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English Text
Normal Bowel Function and Dysfunction Related to
Constipation and its Treatment
Video Transcript
Professional Oncology Education
Normal Bowel Function and Dysfunction Related to
Constipation and its Treatment
Time: 33:08
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.
Spanish Translation
Función intestinal normal y disfunción relacionada con el
estreñimiento y su tratamiento
Transcripción del video
Educación Oncológica Profesional
Función intestinal normal y disfunción relacionada con el
estreñimiento y su tratamiento
Duración: 33:08
Annette Bisanz, MPH, RN
Enfermera de Práctica Avanzada
Administración de enfermería
MD Anderson Cancer Center de la Universidad de Texas
Hola, mi nombre es Annette Bisanz y hoy vamos a hablar
sobre la función intestinal normal y la disfunción relacionada
con el estreñimiento y su tratamiento.
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.
El objetivo de esta sesión es que todos los participantes
puedan establecer expectativas para la frecuencia del
movimiento intestinal; normalizar el intestino estreñido; y
asignar un programa de mantenimiento del intestino.
Normal Bowel Function
and Dysfunction Related
to Constipation and
its Treatment
Annette Bisanz, MPH, RN
Advanced Practice Nurse
Nursing Administration
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Objectives
All participants will be able to:
• Set expectations for frequency of
bowel movements
• Normalize the constipated bowel
• Assign a bowel maintenance program
1
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Normal Bowel Function
• The literature states that the norm for a bowel
movement varies from three times per day to
three times per week
• The most normal time for a bowel movement is
upon arising or after breakfast when a normal
gastro-colic reflex occurs
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Setting an Expectation for Frequency of
Bowel Movements
• If a person eats three good sized meals per day,
expect a bowel movement every day
• If a person eats one half his/her normal amount,
expect a bowel movement every other day
• If a person eats one third his/her normal amount
expect a bowel movement every third day
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.
La función intestinal normal puede variar de tres veces al
día a tres veces por semana. El momento más normal para
tener un movimiento intestinal es por la mañana después de
levantarse o después del desayuno, cuando se tiene un
reflejo gastrocólico normal.
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.
Es importante establecer una expectativa para la frecuencia
del movimiento intestinal, algo que los pacientes parecen
ignorar. Cuando un paciente viene al centro de emergencias
porque hace dos semanas que no tiene un movimiento
intestinal, sabemos que no le hemos enseñado los
requisitos para la frecuencia. Hoy hablaremos sobre este
tema. Si una persona consume tres comidas de buen
tamaño al día, debe tener una evacuación intestinal todos
los días. Si come la mitad de lo normal, necesita una
evacuación intestinal cada dos días. Y si una persona come
un tercio de su cantidad normal, se espera una evacuación
intestinal cada tres días. Nadie pasa más de tres días sin un
movimiento intestinal, aunque esté en la unidad de cuidados
intensivos, con respirador y sin recibir alimentos por boca.
Esto se debe a que hay un desprendimiento normal del
tracto gastrointestinal y enzimas que ingresan al tracto, que
crean la necesidad de mover el intestino al menos cada tres
días.
2
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Prevalence of Constipation
•
•
•
•
10% of the general population
20% of people over 65 years of age
50% of people with cancer
78% of patients with terminal cancer
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Constipation From a Cost Perspective
• Accounts for 2.5 million physician visits annually
• $400 million in laxative preparations sold
per year
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.
Con respecto a la prevalencia del estreñimiento, el 10% de
la población general tiene estreñimiento; el 20% de las
personas mayores de 65 años (a medida que envejecemos
tendemos a tener más estreñimiento); el 50% de las
personas con cáncer; y el 78% de los pacientes con cáncer
terminal. Siempre les digo a los pacientes que somos socios
en este proceso de ayudarlos con su control intestinal. Si
ellos no tienen problemas intestinales antes de acudir a
nosotros, se los provocaremos con nuestros tratamientos.
Debemos enseñarles a controlar sus intestinos y a ayudarse
con los problemas de estreñimiento y diarrea.
Desde la perspectiva del costo, el estreñimiento representa
2.5 millones de visitas médicas al año, y cada año se
gastan 400 millones de dólares en preparaciones laxantes.
Es un número extraordinario que revela la cantidad de
personas que intentan automedicarse y la gravedad del
problema. Debemos guiar a nuestros pacientes para que
elijan los tratamientos adecuados y puedan ayudarse.
