week, is fine – it’s more about what is standard for you.
What causes it?
In a person with cancer, there can be several causes:-
- Dehydration and lack of fibre in the diet. If you’re not feeling hungry, or you’re nauseous, sometimes it’s difficult to drink plenty of fluids, or face food.
- Cancer treatments – some chemotherapy and biological therapies can cause constipation.
- Medications – particularly pain relief such as codeine and morphine, but also other medicines such as anti sickness tablets, iron supplements and some blood pressure medications.
- Being confined to bed or being physically inactive – this slows the gut down. There may also be the ‘inhibition’ factor of not wanting to have bowels open in hospital, etc, so putting off the urge to go.
- The cancer itself – perhaps tumour pressure or unsettled, sluggish bowel post surgery, etc. Also if the blood level of calcium elevates (hypercalcaemia) then constipation can occur.
- Diabetes can trigger constipation too, as can low potassium levels.
Ideally, prevention is better than cure – although it’s not always possible to prevent it.
- More fibre in the diet is helpful, and CarolineH, our nutritional advisor, has previously written a useful blog on ‘dealing with cancer treatment side effects’ which includes the management of constipation. Basically, increasing intake of high fibre cereals, pulses, plenty of fruit and vegetables, nuts, beans, dried fruit, granary bread, etc.
- Flax seed works very well, and can be sprinkled on cereals. (NB - however, for some cancers, adding fibre to the diet is not encouraged.This can include bowel cancer, or any cancer where there is the chance of abdominal obstruction – the bowel being blocked).
- Fluids, fluids and more fluids…which can be hard to do if you’re feeling unwell, sometimes. Ideally 8 – 10 glasses a day helps keep the bowels functioning.
- Regular, gentle exercise, to help keep things moving. It may simply be to the end of the garden and back, but it all helps.
- Finding privacy and time, to relax enough to have a bowel movement – without straining, can help create a regular pattern. Some people swear by their early morning cup of tea, as sufficient stimulant to ‘get things moving’.
As with prevention, an increase in dietary fibre and fluids is a good starting place.
Sometimes constipation seems inevitable. There may be times where you’re not hungry, nauseated or have a sore mouth, or are just very fatigued, and combined with your medications – it often leads to the bowel slowing down.
When a person has constipation, and has cancer, it is wise to alert someone – whether it’s your GP, district nurse, specialist nurse and/or hospital team in charge of your care. It may be that some laxatives, or suppositories are needed to prompt the bowel into action, and the nurse or GP/hospital doctor may like to examine you to ascertain what the cause might be.
Sometimes the doctor will prescribe 'bulk forming' laxatives, which work by helping the stool retain fluid, and help move things along. (Fybogel, for example)
There are a range of medications which can help, which are best prescribed by those who know about you and your cancer personally. (They often start with something to soften the stool, and to stimulate the bowel)
Have a talk with your district nurse – sometimes abdominal massage in a clockwise direction can help relieve the pain and discomfort of constipation – and get things moving. However, there are some medical conditions, such as bowel obstruction, or inflammatory bowel disease where this is not advisable. Other complementary therapies such as reflexology and acupuncture can help, but check with your medical team first.
The main thing to remember, is don’t ignore constipation, or hope it will resolve itself. If you’re dealing with cancer, this common symptom can cause much discomfort. Let someone know.
It’s hard to end a blog on constipation, on a cheery note, but I’m hoping it has been a useful read. Maggie's can help here too, with nutritional advice, our 'Eating Well' workshops, and gentle exercise, so do drop into your local Maggie's Centre to find out more.
I’ve added some helpful websites for additional information.
Nutrition - dealing with cancer treatment side effects:- constipation and diarrhoea Caroline, Maggie's blog
Bristol stool chart - Bladder and Bowel Foundation
Constipation – Cancer Research UK
Constipation - NHS Choices
Constipation – Cancer.Net
If you have constipation – Macmillan Cancer Support
Constipation - American Cancer Support