Constipation and nausea: causes and treatment

Constipation and nausea - causes

Changes in diet and lifestyle, as well as lack of exercise, can cause constipation in some people. However, chronic or recurring constipation may indicate a serious underlying medical condition such as intestinal obstruction and inflammatory bowel disease (IBD). In general, conditions that cause constipation can also lead to nausea and other digestive symptoms.

Some possible causes of nausea due to constipation include:

Intestinal obstruction

An intestinal obstruction occurs when a blockage forms in the intestines, preventing the passage of digested food and waste products. Intestinal obstruction can be caused by stool, inflammation, or the buildup of scar tissue after surgery. Sometimes the intestines can twist around themselves, leading to a condition doctors call volvulus.

Intestinal obstructions prevent stool from passing normally, which can lead to constipation. People with intestinal obstruction may experience a wide range of symptoms, depending on the location and severity of the blockage.

An obstruction in the small intestine can cause nausea and vomiting. If the condition is left untreated, intestinal obstruction can cause serious complications, such as:

• severe infections such as sepsis
• intestinal necrosis
• intestinal perforation

Inflammatory bowel diseases (IBD)

IBD refers to a group of diseases that cause inflammation in the gastrointestinal (GI) tract. Common types of IBD include ulcerative colitis and Crohn's disease. Inflammation caused by IBD can cause numerous digestive symptoms, such as:

• diarrhea
• constipation
• partial bowel movement
• abdominal pain
• nausea
• bloody stool

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic condition that affects the large intestine, causing symptoms such as:

• abdominal pain and cramps
• excess gas or bloating
• constipation
• diarrhea

The effects of IBS symptoms can lead to nausea. The exact cause of IBS remains unknown. However, researchers have identified several underlying factors:

• increase in bacteria in the intestines
• food sensitivity
• genetics
• stress
• anxiety or depression

Side effects of laxatives or other medications

Some medicines can cause digestive problems, including constipation and nausea. People who develop constipation after taking a new drug should talk to their doctor.

Lubiprostone is a constipation medication used for IBS. Nausea is one of the main side effects. Laxatives can stimulate intestinal motility and relieve constipation. However, these treatments may have side effects such as:

• nausea
• vomit
• bloating
• diarrhea
• abdominal pain
• headache

Nausea, vomiting and intestinal obstruction

Contents Nausea and vomiting

How to rationally choose an antiemetic drug?

Intestinal obstruction

Surgery

Nausea, vomiting and intestinal obstruction are painful symptoms that often bother patients in the terminal stage of the disease. We are publishing an excerpt from the book by British doctor Bruce Cleminson, “Introduction to Palliative Care,” about how to relieve these symptoms. The full version of the book is available here.

Nausea and vomiting

It occurs in 50% of terminally ill patients and has four main causes: 1. Gastrostasis and intestinal obstruction. 2. Intoxication. 3. Stretching or irritation of organs. 4. Increased intracranial pressure.

All of these conditions have different causes and different treatments.

Gastrostasis and intestinal obstruction can be caused by:

• medications such as anticholinergics;
• autonomic disorders (nerve infiltration, diabetes);
• ascites;
• hepatomegaly;
• tumor germination;
• peptic ulcer or irritation.

Symptoms:

• discomfort in the epigastrium;
• loss of appetite;
• feeling better after vomiting; quick satiety during meals;
• symptoms occur when body position changes;
• associated belching and hiccups.

Intoxication:

• medications: antibiotics, opioids, digoxin, anti-inflammatory drugs, antispasmodic drugs;
• metabolic products (renal failure, liver failure, ketoacidosis, hypercalcemia, hyponatremia);
• toxins.

Symptoms:

• constant nausea;
• incessant vomiting;
• various signs of drug intoxication.

Introduction to Palliative Care Basic information about the key aspects of palliative care Bruce Cleminson

About palliative care

Organ stretching or irritation:

• liver metastases;
• ureteral obstruction;
• retroperitoneal lymph nodes (tumor);
• constipation;
• intestinal obstruction.

Symptoms:

• constant nausea
• vomiting is not very common;
• frequent accompanying pain;
• other symptoms.

Increased intracranial pressure or meningismus:

• intracranial tumor;
• cerebral edema; intracranial bleeding;
• meningeal tumor infiltration;
• metastases to the bones of the skull; cerebral infection.