3
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Patient Assessment
• Normal frequency of stools and date of last
bowel movement
• Consistency of stools
• Describe stool amount (quantity sufficient)
• Accompanying symptoms: abdominal distention, pain,
presence of nausea/vomiting, appetite, fluid intake
• Impaction
• Food, fluid and fiber intake daily
• Medications affecting bowel function
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Patient Assessment Continued
Disease Processes and Other Diseases
• Diabetes, neurological disease, IBS,
Parkinson’s Disease
• Surgical changes in the GI Tract
• Treatment causing constipation
• Physical effects of disease and/or treatment
• Placement of tumor and metastatic/advanced disease
• Obstruction from adhesions
• Spinal cord compression or autonomic neuropathy
• Metabolic factors (fluid/electrolyte imbalances)
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
Para evaluar a los pacientes, debemos saber cuál es la
frecuencia normal de sus evacuaciones y cuándo fue la
última; qué consistencia tienen; queremos que describan en
qué cantidad las tienen. Las personas deben comprender
que si están consumiendo tres buenas comidas por día y
tienen movimientos intestinales, deben esperar uno por día.
Si están acostumbrados a hacer una determinada cantidad
y hacen menos, cada día acumulan la cantidad restante.
Nuestros pacientes deben comprender que la cantidad
suficiente es muy importante. También queremos conocer
los síntomas concomitantes, como distensión abdominal,
dolor, presencia de náuseas o vómitos, apetito e ingesta de
líquidos. Queremos comprobar si hay impactación; conocer
su ingesta diaria de alimentos, líquidos y fibra; y conocer los
medicamentos que pueden estar afectando sus intestinos.
Debemos conocer los procesos de otras enfermedades,
porque nuestros pacientes con cáncer acuden a nosotros
con condiciones preexistentes. Algunos pacientes son
diabéticos. Otros tienen enfermedades neurológicas,
síndrome del intestino irritable o enfermedad de Parkinson.
Estas condiciones pueden afectar el tracto gastrointestinal.
Los cambios quirúrgicos en el tracto gastrointestinal pueden
afectar la motilidad gastrointestinal del paciente. El
estreñimiento causado por tratamientos, como nuestros
opioides o quimioterapias; los efectos físicos de la
enfermedad y/o su tratamiento; la ubicación del tumor y la
enfermedad metastásica o avanzada. Si el paciente tiene un
tumor o enfermedad metastásica en el abdomen, este suele
ejercer presión sobre el colon y dificultar los movimientos
intestinales del paciente. El paciente podría tener una
obstrucción por adherencias. Quizás ha tenido una cirugía
abdominal previa y tiene adherencias que están
4
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Considerations for Treatment Possibilities
• Age
• Hydration status
• Labs needed for treatment planning: platelets,
BUN, creatinine
• Need for abdominal X-ray (KUB vs.
abdominal series)
• Recent CT scan with barium ingestion
• Successful self-care measures in past
• Decreased physical activity
• Result of abdominal exam
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
constriñendo el colon e inhibiendo el funcionamiento del
intestino. Como una complicación del cáncer, puede tener
una compresión en la médula espinal que provoca
problemas intestinales o una neuropatía autonómica. Los
factores metabólicos, como desequilibrios hídricos y
electrolíticos, también pueden afectar la función intestinal.
Queremos saber su edad y su estado de hidratación. Los
análisis necesarios para tratar y planificar para pacientes
con estreñimiento incluyen los recuentos de plaquetas,
nitrógeno ureico en la sangre, creatinina y glóbulos blancos.
Posiblemente se necesite una radiografía abdominal, como
una KUB o una serie abdominal. La serie abdominal es más
completa porque obtiene seis vistas. Si no se sabe qué está
causando los problemas o la distensión abdominal del
paciente, lo mejor es pedir una serie abdominal. Compruebe
si su paciente recientemente se hizo una tomografía
computada con ingesta de bario, porque muchas veces los
pacientes retienen el bario y queremos asegurarnos de que
sea excretado, ya que puede causar estreñimiento grave.
