Constipation and Bowel Care

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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Constipation is near-universal in palliative care — caused by opioids, immobility, reduced oral intake, dehydration, hypercalcaemia, and autonomic dysfunction from advanced disease.
Prevention is paramount: all patients starting opioids must receive a co-prescribed stimulant laxative (e.g. senna ± docusate) from day one; failure to do so constitutes a clinical safety gap.
Opioid-induced constipation (OIC) is mediated by µ-receptor agonism in the myenteric and submucosal plexuses; tolerance does not develop, so laxatives are required for the duration of opioid use.
Assess before treating: perform a digital rectal examination (DRE) and abdominal examination to exclude faecal impaction and bowel obstruction before escalating laxatives.
First-line laxatives for OIC: senna 15–30 mg nocte + docusate sodium 100 mg BD (stimulant + softener); titrate to effect. Movicol® (macrogol) is preferred second-line or for hard stool.
Refractory OIC: consider methylnaltrexone (Relistor®) 8–12 mg SC alternate days — a peripherally-acting µ-opioid receptor antagonist (PAMORA) that does not cross the blood-brain barrier and does not reverse analgesia.
Faecal impaction presents with paradoxical diarrhoea, overflow, urinary retention, or delirium; managed with oral macrogol or phosphate/enema preparations, followed by manual evacuation if refractory.
Malignant bowel obstruction (MBO) is common in advanced ovarian, colorectal, and gastric cancers; management is primarily medical (anti-emetics, antisecretory agents, corticosteroids) with surgery reserved for selected patients.
Stomas in palliative care may be fashioned for symptom relief (faecal diversion in MBO) or pre-existing stomas require ongoing care; involve a stomal therapy nurse early.
Bowel protocols should be individualised, documented, and reviewed at least weekly; a structured bowel chart (frequency, consistency, straining, flatus) guides titration.
Special populations: elderly patients are more susceptible to impaction; patients with renal impairment need dose adjustments for magnesium- and phosphate-containing laxatives; pregnant patients require osmotic rather than stimulant laxatives where possible.
Aboriginal and Torres Strait Islander peoples may face barriers including remote location, limited access to stomal therapy services, cultural sensitivities around rectal examination, and higher rates of gastrointestinal malignancy; culturally safe care is essential.

Introduction & Australian Epidemiology

Constipation is one of the most prevalent and distressing symptoms in palliative care, affecting between 40% and 90% of patients depending on the underlying diagnosis and treatment received. It significantly impairs quality of life, causing abdominal pain, nausea, anorexia, confusion, and urinary retention. In the Australian palliative care setting, constipation is frequently multifactorial — arising from opioid analgesia, reduced mobility, diminished oral intake, dehydration, autonomic neuropathy, metabolic derangements (notably hypercalcaemia), and direct tumour effects on the bowel.

The Australian Institute of Health and Welfare (AIHW) reports that over 160,000 Australians receive palliative care services annually, with the majority managed in the community by general practitioners and specialist palliative care teams. Despite the high prevalence of constipation, studies consistently demonstrate under-recognition and under-treatment. The Palliative Care Outcomes Collaboration (PCOC) data indicate that bowel symptoms are among the top five reported problems at initial palliative care assessment.

Prevention and proactive management of constipation are core components of quality palliative care and are mandated under the National Consensus Statement: Essential Elements for Safe and High-quality End-of-life Care (ACSQHC, 2015). A systematic approach — incorporating regular bowel assessment, prophylactic laxatives with opioid initiation, and escalation pathways for refractory symptoms — is essential.

This article provides a comprehensive Australian clinical guideline covering opioid-induced constipation, faecal impaction, bowel obstruction (including malignant bowel obstruction), and stoma considerations in the palliative care context.

Opioid-Induced Constipation

Opioid-induced constipation (OIC) is the most common cause of constipation in palliative care. Unlike other opioid side effects (nausea, sedation), tolerance does not develop to OIC — it persists for the entire duration of opioid therapy. OIC occurs with all opioids (morphine, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and all routes (oral, transdermal, subcutaneous, intrathecal).

Pathophysiology

Opioids bind to µ-opioid receptors in the myenteric (Auerbach's) and submucosal (Meissner's) plexuses of the gastrointestinal tract. This results in:

Decreased propulsive peristaltic contractions
Increased non-propulsive (segmental) contractions — causing spasm and prolonged transit time
Increased fluid absorption from the gut lumen — harder, drier stools
Decreased secretion of intestinal fluid and electrolytes
Increased anal sphincter tone — reducing the urge to defecate

The consequence is delayed colonic transit, stool desiccation, and difficulty with evacuation. These effects are dose-dependent but can occur even at low opioid doses in susceptible individuals.

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Critical safety point: Every patient commenced on an opioid must be co-prescribed a stimulant laxative. Failure to prescribe prophylactic laxatives is a recognised patient safety incident and is auditable under NSQHS standards.

