Obstipation bei Patienten mit nicht-heilbarer Krebserkrankung

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
• 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
• 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
• 4 Ashton MR, Sutton D, Nielsen M. Severe magnesium toxicity after magnesium sulphate enema in a chronically constipated child. BMJ 1990; 300: 541
• 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
• 6 Badiali D, Bracci F, Castellano V et al. Sequential treatment of chronic constipation in paraplegic subjects. Spinal Cord 1997; 35: 116-120
• 7 Baines MJ. The pathophysiology and management of malignant intestinal obstruction. In: Oxford Textbook of Palliative Medicine. Oxford University Press; Oxford: 1998: 526-534
• 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
• 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
• 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
• 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
• 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
• 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
• 14 Drossmann DA. Rome III. The functional gastrointestinal disorders. Allen Press, Inc.; Lawrence, KS, USA: 2006: 419-486
• 15 Frieling T. Acute abdomen from the internal medicine point of view. Dtsch Med Wochenschr 2009; 134: 246-250
• 16 Golzarian J, Scott Jr HW, Richards WO. Hypermagnesemia-induced paralytic ileus. Dig Dis Sci 1994; 39: 1138-1142
• 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
• 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
• 19 Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003; 349: 1360-1138
• 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
• 21 Meissner W, Schmidt U, Hartmann M et al. Oral naloxone reverses opioid-associated constipation. Pain 2000; 84: 105-109
• 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
• 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
• 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
• 25 Quigley EM. Prucalopride: safety, efficacy and potential applications. Therap Adv Gastroenterol 2012; 5: 23-30
• 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
• 27 Sykes NP. The relationship between opioid use and laxative use in terminally ill cancer patients. Palliat Med 1998; 12: 375-382
• 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
• 29 Tamayo AC, Diaz-Zuluaga PA. Management of opioid-induced bowel dysfunction in cancer patients. Support Care Cancer 2004; 12: 613-618
• 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
• 31 Twycross RG, Harcourt JMV. The use of laxatives at a palliative care centre. Pall Med 1991; 5: 27-33
• 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
• 33 Wirz S, Beck D. Obstipation in der Palliativmedizin. Z Palliativmedizin 2008; 9: 11-24
• 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
• 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
• 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
• 37 Zorn M, Domagk D, Auerbauch T et al. Malignant bowel obstruction. Z Gastroenterol 2010; 48: 264-273