Las medidas de cuidado exitosas que el paciente haya
usado son muy importantes; y si ha disminuido su actividad
física. Se hace un examen abdominal para observar el
abdomen. Descubra y observe el vientre. Asegúrese de que
el contorno sea el mismo a ambos lados. Con el
estetoscopio evalúe los sonidos intestinales. Si el paciente
está lleno de materia fecal, no oirá nada, y tampoco si tiene
un íleo. Es algo que puede utilizar como herramienta de
diagnóstico. También debe palpar el abdomen y determinar
si está firme o blando; si hay dolor al palparlo; si el paciente
tiene molestias adicionales. También puede percutir el
abdomen para determinar cuánto aire hay en el vientre, ya
que el aire en exceso va de la mano con el síndrome de
Ogilvie.
5
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Definition of Constipation
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.
La definición clínica de estreñimiento es la dificultad para
eliminar la materia fecal. No depende tanto de la frecuencia,
pero si las heces son duras y difíciles de eliminar, el
paciente está estreñido.
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
Nunca debemos subestimar la cantidad de materia fecal
que un paciente puede contener. Daré tres ejemplos
clínicos de esto porque me han ayudado a comprender
cómo realizar mi trabajo correctamente y a prevenir futuros
episodios de estreñimiento. El primer paciente es un
hombre asiático de 42 años. Tenía una colostomía y no
había tenido un movimiento intestinal en 10 días. Fue
admitido en el hospital a través de la sala de emergencias y
estaba muy molesto. Tenía el abdomen distendido,
vomitaba, y no podía comer ni beber. Al tomar su historia
médica, me enteré de que se había hecho una radiografía y
que no había obstrucción, es decir, tenía una obstrucción
fecal, pero no tenía ninguna obstrucción tumoral. Entonces
empezamos a irrigar la colostomía con leche y melaza, y
este señor literalmente llenó un balde de materia fecal. Lo
miré y me pregunté dónde guardaba toda esa materia fecal.
Era de constitución pequeña, aproximadamente 120 libras,
Hard, difficult to eliminate stool
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Don’t Ever Underestimate the Amount of Stool
a Patient Can Hold!
• 42 year old Asian man
• 44 year old female on radiation treatment
for colorectal cancer
• 72 year old male with progressive disease
from lymphoma
6
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
pero con solo mirar a una persona no se puede saber qué
sucede en su tracto gastrointestinal. También utilizaré a otro
paciente como ejemplo. Una mujer de 44 años, empresaria,
con su propio negocio. Había tenido una cirugía colorrectal
y seis semanas más tarde comenzó con radioterapia para
ese cáncer. La radiación abarcó el tracto gastrointestinal.
Transcurridas dos semanas de su radioterapia, desarrolló
distensión abdominal, dolor intenso y vómitos. Fue admitida
en el centro de emergencias. Cuando la evalué, descubrí
que no había tenido un buen movimiento intestinal (con
materia fecal normal, bien formada) desde su cirugía. A las
dos semanas de comenzar la radioterapia, desarrolló
®
diarrea y le dimos Lomotil para frenarla. Estaba tan llena
de materia fecal que estaba teniendo una diarrea que se
filtraba del intestino delgado. Le administramos enemas de
leche y melaza. Realizamos cuatro el primer día. Limpiamos
aproximadamente 20 cm de su tracto gastrointestinal. Al día
siguiente decidimos llamar al gastroenterólogo porque esta
señora necesitaba ayuda, estaba en total agonía. El médico
la llevó a endoscopia e irrigaron las heces. Yo la acompañé
y no lo podía creer… las heces eran como una arcilla y
estaban desgastando la mucosa del colon, que estaba lleno
de hematomas. Así aprendí que debemos enseñar a
nuestros pacientes con qué frecuencia deben esperar un
movimiento intestinal. Debemos evaluar y averiguar el
patrón de movimiento intestinal cuando el paciente acude a
nosotros. El siguiente paciente es un hombre de 72 años
con linfoma progresivo. Este paciente había estado
alimentándose bien. Hacía seis meses que estaba
experimentando algunas dificultades intestinales. Estaba
teniendo movimientos intestinales cada dos días, pero en
cantidad insuficiente; es decir, acumuló materia fecal
diariamente durante seis meses. Le administramos cuatro
enemas de leche y melaza. El primer día llenó un balde de
heces. El segundo día le administramos cuatro enemas
más; otro balde de heces. Cuando estaba en el inodoro,
llamó la enfermera y le solicitó que entrara porque sentía
7
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
mucho dolor en el recto. La enfermera lo llevó a la cama, se
colocó un guante, realizó un examen rectal digital y detectó
una impactación. Solicitó mi ayuda. La impactación era
grande, dura y tenía puntas. Me coloqué un guante y traté
de rebajar las puntas porque si pasaba por el ano,
provocaría sangrado y un dolor terrible; pero no pude
hacerlo con mi dedo. Llamé al gastroenterólogo y me dijo
que había realizado un buen trabajo purgando a este
paciente, y ahora que ya no tenía náuseas le administraría
®
un galón de GoLytely . El paciente obedientemente bebió
ocho onzas cada 10 minutos. Pudo beber el galón entero
porque tenía lugar, solo debía deshacerse del fecalito. Al
día siguiente, el fecalito ya se había disuelto. Quiero
destacar que nuestros pacientes acumulan heces, y que
necesitamos estar al tanto de su función intestinal porque
nuestros tratamientos provocan estreñimiento.
