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Dtsch Med Wochenschr 2016; 141(16): 1177-1181
DOI: 10.1055/s-0042-101899
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© Georg Thieme Verlag KG Stuttgart · New York

Obstipation bei Patienten mit nicht-heilbarer Krebserkrankung

Empfehlungen der S3-Leitlinie PalliativmedizinConstipation in Patients with Incurable Cancer – Recommendations of the German S3 Guideline ‘Palliative Medicine’
Stefan Wirz
1   Abteilung für Anästhesie, Interdisziplinäre Intensivmedizin, Schmerzmedizin / Palliativmedizin, CURA – katholisches Krankenhaus im Siebengebirge
9   Arbeitskreis Tumorschmerz der Deutschen Schmerzgesellschaft
,
Steffen T. Simon
2   Zentrum für Palliativmedizin, Klinisches Studienzentrum Palliativmedizin, Uniklinik Köln
,
Thomas Frieling
3   Innere Medizin / Klinik II, HELIOS Privatklinik Krefeld
,
Claudia Bausewein
4   Klinik und Poliklinik für Palliativmedizin, Klinikum der Universität München
,
Raymond Voltz
2   Zentrum für Palliativmedizin, Klinisches Studienzentrum Palliativmedizin, Uniklinik Köln
,
Anne Pralong
2   Zentrum für Palliativmedizin, Klinisches Studienzentrum Palliativmedizin, Uniklinik Köln
,
Stefan Mönig
5   Klinik und Poliklinik für Allgemein-, Viszeral- und Tumorchirurgie, Uniklinik Köln
,
Markus Follmann
6   Deutsche Krebsgesellschaft, Berlin
,
Martin Holtmann
7   Medizinische Klinik I, Klinikum Bremerhaven-Renkenheide gGmbH
,
Gerhild Becker
8   Klinik für Palliativmedizin, Universitätsklinikum Freiburg
› Author Affiliations
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Publication History

Publication Date:
10 August 2016 (online)

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Obstipation bei Patienten mit nicht-heilbarer KrebserkrankungDtsch Med Wochenschr 2017; 142(04): 249-249
DOI: 10.1055/s-0043-100769

Zusammenfassung

Nach der durch das Leitlinienprogramm Onkologie geförderten deutschen S3-Leitlinie Palliativmedizin für Patienten mit einer nicht-heilbaren Krebserkrankung erfordert das häufige Auftreten einer Obstipation bei Palliativpatienten eine konsequente Prophylaxe und Therapie. Als Ursachen der Verstopfung finden sich häufig Immobilität, ein reduzierter Allgemeinzustand, ein geringer Volumenstatus bzw. eine ballaststoffarme Ernährung oder auch eine vorbestehende chronische Obstipation. Obstipierende Pharmaka wie z. B. Opioide oder Substanzen mit anticholinergen Eigenschaften stellen weitere wichtige Ursachen dar. Die Diagnose einer Obstipation erfolgt pragmatisch überwiegend durch subjektive Parameter wie das Gefühl einer unvollständigen Entleerung, die Notwendigkeit vermehrten Pressens bzw. stuhlgangabhängige Beschwerden. Objektive Parameter sind eine harte Stuhlkonsistenz bzw. eine verminderte Stuhlmenge und -frequenz. Zur Therapie der Obstipation wird ein standardisiertes stufenförmiges Vorgehen mit ausreichender Flüssigkeitszufuhr, ballaststoffreicher Ernährung und Laxanzien empfohlen. Neue prokinetische Substanzen, Sekretagoga oder Opioidantagonisten können als Reservemedikamente eingesetzt werden.

Abstract

According to the German S3-guideline ‘Palliative Medicine’ which has been supported by the German Guideline Program in Oncology, constipation in palliative patients requires a consistent prophylaxis and therapy. Constipation is caused by immobilisation, poor health, exsiccosis, a low-fiber diet or a preexisting functional constipation. Further important causes are substances with constipating side effects, such as opioids or anticholinergic drugs. Pragmatically, constipation should be assessed by subjective parameters such as the feeling of incomplete evacuation, straining, or other complaints. Objective parameters are hard stool or reduced number of bowel movements. For the early detection of constipation the amount of the stool mass and the stool frequency are applicable. If constipation occurs, a standardized escalating protocol applying adequate fluid intake, a high fibre diet, and laxatives is recommended. New prokinetic agents, secretagogues, or opioid antagonists may be used as reserve drugs.

