Gastrointestinal complications (constipation, impaction, bowel obstruction, diarrhea, and radiation enteritis) are common problems for oncology patients. The growth and spread of cancer, as well as its treatment, contribute to these conditions.

Constipation is the slow movement of feces through the large intestine that results in the passage of dry, hard stool. This can result in discomfort or pain.[1] The longer the transit time of stool in the large intestine, the greater the fluid absorption and the drier and harder the stool becomes.

Inactivity, immobility, or physical and social impediments (particularly inconvenient bathroom availability) can contribute to constipation. Depression and anxiety caused by cancer treatment or cancer pain can lead to constipation. Perhaps the most common causes of constipation are inadequate fluid intake and pain medications; however, these causes are manageable.

Constipation may be annoying and uncomfortable, but fecal impaction can be life-threatening. Impaction refers to the accumulation of dry, hardened feces in the rectum or colon. The patient with a fecal impaction may present with circulatory, cardiac, or respiratory symptoms rather than with gastrointestinal symptoms.[2] If the fecal impaction is not recognized, the signs and symptoms may progress and result in death.

In contrast to constipation or impaction, an intestinal obstruction is a partial or complete occlusion of the bowel lumen by a process other than fecal impaction. Intestinal obstructions can be classified by three means: the type of obstruction, the obstructing mechanism, and the part of the bowel involved.

Structural disorders, such as intraluminal and extraluminal bowel lesions caused by primary or metastatic tumor, postoperative adhesions, volvulus of the bowel, or incarcerated hernia, affect peristalsis and the maintenance of normal bowel function. These disorders can lead to total or partial obstruction of the bowel. Patients who have colostomies are at special risk of developing constipation. If stool is not passed on a regular basis (once a day to several times a day), further investigation is warranted. A partial or complete blockage may have occurred, particularly if no flatus has been passed.[3]

Diarrhea can occur throughout the continuum of cancer care, and the effects can be physically and emotionally devastating. Although less prevalent than constipation, diarrhea remains a significant symptom burden for people with cancer. Diarrhea can alter dietary patterns, trigger dehydration, create electrolyte imbalance, impair function, cause fatigue, impair skin integrity, limit activity, and in some cases, be life threatening. Furthermore, diarrhea can lead to increased caregiver burden. Specific definitions of diarrhea vary widely. Acute diarrhea is generally considered to be an abnormal increase in stool liquid that lasts more than 4 days but less than 2 weeks. Another definition suggests that diarrhea is an increase in stool liquidity (>300 mL of stool) and frequency (the passage of more than three unformed stools) during a 24-hour period.[4] Diarrhea is considered chronic when it persists longer than 2 months.

Radiation enteritis is a functional disorder of the large and small bowel that occurs during or after a course of radiation therapy to the abdomen, pelvis, or rectum.

The large and small bowel are very sensitive to ionizing radiation. Although the probability of tumor control increases with the radiation dose, so does the damage to normal tissues. Acute side effects to the intestines occur at approximately 10 Gy. Because curative doses for many abdominal or pelvic tumors range between 50 and 75 Gy, enteritis is likely to occur.[5]

Management of constipation, impaction, bowel obstruction, diarrhea, and radiation enteritis in the pediatric patient varies from management in the adult patient and should be adjusted accordingly.

References

1. Culhane B: Constipation. In: Yasko J, ed.: Guidelines for Cancer Care: Symptom Management. Reston, Va: Reston Publishing Company, Inc., 1983, pp 184-7. 
   
   
2. Wright BA, Staats DO: The geriatric implications of fecal impaction. Nurse Pract 11 (10): 53-8, 60, 64-6, 1986.  [PUBMED Abstract]
   
   
3. Hampton BG, Bryant RA, eds.: Ostomies and Continent Diversions: Nursing Management. St. Louis, Mo: Mosby Year Book, Inc., 1992. 
   
   
4. Tuchmann L, Engelking C: Cancer-related diarrhea. In: Gates RA, Fink RM, eds.: Oncology Nursing Secrets. 2nd ed. Philadelphia, Pa: Hanley and Belfus, 2001, pp 310-22. 
   
   
5. Perez CA, Brady LW, eds.: Principles and Practice of Radiation Oncology. 3rd ed. Philadelphia, Pa: Lippincott-Raven Publishers, 1998. 
   
   

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