8
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Two Types of Impaction
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Clean Out All Stool From the Colon
• Low Impaction
– Digitally
remove impaction
– Give enemas
of choice till no
more formed stool
is eliminated
• High Impaction
– Give milk and
molasses enemas
(repeat four times
per day till no more
formed stool is
eliminated)
– Give oral laxative
based on lab values
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.
Existen dos tipos de impactación fecal. En la escuela de
enfermería aprendí que puedo colocarme un guante y
realizar un examen rectal digital para determinar si hay
impactación. A la derecha se ve el desarrollo inicial de una
impactación inferior. El intestino puede expandirse y
agrandarse, y las heces se agrandan tanto que no pueden
pasar por el ano; debemos romperlas digitalmente y
hacerlas descender manualmente. A la izquierda se ve una
impactación superior. Los pacientes con cáncer vienen sin
haber tenido movimientos intestinales por cinco días o más,
aunque se alimentan bien, y al realizarles un examen digital
rectal no siento nada. La conclusión es que como nuestros
pacientes no se alimentan ni beben lo suficiente, no están
teniendo un movimiento peristáltico masivo en su tracto
gastrointestinal, y están reteniendo líquido en la parte
superior del colon, que en realidad es materia fecal
impactada. Al tratar a estos pacientes, debemos diferenciar
entre la impactación inferior y superior.
La impactación inferior se remueve digitalmente, usando los
dedos para romperla y ayudarla a salir. Se administran
enemas al paciente hasta que ya no elimina heces
formadas. Cuando el paciente tiene una impactación
superior, recomiendo usar enemas de leche y melaza, y
repetirlos cuatro veces al día hasta que ya no elimine heces
formadas. Administramos laxantes orales y el tipo de
medicación se basa en los valores de laboratorio.
9
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Milk and Molasses Enema Recipe
• Mix ¾ cup hot water with 3 ounces
powdered milk
• Add 4 ½ ounces molasses
• Give four times per day
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Why Milk and Molasses Enema Works
•
•
•
•
Low volume
Hyperosmolar solution
Comfort of patient
Ease of administering
*Need research for evidence based practice
So if you’re going to give a milk and molasses enema,
this is the recipe: you mix ¾ 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.
Esta es la receta para un enema de leche y melaza:
mezclar ¾ taza de agua caliente con 3 onzas de leche en
1
polvo; añadir 4 /2 onzas de melaza, y administrar cuatro
veces al día.
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.
Utilizo leche y melaza porque funciona, debido a que
usamos un volumen bajo. Esta receta es solo una taza y
media, y los pacientes que están tan llenos de heces no
pueden tolerar un litro de líquido de un enema. Es una
solución hiperosmolar, y como es un volumen muy bajo,
muy concentrado, ayudará a romper las heces y a que
desciendan. Es un enema cómodo para el paciente, solo
son alimentos, no es un estimulante. Los pacientes nunca
se han quejado de este tipo de enema. Es muy fácil de
administrar porque es un enema de retención, no va a salir
enseguida. Demostraré cómo administrar este enema.
10
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Tips on How to Get Good Results from Enema
Type of enema bag
Position on left side to advance enema tube
Turn patient to right side
Administer solution slowly
Clamp enema tube and keep in place for 20
minutes while patient stays on right side
• Then remove enema tube
•
•
•
•
•
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.