Schlüsselwörter

Obstipation - Palliativmedizin - Opioide - Laxantien - Opioidantagonisten

Keywords

constipation - palliative medicine - opioids - laxatives - opiod-antagonists
 

  • Literatur

  • 1 Andresen V, Enck P, Frieling T et al. Deutsche Gesellschaft für Neurogastroenterologie und Motilität (DGNM); Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS). Chronische Obstipation bei Erwachsenen. DGNM / DGVS. Z Gastroenterol 2013; 51: 651-672
    PubMedGoogle Scholar
  • 2 Andresen V, Camilleri M, Busciglio IA et al. Effect of 5 days linaclotide on transit and bowel function in females with constipation-predominant irritable bowel syndrome. Gastroenterol 2007; 133: 761-768
    CrossrefPubMedGoogle Scholar
  • 3 Anthony T, Baron T, Mercadante S et al. Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction. J Pain Symptom Manage 2007; 34 (1 Suppl) 49-59
    CrossrefPubMedGoogle Scholar
  • 4 Ashton MR, Sutton D, Nielsen M. Severe magnesium toxicity after magnesium sulphate enema in a chronically constipated child. BMJ 1990; 300: 541
    PubMedGoogle Scholar
  • 5 Bader S, Weber M, Becker G. Is the pharmacological treatment of constipation in palliative care evidence based?. A systematic literature review. Schmerz 2012; 26: 568-586
    PubMedGoogle Scholar
  • 6 Badiali D, Bracci F, Castellano V et al. Sequential treatment of chronic constipation in paraplegic subjects. Spinal Cord 1997; 35: 116-120
    CrossrefPubMedGoogle Scholar
  • 7 Baines MJ. The pathophysiology and management of malignant intestinal obstruction. In: Oxford Textbook of Palliative Medicine. Oxford University Press; Oxford: 1998: 526-534
    Google Scholar
  • 8 Becker G, Galandi D, Blum HE. Peripherally acting opioid antagonists in the treatment of opiate-related constipation: a systematic review. J Pain Symptom Manage 2007; 34: 547-565
    CrossrefPubMedGoogle Scholar
  • 9 Camilleri M, Drossman DA, Becker G et al. Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation. Neurogastroenterol Motil 2014; 26: 1386-1395
    CrossrefPubMedGoogle Scholar
  • 10 Camilleri M, Bharucha AE, Ueno R et al. Effect of a selective chloride channel activator, lubiprostone, on gastrointestinal transit, gastric sensory, and motor functions in healthy volunteers. Am J Physiol Gastrointest Liver Physiol 2006; 290: 942-947
    PubMedGoogle Scholar
  • 11 Candy B, Jones L, Larkin PJ et al. Laxatives for the management of constipation in people receiving palliative care. Cochrane Database Syst Rev 2015; 13: 5
    PubMedGoogle Scholar
  • 12 Cheng CW, Kwok AO, Bian ZX, Tse DM. A cross-sectional study of constipation and laxative use in advanced cancer patients: insights for revision of current practice. Support Care Cancer 2013; 21: 149-156
    CrossrefPubMedGoogle Scholar
  • 13 Dhingra L, Shuk E, Grossman B et al. A qualitative study to explore psychological distress and illness burden associated with opioid-induced constipation in cancer patients with advanced disease. Palliat Med 2013; 27: 447-456
    CrossrefPubMedGoogle Scholar
  • 14 Drossmann DA. Rome III. The functional gastrointestinal disorders. Allen Press, Inc.; Lawrence, KS, USA: 2006: 419-486
    Google Scholar
  • 15 Frieling T. Acute abdomen from the internal medicine point of view. Dtsch Med Wochenschr 2009; 134: 246-250
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Golzarian J, Scott Jr HW, Richards WO. Hypermagnesemia-induced paralytic ileus. Dig Dis Sci 1994; 39: 1138-1142
    CrossrefPubMedGoogle Scholar
  • 17 Larkin PJ, Sykes NP, Centeno C et al. European Consensus Group on Constipation in Palliative Care. The management of constipation in palliative care: clinical practice recommendations. Palliat Med 2008; 22: 796-807
    PubMedGoogle Scholar
