Palliative medicine and end of life care for MRCP Part 1

A 68-year-old man with metastatic cancer is started on morphine for pain. A week later he has hard, infrequent stools and abdominal discomfort. He has no bleeding or weight change beyond his illness. What is the most likely diagnosis?

1. Hypercalcaemia Constipation with thirst, confusion and a raised calcium. Hard infrequent stools soon after starting a strong opioid makes it a consideration.
2. Neurogenic bowel Constipation from spinal or autonomic neurological disease. Hard infrequent stools soon after starting a strong opioid redirects it.
3. Constipation Infrequent, hard or difficult stools without an alarming cause. Hard infrequent stools soon after starting a strong opioid fits.
4. Hypothyroidism Constipation with fatigue, cold intolerance and weight gain. Hard infrequent stools soon after starting a strong opioid points elsewhere.
5. Opioid-induced constipation correct Correct. Hard infrequent stools soon after starting morphine are opioid-induced constipation.

The point: Constipation is infrequent or difficult defecation, and it is a very common and distressing problem in palliative and geriatric care. It is best divided into primary (functional) constipation and secondary constipation with an identifiable cause, and the causes worth remembering are drugs (opioids above all, but also anticholinergics, iron, calcium-channel blockers and antacids), metabolic upset (hypothyroidism, hypercalcaemia, hypokalaemia), mechanical obstruction, and neurological disease. In palliative care, opioid-induced constipation is almost universal because opioids reduce gut motility, and, unlike other opioid side effects, tolerance does not develop, so a stimulant laxative (usually with an osmotic laxative) is co-prescribed prophylactically whenever a strong opioid is started. The important safety step in a new presentation, especially in an older patient, is to screen for the red flags of colorectal cancer, such as a persistent change in bowel habit, rectal bleeding, weight loss and iron-deficiency anaemia, which warrant investigation. Faecal impaction can cause overflow diarrhoea that is easily mistaken for simple diarrhoea. Management combines attention to fluid, fibre and mobility with laxatives chosen by mechanism: bulk-forming (ispaghula), osmotic (macrogol or lactulose) and stimulant (senna or bisacodyl), with rectal measures for impaction. The exam themes are opioid-induced constipation and its prophylactic laxative, the red flags that prompt cancer investigation, and matching the laxative class to the problem.

Source: BNF — constipation treatment summary British National Formulary · tier 3, national formulary

A 68-year-old man with metastatic cancer is started on morphine for pain. A week later he has hard, infrequent stools and abdominal discomfort. He has no bleeding or weight change beyond his illness. What is the most appropriate investigation?

1. Check calcium, thyroid function and potassium Metabolic causes are reversible. Hard infrequent stools soon after starting a strong opioid makes it useful.
2. Imaging if bowel obstruction is suspected It confirms or excludes obstruction. Hard infrequent stools soon after starting a strong opioid makes it selective.
3. A history of stool frequency, consistency and drugs It defines the problem and its cause. Hard infrequent stools soon after starting a strong opioid makes it central.
4. Screen for red flags of colorectal cancer Bleeding, weight loss and anaemia change management. Hard infrequent stools soon after starting a strong opioid makes it decisive.
5. Review the opioid and other constipating drugs correct Correct. The opioid is the treatable cause to address.

The point: Constipation is infrequent or difficult defecation, and it is a very common and distressing problem in palliative and geriatric care. It is best divided into primary (functional) constipation and secondary constipation with an identifiable cause, and the causes worth remembering are drugs (opioids above all, but also anticholinergics, iron, calcium-channel blockers and antacids), metabolic upset (hypothyroidism, hypercalcaemia, hypokalaemia), mechanical obstruction, and neurological disease. In palliative care, opioid-induced constipation is almost universal because opioids reduce gut motility, and, unlike other opioid side effects, tolerance does not develop, so a stimulant laxative (usually with an osmotic laxative) is co-prescribed prophylactically whenever a strong opioid is started. The important safety step in a new presentation, especially in an older patient, is to screen for the red flags of colorectal cancer, such as a persistent change in bowel habit, rectal bleeding, weight loss and iron-deficiency anaemia, which warrant investigation. Faecal impaction can cause overflow diarrhoea that is easily mistaken for simple diarrhoea. Management combines attention to fluid, fibre and mobility with laxatives chosen by mechanism: bulk-forming (ispaghula), osmotic (macrogol or lactulose) and stimulant (senna or bisacodyl), with rectal measures for impaction. The exam themes are opioid-induced constipation and its prophylactic laxative, the red flags that prompt cancer investigation, and matching the laxative class to the problem.

Source: BNF — constipation treatment summary British National Formulary · tier 3, national formulary

A 68-year-old man with metastatic cancer is started on morphine for pain. A week later he has hard, infrequent stools and abdominal discomfort. He has no bleeding or weight change beyond his illness. What is the most appropriate management?

1. Investigate red flags for colorectal cancer A dangerous cause is excluded. Hard infrequent stools soon after starting a strong opioid makes it decisive.
2. Rectal measures for faecal impaction Suppositories or enemas clear impaction. Hard infrequent stools soon after starting a strong opioid makes it targeted.
3. Treat a reversible metabolic cause Correcting calcium or thyroid resolves it. Hard infrequent stools soon after starting a strong opioid makes it selective.
4. Co-prescribe a stimulant laxative when starting a strong opioid correct Correct. A stimulant laxative is co-prescribed because opioid constipation does not develop tolerance.
5. Combine a stimulant with an osmotic laxative The combination targets motility and stool softening. Hard infrequent stools soon after starting a strong opioid makes it standard.

The point: Constipation is infrequent or difficult defecation, and it is a very common and distressing problem in palliative and geriatric care. It is best divided into primary (functional) constipation and secondary constipation with an identifiable cause, and the causes worth remembering are drugs (opioids above all, but also anticholinergics, iron, calcium-channel blockers and antacids), metabolic upset (hypothyroidism, hypercalcaemia, hypokalaemia), mechanical obstruction, and neurological disease. In palliative care, opioid-induced constipation is almost universal because opioids reduce gut motility, and, unlike other opioid side effects, tolerance does not develop, so a stimulant laxative (usually with an osmotic laxative) is co-prescribed prophylactically whenever a strong opioid is started. The important safety step in a new presentation, especially in an older patient, is to screen for the red flags of colorectal cancer, such as a persistent change in bowel habit, rectal bleeding, weight loss and iron-deficiency anaemia, which warrant investigation. Faecal impaction can cause overflow diarrhoea that is easily mistaken for simple diarrhoea. Management combines attention to fluid, fibre and mobility with laxatives chosen by mechanism: bulk-forming (ispaghula), osmotic (macrogol or lactulose) and stimulant (senna or bisacodyl), with rectal measures for impaction. The exam themes are opioid-induced constipation and its prophylactic laxative, the red flags that prompt cancer investigation, and matching the laxative class to the problem.

Source: BNF — constipation treatment summary British National Formulary · tier 3, national formulary