Consejos para conseguir buenos resultados con el enema
administrado. En primer lugar, necesita una bolsa de enema
del hospital. Si está hablando con un paciente que está en
su hogar, en la farmacia no conseguirá una bolsa de enema
efectiva porque suele ser la de goma roja, con un tubo largo
y un pico de enema conectado a un pico para duchas.
Queremos insertar el tubo, por lo que la bolsa de enema de
farmacia no funcionará. Para que los pacientes puedan
hacerlo si lo necesitan como remedio casero, debe
proporcionarles una bolsa de enema del hospital. Coloque
al paciente sobre su lado izquierdo e inserte el tubo de
enema 12 pulgadas. Luego colóquelo sobre su lado
derecho. Mientras gira al paciente hacia la derecha, cuando
administre la solución esta pasará del colon transverso al
colon ascendente y no saldrá. Recuerde que es un enema
de retención. Luego de administrarlo, no debe tirar del tubo
de enema; si lo hace, el paciente tendrá el reflejo inmediato
de evacuar, y queremos que lo retenga durante 20 minutos.
Debe sujetar el tubo, dejar al paciente sobre su lado
derecho durante 20 minutos y luego retirar el tubo. Se
sorprenderá con los resultados obtenidos.
11
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Also Cleanse Colon from Above
• Give magnesium citrate, one bottle and repeat
next day if needed
• If kidney function is compromised, give lactulose
30cc every 4-6 hours unless patient’s abdomen
is distended
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
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.
Al mismo tiempo debe darle citrato de magnesio (un frasco
por boca) y, si es necesario, repetirlo al día siguiente. El
objetivo es empujar todo desde arriba. Si trabajamos desde
ambos extremos, eliminaremos toda la materia fecal. El
único caso en que administro lactulosa es cuando el
paciente tiene la función renal comprometida. Administraría
30 cc cada cuatro a seis horas, a menos que el paciente
tenga el abdomen distendido. En este caso no administraría
lactulosa, ya que fermenta cuando llega al intestino y
provoca el efecto secundario de la flatulencia. También
puede provocar deshidratación. Si se utiliza en el hogar, no
lo recomiendo para intervalos menores a seis horas porque
el paciente puede deshidratarse si no está recibiendo
líquidos por vía intravenosa.
Puede continuar administrando enemas y medicamentos
orales hasta que no haya más heces formadas en el colon.
Continue enemas and oral medications until
there is no more formed stool in the colon
12
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
After colon is free of stool, a bowel
maintenance program can be initiated
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Bowel Maintenance Program Includes
• 2 quarts (64 ounces) fluid per day
• 25-40 grams of fiber per day
• Eat three well balanced, good sized meals
per day if possible
• Provide bowel medications to offset side effects
of opioids and other medications on the GI tract
• Include physical activity in daily regimen
• Bowel training if needed
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.
Con el colon vacío, se alcanza la normalización de los
intestinos y se puede iniciar un programa de mantenimiento
del intestino para el paciente. A menudo recibimos
pacientes estreñidos y les administramos laxantes
estimulantes, pero este no es el momento de administrar
laxantes estimulantes porque provocan molestias a los
pacientes. Primero deben eliminar las heces, y luego se
pueden incorporar otros medicamentos intestinales al
programa de mantenimiento.
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
El programa de mantenimiento del intestino debe incluir una
cantidad de líquidos suficiente, es decir, dos litros de líquido
por día. Necesitan 25 a 40 gramos de fibra por día. Si no
pueden incorporarla a su dieta, deben hacerlo
medicinalmente. Si el paciente está recibiendo alimentación
por tubo, asegúrese de que el dietista le dé una fórmula con
fibra. Debe informarse a los pacientes que no pueden poner
®
Metamucil en el tubo de alimentación, porque lo bloqueará.
Los pacientes deben tener una dieta balanceada y recibir
porciones abundantes de comida todos los días. Esto es
importante para un buen funcionamiento intestinal. Los
pacientes que reciben alimentos líquidos o con tubos de
alimentación creen que porque solo toman líquidos no
tienen que tener movimientos intestinales todos los días. Es
un mito. Si están recibiendo su nutrición en forma líquida,
necesitan tener un movimiento intestinal todos los días. Si
están comiendo la mitad de lo normal en forma líquida, cada
dos días, y así sucesivamente. Asegúrese de que sus
pacientes lo comprendan. Deben proveerse medicamentos
intestinales para compensar los efectos secundarios de los
opioides y otros medicamentos en el tracto gastrointestinal.