Thus, to understand the mechanisms, you need:

• carefully study the medical history;
• conduct a thorough inspection;
• carry out the necessary examinations;
• if possible, eliminate (cure) the cause;
• try any appropriate non-drug treatment;
• rationally approach the choice of antiemetic drug.

How to rationally choose an antiemetic drug?

To make a rational choice, you will need to understand which receptors are involved in the vomiting mechanism. Three zones are involved: 1. Chemoreceptor trigger zone (CTZ). Its other name is “posteriormost field” and is located in the brain. Blood vessels in CTZ have fenestrated epithelium. Fenestrated epithelium (from the Latin fenestra - window) are “windows” in the walls of blood vessels in the epithelial lining, so that chemicals in the blood come into close contact with CTZ cells.

Receptors in CTZ are effective drugs:

• dopamine receptors (D2) - haloperidol;
• 5-HT3 receptors - ondansetron. They cause persistent nausea in response to medications, toxins, and organ failure.

2. Vomiting center:

• H1-histamine receptors - cyclizine or other antihistamines;
• acetylcholine receptors - cyclizine or other antihistamines;
• 5-HT2 receptors - methotrimeprazine.

Opioid receptors

Nausea and vomiting as a result of intestinal obstruction, pharyngeal irritation, liver enlargement, gastric compression and emotional reactions all pass through the vomiting center.

3. Gastrointestinal tract:

• 5-HT → achromatopsia → vagus nerve - cyclizine or other antihistamines;
• 5-HT3 - cilancetron;
• 5-HT4 prokinetic - metoclopramide;
• D2-antikinetic - metoclopramide;
• H2 - ranitidine (or pyrophosphates).

Thus, you need to remember three main drugs:

1) haloperidol - phenothiazine - for CTZ - chemicals - drugs - toxins; 2) cyclizine or other antihistamines - for the vomiting center - feelings - fears - sensations; 3) metoclopramide - gastric prokinetic - with delayed gastric emptying.

And four other drugs you may want to remember:

1) dexamethasone - a steroid - for increased intracranial pressure; 2) hyoscine butyl bromide - an anticholinergic agent (buscopan) to reduce gastrointestinal motility; 3) octreotide - to reduce gastrointestinal secretion; 4) ondansetron - a 5-HT3 antagonist - for nausea associated with chemotherapy.

Intestinal obstruction

Intestinal obstruction is a common occurrence in cancer patients at an advanced stage of the disease. It occurs in 3% of all hospice patients and 40% of patients with ovarian or pelvic tumors.

Establishing diagnosis

It is worth thinking about intestinal obstruction if there is a history of intestinal colic, nausea and vomiting, lack of peristalsis and intestinal bloating in various areas, depending on the level of obstruction.

Nutritional support and rehydration therapy in adult patients Clinical guidelines 2022 Editorial

Main reasons

1. Cancerous tumor:

• compression or germination of the intestinal lumen by a tumor.

2. Reasons not related to the tumor:

• constipation or fecal blockage, which is a common problem in declining patients;
• strangulation intestinal obstruction or strangulated hernia.

Examinations:

• palpation of the abdomen and rectal examination;
• Is the tumor palpable? Where? how big?
• Is the full descending colon palpable?
• An abdominal x-ray can be very informative.

Therapy for causes other than cancer

Resolution of constipation or coprostasis by oral administration of softening laxatives such as lactulose, docusate, phenolphthalein or petroleum jelly. In more serious cases, suppositories, enemas, or, if necessary, manual evacuation of stool can be used.

Treatment for other causes not related to cancer

Strangulated intestinal obstruction or strangulated hernia can be resolved surgically or conservatively, depending on the patient's condition.

Treatment for intestinal obstruction directly related to the presence of cancer

To relieve cramping pain and vomiting, we prescribe hyoscine butyl bromide (buscopan) at a dose of 20 mg or atropine 300–600 mcg subcutaneously. When colic, nausea and vomiting are under control, we prescribe buscopan orally 4 times a day. An oral antiemetic such as haloperidol may be needed.

Attempts should be made to restore bowel function with softening laxatives (eg, lactulose, phenolphthalein, docusate, paraffin). The dose of hyoscine butyl bromide (buscopan) should be reduced after 1 to 2 days of use to see if loose stools are passed. If there is still no stool, you need to think about surgery. If surgery is impossible or impractical, we prescribe buscopan orally 4 times a day to relieve cramping pain and haloperidol to relieve nausea.

If buscopan is not available, replace it with parenteral atropine (eg, subcutaneously using a syringe pump).

