Bowel Problems: Prevention and Treatment

Bowel Changes During Treatment There are 7 types of stool. Types 3 and 4, considered normal stool, is best for comfort and overall health. Cancer can change your normal bowel patterns, depending on the type of cancer you have and your How do bowel movements happen? treatment plan. These changes can affect how you feel and your ability to go about your daily activities. If you The organs in the body that help digest food are part have constipation or diarrhea, this guide can help. You of the digestive system, also called the gastrointestinal will learn the symptoms and causes of bowel problems (GI) tract (Figure 1). After food passes through the and how to treat them. stomach and small intestine, the remaining material is mostly waste products in liquid form. This liquid Normal Bowel Movements stool then enters the colon where water is absorbed for use in the body. The last portion of the colon empties Body waste (called stool) is usually medium brown, stool into the rectum. The rectum acts like a pouch to soft and formed. “Normal” depends on the person. hold stool until a bowel movement happens. During Only you know what is normal for you. Is your stool a bowel movement, stool passes through the anus and too difficult to pass? Do you have bowel movements out of the body. New food and fluids can then move more or less frequently than before?

Bristol Stool Chart

Type 1 Separate hard lumps Severe constipation

Type 2 Lumpy and sausage like Mild constipation

A sausage shape with cracks Normal Type 3 in the surface Like a smooth, sausage Normal Type 4 or snake Soft blobs with Lacking fiber Type 5 clear-cut edges Mushy consistency Mild diarrhea Type 6 with ragged edges Liquid consistency with Severe diarrhea Type 7 no solid pieces

Created by the Bristol Royal Infirmary, Bristol, England, 1997 3 Figure 1 GI Tract

through the digestive system and supply the body with Constipating Medicines nutrients. If you take constipating medicines, such as opioids for pain or Zofran® for nausea, begin to take stimulant How often should I go? laxatives and stool softeners daily. Check with your Normal frequency is different for each person, but doctor or nurse about how much to take per day. See should happen in a consistent pattern day to day. page 11 for more information. Bowel movements usually happen after a big meal when contents in the GI tract move down to make Opioid pain medicines slow down the movement room for incoming food. For example, many people of stool through the GI tract and will cause stool to have a bowel movement in the morning after eating harden. Common opioids prescribed are: breakfast. • Morphine (MS Contin®)

The frequency of how often you go is related to how • Hydrocodone (Norco®) much food you eat. Everyone is different, but a general • Oxycodone (OxyContin®) guideline is: • Fentanyl (Duragesic®) • If you eat 3 meals a day, expect a bowel movement • Hydromorphone (Dilaudid®) every day. • If you eat half your normal amount of food, expect Other medicines may also cause constipation, a bowel movement every other day. including: • If you eat one-third of the amount, expect a bowel • Some anti-nausea drugs such as ondansetron movement every third day. (Zofran®) • Some anti-depressants such as fluoxetine (Prozac®) Constipation and amitriptyline (Elavil®) Constipation is the infrequent or difficult passing • Antihistamines of hard, dry stool. • Calcium channel blockers • Diuretics (water pills) Causes • Iron supplements • Not drinking enough fluid • Muscle relaxers • Not eating enough food • Parkinson’s disease medicines • Not enough fiber in the diet • Calcium-based antacids or calcium supplements. • Lack of physical activity Magnesium-based products may cause softer • Constipating medicines and more frequent (loose) stools. If the product is a combination of calcium and magnesium, 4 Figure 2 High Impaction Figure 3 Low Impaction

it may affect bowel movements. Check the Impactions ingredient label. An impaction is a case of severe constipation. It is a Always read the label on over-the-counter products build-up of stool either in the upper or lower part of and understand what you are taking and why. the colon. Sometimes your health care provider may tell you to take over-the-counter medicine differently than There are several ways to diagnose impactions. An the package label says. Always follow your provider’s impaction can happen if constipation is not treated. instructions. Call your health care provider if you think you may have an impaction. Prescription medicines can cause changes in your bowel. Check with your doctor or pharmacist about High and low impactions have different symptoms how your medicines may affect your bowel. (Figures 2 and 3).