Además, debe incluirse actividad física en el régimen diario
del paciente y si este necesita entrenamiento intestinal,
debemos ayudarlo.
13
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Front Line Therapy for Constipation
• Adequate fluid (2 quarts per day)
• Fiber (nutritional or medicinal)
– Nutritional - 1 cup of Fiber One® cereal
(noodle type) per day
– Medicinal - 1 tablespoon (6.8 grams) of psyllium
or methylcellulose in 8 ounces of water followed
immediately by 8 more ounces of water daily
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
If Front Line Therapy is Not Effective
Add:
• Osmotic laxatives (i.e., magnesium
hydroxide, polyethylene glycol)
• Stool softeners (i.e., docusate sodium)
• Lubricants as needed
If this is not effective, add stimulants (i.e., senna)
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.
El tratamiento principal para el estreñimiento es la ingesta
de líquidos suficientes (2 cuartos por día) y fibra nutricional
®
o medicinal. Como fibra nutricional, el cereal Fiber One es
muy eficaz. Tiene forma de fideos y la caja indica que una
taza de cereal contiene 28 gramos de fibra. Si a eso le
añaden frutas, ya tienen su cuota diaria de fibra. En una
sociedad donde no se consume suficiente fibra, esta es una
buena manera de enseñar a los pacientes a hacerlo. Lo
incorporamos al menú para los pacientes y pueden elegirlo
como desayuno todos los días. Si no pueden consumir fibra
nutricional o esta es insuficiente, recomiendo la fibra
medicinal: 1 cucharada (6.8 gramos) de psilio o 1 cucharada
de metilcelulosa en 8 onzas de agua, seguidas de otras 8
onzas de agua, ya que es la cantidad de líquido que beban
la que dictará cómo actuará en el tracto gastrointestinal. Si
no pueden beber tanto líquido de una vez, recomiendo una
cucharadita copiosa en 4 onzas de líquido, y 4 onzas de
líquido adicionales, dos veces al día.
Si la terapia de fibra y líquidos no es efectiva, pueden
®
agregarse leche de magnesia, MiraLax , ablandadores de
materia fecal y lubricantes. Para prevenir el estreñimiento,
recomendamos a los pacientes que si esperan tener un
movimiento intestinal cada dos días (comiendo la mitad de
lo normal) y a las 4 pm no lo han tenido, que beban 4 onzas
de jugo de ciruela. Si a la hora de dormir no han tenido un
movimiento intestinal, deben tomar leche de magnesia.
14
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Set Expectation for Frequency of Bowel
Movements and Then:
• If no bowel movement by 4 p.m. on the expected day,
take 4 ounces of prune juice followed by a hot liquid
• If no bowel movement by bedtime, take 2 tablespoons
or 2 caplets of magnesium hydroxide
• If no bowel movement after breakfast the next day,
repeat magnesium hydroxide every 6 hours until bowel
movement
• If patient needs to repeatedly take magnesium
hydroxide, increase maintenance program medications
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
If on Opioids or Other Constipating Medications
• Take up to 8 senna-s per day
• If laxation does not occur, add polyethylene
glycol:
17 grams in 8 ounces of water daily
• Next, increase polyethylene glycol to two doses
daily
• If no relief from above regimen, consider giving
subcutaneous methylnaltrexone every other day
for opioid-induced constipation
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.
Reitero: si no hay movimiento intestinal a las 4 pm del día
esperado, tomar 4 onzas de jugo de ciruela y una bebida
caliente. Si no hay movimiento intestinal a la hora de dormir,
tomar 2 cucharadas —o dos cápsulas si no le agrada el
sabor— de leche de magnesia; si no tiene un movimiento
intestinal después de desayunar al día siguiente, continúe
tomando leche de magnesia cada seis horas hasta que se
produzca una evacuación. Si el paciente debe tomar leche
de magnesia varias veces, su programa de mantenimiento
del intestino no es lo suficientemente intenso. Si están
tomando opioides y medicamentos para el estreñimiento,
pueden tomar hasta 8 Senna-S por día. Si están tomando 2
Senna-S dos veces al día, pueden aumentarlo a 3 veces al
día. Si están tomando 4 Senna-S dos veces al día, que es
®
la dosis óptima, y eso no funciona, añada MiraLax una vez
®
al día. Si eso no funciona, pueden tomar MiraLax dos
veces al día.