Surgery

Many patients benefit from palliative surgical treatment, but the mortality rate is 12–33%, and the risk of external intestinal fistula formation is 7–18%. In a significant number of patients, the obstruction does not resolve, while in others it recurs within a short time. Thus, conservative treatment may be the best option, in each case the surgeon should give his opinion and recommendations so that the patient can make the right decision with all the information.

Example 1

A 75-year-old woman was seen by her family doctor. She suffered from ovarian cancer and made an excellent recovery after undergoing platinum-based chemotherapy. About a year before her death, she suddenly developed heavy bleeding from the lower gastrointestinal tract. As it turned out, this was due to the growth of a tumor in the pelvis into the lower intestines. After the next course of chemotherapy, the tumor shrank again and the bleeding stopped. After 6 months, the family doctor was informed that the patient had cramping abdominal pain and intestinal dysfunction.

The examination showed that 10 cm of the sigmoid colon was not functioning due to tumor infiltration. A stent was placed, but this did not restore normal bowel function, possibly because there was another lesion above the stent or because the stent was a little short or did not fully dilate the bowel, 10 cm is a long distance for a stent. A double-barreled ileostomy was performed, which functioned perfectly until the patient's death.

Example 2

Nutrition in the terminal stage, with dementia or in a state of waking coma An excerpt from the book of the doctor Jean Domenico Borasio “On Death. What do we know? What we can do. How can we prepare for it? Gian Domenico Borasio

Symptomatic treatment

The elderly woman was under the care of her general practitioner. She suffered from widespread oncology, and signs of intestinal obstruction began to appear. The family doctor prescribed her an antispasmodic drug (hyoscine butylbromide), initially by injection, with a gradual transition to oral administration to relieve colic and nausea. After oral administration of lactulose, the intestines began to function. Antispasmodic treatment was later discontinued.

A few weeks later the same thing happened again, but the bowels did not work with an increased dose of the emollient laxative. The antispasmodic dose was increased to prevent colic and nausea, and the patient remained on this treatment until death 3 months later. She had a good quality of life and died very calmly, without vomiting or abdominal cramping.

Conclusion

Intestinal obstruction in a patient with terminal cancer can be successfully managed conservatively. Surgery can also be considered, but if the patient does not have much time left, the operation may not provide a positive effect, but only add suffering, pain and difficulty to the patient and his family.

Treatment

Treatments for nausea associated with constipation depend on the underlying cause. Doctors prescribe medications to treat symptoms of IBS and IBD. Dietary and lifestyle changes can help relieve constipation. People should avoid foods and drinks that can upset the digestive system. They include:

• processed products
• high fat foods
• carbonated drinks
• caffeinated drinks
• dairy products
• red meat

Keeping a food diary can help you identify which foods cause constipation or nausea. Eating more fiber and staying hydrated can relieve constipation. Fiber adds bulk to the stool, and water keeps it soft, making stool easier to pass. Physical activity also promotes regular bowel movements. However, when a person feels nauseous and constipated, he is unlikely to go to the gym. If this is the case, then you can simply take a walk after eating.

Causes of constipation in adults

Constipation in adults can be an independent disease, in which disturbances in the functioning of the intestines (due to lifestyle, stress, nutrition) lead to stool retention, a feeling of fullness, and discomfort. But the same symptoms sometimes accompany diseases of other organs. It can be:

• diseases of the gastrointestinal tract (ulcers, pankeratitis, etc.);
• anus (anal fissures, hemorrhoids);
• some neurological diseases (spinal cord injury, stroke, Parkinson's disease)
• endocrine (diabetes mellitus, hypothyroidism).

In addition to the above, constipation can be caused by certain medications that affect intestinal motility. Pregnancy or prescribed bed rest can also cause constipation.

It is customary to divide constipation into acute and chronic. Acute ones last from one to several days. If constipation constantly returns for a month or more, it is considered chronic.

Although the symptoms are obvious, constipation can manifest itself in different ways. The frequency of stool, the presence or absence of pain, the effectiveness of straining and the sensation after you go to the toilet will differ1,2.

When to see a doctor

If a person's symptoms do not improve after lifestyle and diet changes, then a doctor should be contacted. People should seek medical help immediately if they have constipation or nausea in addition to the following symptoms, such as:

• increased thirst
• fever
• severe abdominal pain
• black or bloody stools
• dizziness
• unexplained weight loss

People who experience multiple episodes of vomiting or diarrhea lasting more than 3 days may have severe food poisoning and should seek medical attention as soon as possible.