Symptoms of Constipation High Impaction Symptoms • No bowel movement for 3 or more days • No bowel movement for 5 or more days • Straining during a bowel movement • Not being able to eat • Hard stool • Pain in the belly or the belly becoming swollen and possibly hard • Gas • Passing liquid stool that is seeping around formed • Bloating stool Report the following symptoms to your doctor: Low Impaction Symptoms • No bowel movement for more than 3 days • No bowel movement for 5 or more days • Abdominal pain, cramping • Not being able to pass stool that you feel in the • Fever rectum • Nausea and vomiting • Not being able to sit comfortably, because it feels like you are sitting on something • Pain in the belly • Passing liquid stool that is seeping around formed stool

5 Preventing Constipation Laxatives and Stool Softeners • Fluid: Drink at least 2 quarts (equal to 64 ounces) Stimulant laxatives and stool softeners are medicines of non-alcoholic fluids each day. Half of your daily that can help you have a bowel movement. Stimulant fluid intake should be from non-caffeinated fluids, laxatives help move stool down the GI tract and stool like water. softeners help keep fluid in the stool.Some are in pill • Food: Eat a well-balanced diet that includes: form while others are in liquid. Many are available without a prescription. – Items from all food groups: milk and milk products, lean meat and beans, vegetables, The chart on page 11 provides information on laxatives fruits and whole grains. and other products available to help pass stool. Your – 30-40 grams of fiber a day. Good sources of care team can help you decide which product is best dietary fiber include pears, raspberries, for you. Keep in mind that many store brand or blackberries, green leafy vegetables, peas, generic products work equally as well as name brand beans, lentils and foods made with whole products and often cost less. grains. Ask your doctor or dietitian about adding flaxseed or chia seeds to yogurt, cereal Contact your doctor, nurse or pharmacist if you have or oatmeal. questions. – Foods that may help you have a bowel movement, like prunes or high-fiber cereal Treating Constipation (such as General Mills Fiber One®). Follow these tips to help treat constipation. • Fiber: You may need to take medicinal fiber. • Drink a hot or warm liquid after eating a meal. For Follow these steps: mix 6.8 grams of Metamucil® some people, drinking a hot liquid helps to bring or 1 tablespoon of Citrucel® in 8 ounces of water on a bowel movement. For example, drinking and drink. Next, drink 8 more ounces of fluid, like senna-based hot tea can help relieve constipation. water. Do not take medicinal fiber if you have a Senna is an herb that is approved by the Federal history of blockages in the bowel, or if you are on Drug Association (FDA) for use as an over-the- chemotherapy that causes diarrhea. counter laxative. Several senna tea brands are available in the tea or natural remedy section • Activity: Daily physical activity helps keep the of grocery and drug stores. Avoid tea labeled as digestive system active. Ask your doctor about how dieter’s tea. This tea contains herbal ingredients much physical activity is best for you. that can cause pain, gas and cramping leading to • Timing: Go to the bathroom right away when you diarrhea. feel the urge to have a bowel movement – don’t wait. • If you do not have a bowel movement by 4 p.m. on the day you expect, follow these guidelines.

6 For constipation: Several generic brands of combination stool softener and stimulant laxatives

– Drink 4 ounces of prune juice followed by 8 Causes ounces of hot liquid. Hot or warm tea is a good • Anxiety choice. Avoid drinking caffeinated coffee. • Fried and spicy foods – If you do not have a bowel movement by • Food allergies bedtime, take milk of magnesia. This gentle • Impaction - See page 5. laxative is available over-the-counter in liquid or pill form. Take 2 tablespoons or 2 pills of • Infections or parasites in the GI tract milk of magnesia at bedtime with 8 ounces of • Irritable bowel syndrome (IBS) water. • Inflammatory bowel disease (IBD) – If you do not have a bowel movement by • Increasing your daily intake of fiber too quickly breakfast the next morning, you may repeat the • Medicines and medical treatment dose of milk of magnesia and 8 ounces of water every 6 hours until you have a bowel movement. If you have kidney problems, ask Medicines and Medical Treatment That May your health care provider before repeating the Cause Diarrhea dose. • Broad spectrum antibiotics • You may need an enema if you feel like you have • Laxatives a large amount of stool in your bowel. Speak with • Radiation treatment to the abdomen your nurse or doctor before using an enema. You • Surgery that shortens the small intestine or colon will receive instructions on the type of enema that is right for you and how to take it. • Some chemotherapy medicines • Antacids with a magnesium base • Follow the prevention guidelines on page 5 after Some liquid nutrition supplements, such as Boost you no longer feel constipated. Plus® can cause diarrhea in some people. Your dietitian Learn about your risk for constipation by answering can help you choose the best supplement for you. the Constipation Risk Assessment on page 10. Symptoms Diarrhea • More bowel movements than normal Diarrhea is the passing of loose, liquid stool more than • Loose, liquid stools 3 times per day. • Pain in the belly • You are unable to hold back a bowel movement