Pueden tomar hasta 8 Senna-S por día; si no se produce un
®
efecto laxante, agregue MiraLax , y auméntelo a dos dosis
por día si fuera necesario. Si no hay alivio con este régimen,
®
considere administrar Relistor por vía subcutánea. Este es
un nuevo medicamento para el estreñimiento inducido por
opioides. No tendrá ningún efecto sobre ningún otro factor
causal del estreñimiento, solo sobre los opioides.
15
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Methylnaltrexone
• Indicated for treatment of opioid-induced
constipation (OIC) in patients with advanced
illness who are receiving palliative care
when response to laxative therapy has not
been sufficient
• Decreases constipating effects of opioids
• Does not diminish the central analgesic
effects of opioids
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Curative Care
Discussion of Palliative Care
Palliative Care (Symptom Management)
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.
También está indicado para tratar el estreñimiento inducido
por opioides en pacientes con enfermedades avanzadas, o
que reciben cuidados paliativos cuando la respuesta al
tratamiento con laxantes no ha sido suficiente. Disminuye
los efectos de estreñimiento de los opioides porque los
retira de los receptores Mu en el colon y permite un efecto
laxante normal. No disminuye el efecto analgésico central
de los opioides, por lo que es un buen medicamento para
administrar porque se obtienen los beneficios de los
opioides y el efecto analgésico.
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.
Ya que menciona su administración a pacientes de
cuidados paliativos, revisemos el proceso de los cuidados
curativos y paliativos. Al ser diagnosticado inicialmente con
cáncer, se está en el modo curativo y de cuidado agudo.
Del lado izquierdo, vemos que la atención se centra
principalmente en el cuidado curativo. Con una enfermedad
progresiva, la forma curativa del tratamiento es cada vez
menor. En el modo de cuidado curativo, también se reciben
algunos tratamientos paliativos como el control de síntomas
o el tratamiento del dolor. La mayoría de nuestros pacientes
con cáncer reciben cuidado curativo y control de síntomas
durante el proceso de cuidado.
16
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Contraindications for Methylnaltrexone
Patients with known or suspected mechanical
gastrointestinal obstruction
Note
Methylnaltrexone has not been studied in:
- Pregnant or breastfeeding women
- Children
- Patients with severe hepatic impairment
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Methylnaltrexone Administration
• Based on patient’s weight
• Given subcutaneously
• Usually given every other day, but no
more frequently than every 24 hours
• Causes laxation within one half hour
to four hours
• Dose reductions with severe renal impairment
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Bowel Training
• Drink 4 ounces of prune juice before a
big meal of choice
• Eat a big meal
• Drink a hot liquid, then
• Immediately insert a bisacodyl suppository
• Repeat steps above for 14 days
• On day 15, insert a glycerin suppository in
place of the bisacodyl suppository
• If no results, insert bisacodyl suppository, then
• In one week, retry glycerin suppository
®
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.
®
®
Las contraindicaciones del Relistor se aplican a los
pacientes que tienen o en quienes se sospecha obstrucción
mecánica gastrointestinal. Debemos comprender que no es
un medicamento mágico que puede administrarse
libremente, y que con una inyección los pacientes tendrán
un movimiento intestinal. Si tienen impactaciones, esa
materia fecal debe retirarse porque puede tratarse de una
obstrucción mecánica por heces. Si están llenos de materia
fecal, no se puede administrar. Es bueno como dosis de
®
mantenimiento. Relistor no ha sido estudiado en mujeres
embarazadas o en período de lactancia, ni niños o
pacientes con insuficiencia hepática grave.
®
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.
La dosis de Relistor se basa en el peso del paciente. Es
administrado por vía subcutánea. Suele darse cada dos
días, y con una frecuencia de hasta 24 horas. El efecto
laxante aparece dentro de los treinta minutos a cuatro
horas. Las dosis se reducen cuando existe una insuficiencia
renal grave.
