Page 152 Guide to Pain Management in Low-Resource Settings

140 Andreas Kopf

for identifying the targets. However, these techniques months in the past year:
should only be used by experienced therapists—book • Two or fewer discharges weekly.
knowledge is defi nitely insuffi cient. • Physical eff ort to discharge with major pressing.
Th e indication for a neurolytic block in pancre- • Hard and bulbous feces.
atic cancer is well recognized because of the rapid pro- • Feeling of incomplete discharge.
gression of the disease and its insuffi cient sensitivity to • Manual maneuvers for discharge.
radiotherapy and chemotherapy. From the literature, we
know that up to 85% of patients do benefi t from a neuro- Are patient complaints
lytic block. Some patients can even be taken off opioids.
Although serious side eff ects from neurolysis of the ce- about constipation similar
liac plexus are rare, the facts have to be explained to the around the world?
patient, and an informed consent form should be signed.
It is estimated that worldwide 1 in 8 individuals suff er,
at least from time to time, from constipation. Regional
In gastrointestinal cancer, pain is diff erences in prevalence have been described in North
frequent, but what other symptoms and Latin America as well as in the Pacifi c region,
cause the patient suff ering? where the prevalence is approximately double compared
to the rest of the world. Higher age and female sex may
Pain is not the only problem for cancer patients. Actual- increase the prevalence to 20–30%. In advanced stages
ly, the complaint with the highest prevalence is fatigue, of abdominal cancer, especially in palliative treatment
followed by anorexia. Discomfort due to constipation situations, incidences are higher than 60%.
is also a frequent complaint. Unfortunately, constipa-
tion may often be considered unimportant by the thera-
Which tests are indicated?
pist, and therefore overlooked or ignored. In fact, con-
stipation may be a frequent cause of anorexia, nausea,
Basically, the diagnosis of constipation is made by taking
and abdominal pain. Th erefore, constipation must be the history of the patient. If constipation is diagnosed ac-
checked for on a regular basis, and attempts should be
cording to the criteria listed above and abdominal cancer
made to relieve or at least reduce it. is present, the etiology of constipation may be obvious.
For safety, a digital examination of the anal canal and—
Everybody seems to know what if available—a proctoscopy are indicated. Rectal exami-

constipation is, but most people nation should be carried out—with the consent of the
would not agree on when to make the patient—during initial examination in most patients. In
diagnosis, so what is the defi nition? special cases manometric testing and evaluation of the
oral-anal transit time may be done to diff erentiate be-
Constipation is precisely defi ned: delayed bowel move- tween a functional or a morphological problem of the
ments with a frequency of less than twice weekly, com- terminal intestines or more proximal structures.
bined with painful discharge, abdominal swelling, and
irregularity. Nausea and vomiting, disorientation, col- What may be the conclusions
ics, and paradoxical diarrhea may be also present. Th e
from rectal examination?
“Rome criteria for the diagnosis of constipation” are
used to defi ne constipation. Unfortunately, the patient When the rectum is found to be fi lled by hard fecal
may not agree and may feel constipated with less or oth- masses it would not be advised to give fecal expanders
er symptoms. Th e diagnosis is made solely by taking a since they would make the problem even more diffi cult
patient history. to resolve—manual removal is indicated. In terminal
illness, when recurrent hard fecal masses will be ex-
What are the “Rome criteria”? pected, the family should be instructed to perform this
procedure. When the rectum is found empty, but “bal-
According to the “Rome criteria,” at least two of the fol- looned,” laxatives with “softening” and “pushing” eff ects
lowing symptoms must be fulfi lled for a minimum of 3 are indicated. After descent of the feces into the rectum,