7 For diarrhea: Name brand and generic anti-diarrhea medicine

If you have diarrhea and don’t know why, talk to your Treating Diarrhea doctor or nurse. Your treatment will vary depending • Eat small, frequent meals to help slow movement on the cause of the diarrhea. It is important to treat the in the GI tract. cause, not the symptom. • Limit fluids with meals to 8 ounces. Preventing Diarrhea • Avoid fried and spicy foods. • If you are lactose intolerant, take Lactaid® when • Add foods to your diet that slow the movement of eating or drinking milk or milk products. stool in the GI tract, like those in the BRAT diet • Avoid foods containing known allergens. (banana, rice, applesauce and toast). These foods help reduce the number of stools. • Wash all fresh fruits and vegetables before eating. • Avoid drinking hot liquids until your diarrhea • Drink no more than 8 ounces of fluids with meals. stops. • Some antibiotic medicine can kill the healthy • If you will have radiation treatment, chemotherapy bacteria in the GI tract. Acidophilus and or surgery, ask your doctor for a consultation with lactobacillus are over-the-counter supplements a dietitian. that can restore normal bacteria levels and prevent diarrhea. When you take antibiotics, follow these • Check with your health care provider about taking guidelines: over-the-counter anti-diarrhea medicine, such as Imodium®. Do not take more than 16 milligrams of − Take acidophilus or 2 lactobacillus pills Imodium per day. (available at drug stores and pharmacies) 4 times a day. • If you still have diarrhea after taking 16 milligrams of Imodium, ask your doctor about a prescription or medicine called Lomotil®. − Eat yogurt containing acidophilus or live • Tell your medical team if your diarrhea continues. cultures twice a day. Some of these yogurts Fluid loss and electrolyte imbalances can occur if indicate “live cultures” on the container label. diarrhea does not improve.

8 MD Anderson Resources Constipation Risk Assessment This tool will help you determine your risk for Bowel Management Class constipation. Attend a free class with your caregiver. You will learn how the healthy bowel works, how to prevent and Directions: For questions 1 and 2, answer by check- manage constipation and diarrhea and how to promote ing Yes or No. For questions 3 through 18, write in a good bowel health. For class information, visit The number in the score box next to the question. Add the Learning Center or call Patient Education at numbers to find your constipation risk score and write 713-792-7128. it down on page 12.

Videos What does your score mean? MD Anderson offers patient education videos to Low Risk for Constipation – Learn more about help you learn about bowel management. Visit The managing symptoms that may be caused by cancer Learning Center to view videos that your health care treatment. Ask your provider for more information or team recommends. You may also access some patient visit The Learning Center. education videos through MyChart.mdanderson.org. MyChart is a secure, personalized website and mobile Moderate Risk for Constipation – Show your app that helps you take an active role in managing health care provider your score and ask if a bowel your care at MD Anderson. To create an account, call maintenance program is right for you. askMDAnderson at 877-632-6789. High Risk for Constipation – Show your health The Learning Center care provider your score and ask him or her to check The Learning Center is a patient education library. We your bowel. Your health care provider can give you provide current and reliable information on cancer information about how to treat constipation and then prevention, treatment, coping and general health. prevent it. • Theodore N. Law Learning Center Main Building, Floor 4, near Elevator A, 713-745-8063

• Levit Family Learning Center Mays Clinic, Floor 2, near The Tree Sculpture, 713-563-8010