  • 18 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): Palliativmedizin für Patienten mit einer nicht heilbaren Krebserkrankung, Langversion 1. 1, 2015, AWMF-Registernummer: 128/001OL http://www.awmf.org/uploads/tx_szleitlinien/128-001OLl_S3_Palliativmedizin_2015-07.pdf
    PubMed
  • 19 Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003; 349: 1360-1138
    CrossrefPubMedGoogle Scholar
  • 20 Max EK, Hernandez JJ, Sturpe DA, Zuckerman IH. Prophylaxis for opioid-induced constipation in elderly long-term care residents: a cross-sectional study of Medicare beneficiaries. Am J Geriatr Pharmacother 2007; 5: 129-136
    CrossrefPubMedGoogle Scholar
  • 21 Meissner W, Schmidt U, Hartmann M et al. Oral naloxone reverses opioid-associated constipation. Pain 2000; 84: 105-109
    CrossrefPubMedGoogle Scholar
  • 22 Miles CL, Fellowes D, Goodman ML, Wilkinson S. Laxatives for the management of constipation in palliative care patients. Cochrane Database Syst Rev 2006; 4: CD003448
    PubMedGoogle Scholar
  • 23 Pare P. The approach to diagnosis and treatment of chronic constipation: suggestions for a general practitioner. Can J Gastroenterol 2011; 25 (Suppl B) 36B-40B
    PubMedGoogle Scholar
  • 24 Portenoy RK, Thomas J, Moehl Boatwright ML et al. Subcutaneous methylnaltrexone for the treatment of opioid-induced constipation in patients with advanced illness: a double-blind, randomized, parallel group, dose-ranging study. J Pain Symptom Manage 2008; 35: 458-468
    CrossrefPubMedGoogle Scholar
  • 25 Quigley EM. Prucalopride: safety, efficacy and potential applications. Therap Adv Gastroenterol 2012; 5: 23-30
    CrossrefPubMedGoogle Scholar
  • 26 Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006; 31: 58-69
    CrossrefPubMedGoogle Scholar
  • 27 Sykes NP. The relationship between opioid use and laxative use in terminally ill cancer patients. Palliat Med 1998; 12: 375-382
    CrossrefPubMedGoogle Scholar
  • 28 Tack J, van Outryve M, Beyens G et al. Prucalopride (Resolor) in the treatment of severe chronic constipation in patients dissatisfied with laxatives. Gut 2009; 58: 357-365
    CrossrefPubMedGoogle Scholar
  • 29 Tamayo AC, Diaz-Zuluaga PA. Management of opioid-induced bowel dysfunction in cancer patients. Support Care Cancer 2004; 12: 613-618
    PubMedGoogle Scholar
  • 30 Thomas J, Karver S, Cooney GA et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med 2008; 358: 2332-2343
    Google Scholar
  • 31 Twycross RG, Harcourt JMV. The use of laxatives at a palliative care centre. Pall Med 1991; 5: 27-33
    CrossrefPubMedGoogle Scholar
  • 32 Wirz S, Klaschik E. Management of constipation in palliative care patients undergoing opioid therapy: Is polyethylene glycol an option?. Am J Hosp Palliat Care 2005; 22: 375-381
    CrossrefPubMedGoogle Scholar
  • 33 Wirz S, Beck D. Obstipation in der Palliativmedizin. Z Palliativmedizin 2008; 9: 11-24
    PubMedGoogle Scholar
  • 34 Wirz S, Klaschik E. Laxative use and efficacy in palliative care of patients with cancer pain and morphine therapy. A retrospective study with special regard to polyethylene glycol. Schmerz 2003; 17: 233-239
    PubMedGoogle Scholar
  • 35 Wirz S, Klaschik E. Management of constipation in palliative care patients undergoing opioid therapy: is polyethylene glycol an option?. Am J Hosp Palliat Care 2005; 22: 375-381
    CrossrefPubMedGoogle Scholar
  • 36 Wirz S, Nadstawek J, Elsen C et al. Laxative management in ambulatory cancer patients on opioid therapy: a prospective, open-label investigation of polyethylene glycol, sodium picosulphate and lactulose. Eur J Cancer Care (Engl). 2012; 21: 131-140
    CrossrefPubMedGoogle Scholar
  • 37 Zorn M, Domagk D, Auerbauch T et al. Malignant bowel obstruction. Z Gastroenterol 2010; 48: 264-273
    Article in Thieme ConnectPubMedGoogle Scholar