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
Si el paciente necesita entrenamiento intestinal para el
estreñimiento, debe utilizarse el siguiente método: hacerle
beber 4 onzas de jugo de ciruela antes de una comida
abundante de su elección. No importa qué comida, aunque
es preferible el desayuno porque es cuando se tiene el
reflejo gastrocólico normal —aunque algunas personas no
pueden hacerlo sino hasta la noche debido a su situación
en el hogar. Deben elegir una comida abundante y
concentrar su entrenamiento intestinal en ella. El paciente
bebe 4 onzas de jugo de ciruela antes de la comida de su
elección, come abundantemente, bebe algo caliente e
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Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Digital Stimulation is Utilized When
• Regular bowel training is not successful for
patients with neurogenic bowel
• Patient has S2 and below nerve involvement
• When anal sphincter is very tight and stool can’t
pass through without relaxing the external and
internal sphincters
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
How to do Digital Stimulation
• Insert gloved, lubricated index finger ½ inch into
anus and gently rotate finger in a circular motion
• Advance index finger to 1 inch and continue
circular rotation of finger until relaxation of
internal sphincter is felt
• Allow stool to pass and repeat until no more
stool is present
• Repeat daily as part of bowel regimen
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.
inmediatamente después se coloca un supositorio de
bisacodilo. Debe repetir este paso durante 14 días y el día
15, colocarse un supositorio de glicerina en lugar del
bisacodilo. Al llevar a cabo este entrenamiento de dos
semanas, el intestino aprende a responder al estímulo del
jugo de ciruela, la comida abundante y la bebida caliente, y
®
posiblemente ya no necesite el supositorio Dulcolax . Si no
obtienen resultados con el supositorio de glicerina, coloque
el supositorio de bisacodilo durante otra semana y luego
vuelva a intentarlo.
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.
¿Cómo se realiza la estimulación digital? El proceso es el
siguiente: debe colocarse un guante y lubricar el dedo
índice. Introduzca el dedo lubricado media pulgada dentro
del ano y haga una rotación circular, muy suavemente
porque se busca relajar el esfínter externo. Introduzca el
dedo 1 pulgada y continúe la rotación circular hasta relajar
el esfínter interno. Una vez relajado, la materia fecal
comenzará a pasar. Esto puede repetirse hasta que ya no
se elimine materia fecal. Debe repetir el proceso
diariamente como parte del entrenamiento intestinal.
A veces las personas necesitan estimulación digital para
tener un movimiento intestinal. La estimulación digital se
utiliza cuando el entrenamiento intestinal normal no tiene
éxito en los pacientes con un intestino neurogénico. Todos
los pacientes con afectación de los nervios S2 e inferiores
necesitan estimulación digital. Cuando el esfínter anal es
muy estrecho y la materia fecal no puede pasar sin relajar
los esfínteres externo e interno, se necesita estimulación
digital.
18
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Bowel Training With Digital Stimulation
• Bowel train with prune juice, big meal, hot liquid
and immediately
• Do digital stimulation to empty stool in rectal vault
• Insert bisacodyl suppository and 30 minutes later
• Repeat digital stimulation until all stool
is eliminated
• Teach patient to do this daily as only means
of elimination
Normal Bowel Function and Dysfunction
Related to Constipation and its Treatment
Summary
You have learned:
• The importance of normalizing the bowel
before giving a maintenance program
• The way to administer milk and molasses
enemas for the best outcome
• A new medication effective for opioid
induced constipation
• When digital stimulation is needed for
bowel training
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.
Si es necesario, puede combinar el entrenamiento intestinal
con la estimulación digital del siguiente modo: el
entrenamiento intestinal se realiza con el jugo de ciruela, la
comida abundante y la bebida caliente. Inmediatamente
después, debe realizar la estimulación digital para vaciar las
heces en la ampolla rectal. Luego se coloca el supositorio
de bisacodilo y 30 minutos más tarde se repite la
estimulación digital hasta que se elimine toda la materia
fecal. Enseñe al paciente a hacer esto diariamente, porque
es el único medio que tiene para eliminar las heces. Muchos
de nuestros pacientes con intestinos neurogénicos y
afectación de nervios lo practican diariamente de manera
exitosa.
En resumen, hemos aprendido la importancia de normalizar
el intestino antes de administrar al paciente un programa de
mantenimiento del intestino, y cómo administrar enemas de
leche y melaza para obtener mejores resultados.
Conocimos un nuevo medicamento eficaz para el
estreñimiento inducido por opioides que ha sido resistente
al tratamiento normal con laxantes. Y por último,
aprendimos en qué casos es necesaria la estimulación
digital en el entrenamiento intestinal. Muchas gracias por su
atención.
19