9 Risk Factor Score Risk Factor Score

1. Do you believe that you easily 12. Do you have a tumor in your rectum or become constipated? ovary or have had surgery in your Yes No pelvic (hip) area? Yes = 3 No = 0 2. Do you take laxatives to relieve constipation? 13. Have you had a stroke or do you have Yes No a neuromuscular disorder, such as multiple sclerosis, a spinal cord 3. Do you have problems having a compression or Parkinson’s disease? bowel movement when you are away Yes = 3 No = 0 from home? Yes = 2 No = 0 o ou have diaetes or tae throid medicine? 4. Are you? Yes = 3 No = 0 Male = 1 Female = 2 o ou have a lot of cancer in our How moile are ou? ell or have adhesions hemorrhoids • Walk independently = 0 irritale owel sndrome an tpe of • Need a cane, walker or help prolapse or have een told that ou from others to walk = 1 have an ileus? • Restricted to a bed or chair = 2 Yes = 3 No = 0 • Bed bound = 3 re ou currentl taing these medicines? How man servings of fier fruits and • Anti-depressants = 2 vegetales do ou eat each da? • Anti-inﬂammatory medicine = 3 • 2 servings or less = 2 • Anti-nausea medicine, such as • 3-4 servings = 1 ondansetron/Zofran® = 2 • 5 servings or more = 0 • Anti-seizure medicine = 2 • Calcium channel blockers = 2 7. Do you eat bran products (such as • Iron supplements = 2 bran cereal) each day? • Pain medicine (opioids) = 5 Yes = 0 No = 2 • Parkinson’s disease medicine = 2

8. How much ﬂuid do you drink each day? re ou taing one of these constipating • 10 glasses (8 ounces each) or more = 0 chemotherap medicines? • 6-9 glasses (8 ounces each) = 1 • Vincristine • 5 glasses (8 ounces each) or less = 2 • Vinblastine • Thalidomide 9. Have you been told that you have Yes = 5 No = 0 depression? Yes = 2 No = 0 re ou receiving other constipating cancer treatments as eplained 10. Have you been told that you have our health care provider? dementia or a learning disability? Yes = 3 No = 0 Yes = 2 No = 0 otal core 11. Do you have a metabolic disorder, such as low potassium levels, high calcium levels or kidney problems? Score Chart Yes = 2 No = 0 • 10 or less = Low risk for constipation • 11-15 = Moderate risk for constipation • 16 or greater = High risk for constipation

Used with permission by Janice Richmond

10 Laxatives and Stool Sofeners These are examples of over-the-counter medicines that help prevent constipation.

Type Examples Action Side Effects Forms Time to Work Bulk Forming • Methylcellulose Absorbs water • Bloating • Capsule 12-72 hours ® Laxatives (Citrucel ) (adequate water • Gas • Powder to stir • Psyllium husk intake is essential) into water or to form soft, bulky • Cramping (Metamucil ®) other beverage stool triggering • Worsening contraction of constipation intestinal muscles or choking if not taken with enough water Osmotic • Polyethylene Draws fluid into • Bloating • Powder that 12-96 hours Laxatives Glycol 3350 colon to allow • Gas dissolves in a (Miralax ®) easier passage of beverage stool • Cramping • Lactulose • Liquid (prescription • Dehydration only) • Diarrhea Saline • Magnesium Increases fluid • Cramping • Liquid that is 30 minutes- Laxatives citrate in the small • Gas, bloating taken with at 6 hours • Milk of magnesia intestine least 8 ounces • Nausea, of water • Sodium vomiting • Rectal enema phosphate • Diarrhea • Electrolyte imbalance Stimulant • Sennosides Increases • Abdominal • Pills 6-12 hours Laxatives (Senokot ®) the muscle pain • Liquid • Bisacodyl contractions that • Nausea (Dulcolax ®) move stool through the digestive • Weakness system • May turn urine reddish-brown Stool • Docusate sodium Adds more fluid • Cramping • Pills 12-72 hours ® Softeners (Colace ) and fat to stool to • Throat irritation • Liquid that make it easier to is taken with at pass least 8 ounces of water • Rectal enema

Suppositories • Glycerin Draws fluid • Rectal irritation A small cone- 15-30 into the colon • Cramping shaped solid minutes causing muscle that is inserted contractions • Sensation of in the rectum. inability or The solid difficulty to dissolves and empty the releases medicine. bowel