Assessment of OIC

A structured bowel assessment should be performed at every palliative care review and documented in the clinical record. Key elements include:

Last bowel action (date, time)
Stool consistency — use the Bristol Stool Chart (Types 1–2 = constipated; Type 3–4 = ideal)
Straining or digital evacuation required
Passage of flatus (absence suggests obstruction)
Abdominal symptoms — distension, pain, nausea, vomiting
Current opioid type, dose, and route
Current laxative regimen and adherence
Other contributing medications — anticholinergics, calcium channel blockers, ondansetron, 5-HT₃ antagonists, vincristine
Oral intake and hydration status
Mobility level

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Do not assume constipation: Always perform a digital rectal examination (DRE) if faecal impaction is suspected, particularly in patients who have not opened their bowels for >3 days or who report paradoxical diarrhoea. Inability to pass flatus with abdominal distension raises concern for bowel obstruction — investigate before escalating laxatives.

Pharmacological Management of OIC

Laxative therapy for OIC follows a stepwise approach. Australian palliative care guidelines (Palliative Care Therapeutic Guidelines, Palliative Care Australia) recommend the following ladder:

Step 1 — First-line

Stimulant + Softener

Senna 15–30 mg PO nocte + Docusate sodium 100 mg PO BD. This combination addresses both reduced peristalsis and stool hardness.

All patients on opioids — initiate concurrently

Step 2 — Second-line

Add Osmotic Laxative

Macrogol 3350 (Movicol®) 1 sachet BD–TDS, dissolved in 125 mL water. OR Lactulose 15–30 mL BD. Continue Step 1 agents.

If no bowel action after 48 hours despite Step 1

Step 3 — Refractory OIC

PAMORA or Suppository / Enema

Methylnaltrexone 8–12 mg SC alternate days (weight-based). OR bisacodyl suppository 10 mg PR daily. OR sodium phosphate enema PR. Continue Steps 1–2.

Failure of oral laxatives after 72 hours or impaction

Laxative Drug Cards

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Senna

Senokot® · Generic · Stimulant laxative

Adult dose 15–30 mg (1–2 tablets) PO nocte; titrate to 30–60 mg nocte

Paediatric dose 6–12 months: 5 mg nocte; 1–6 years: 7.5–15 mg nocte; 6–12 years: 15 mg nocte

Route / Frequency Oral, once or twice daily (usually nocte)

Renal adjustment No specific adjustment; monitor for electrolyte disturbance

Hepatic adjustment Use with caution; monitor for hepatotoxicity with chronic use

PBS status ✔ PBS General Benefit

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Docusate Sodium

Coloxyl® · Generic · Stool softener

Adult dose 100 mg PO BD (usually combined with senna as Coloxyl with Senna)

Paediatric dose 6 months–2 years: 12.5 mg/kg/day in divided doses; 2–12 years: 50–150 mg/day in divided doses

Route / Frequency Oral, BD

Renal adjustment None required

Hepatic adjustment None required

PBS status ✔ PBS General Benefit

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Macrogol 3350 + Electrolytes

Movicol® · Osmotic laxative

Adult dose 1 sachet BD–TDS dissolved in 125 mL water per sachet; up to 8 sachets daily for faecal impaction (short course)

Paediatric dose 1–6 years: ½–1 sachet daily; 6–12 years: 1–2 sachets daily; impaction dosing differs

Route / Frequency Oral, BD–TDS

Renal adjustment Caution in severe renal impairment (CKD 4–5) — electrolyte content; monitor potassium and sodium

Hepatic adjustment None required

PBS status ✔ PBS General Benefit

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Methylnaltrexone

Relistor® · Peripherally-acting µ-opioid receptor antagonist (PAMORA)

Adult dose ≤62 kg: 8 mg SC alternate days; 62–114 kg: 12 mg SC alternate days; >114 kg: 0.15 mg/kg SC alternate days

Paediatric dose ≥2 years: 0.15 mg/kg SC alternate days (limited data); not routinely recommended

Route / Frequency Subcutaneous injection, alternate days (or daily if required)

Renal adjustment eGFR <30 mL/min: reduce dose to 50% of standard; use 4 mg SC (≤62 kg) or 8 mg SC (>62 kg)

Hepatic adjustment No specific adjustment; use with caution in severe hepatic impairment

PBS status Authority Required (Not widely listed — Special Access Scheme may be required)

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Lactulose

Duphalac® · Generic · Osmotic laxative

Adult dose 15–30 mL PO BD; titrate to 30 mL TDS if needed

Paediatric dose 1 month–1 year: 2.5 mL BD; 1–5 years: 2.5–10 mL BD; 5–18 years: 5–20 mL BD

Route / Frequency Oral, BD–TDS

Renal adjustment None required; useful in renal impairment as does not contain magnesium or phosphate

Hepatic adjustment Can be used therapeutically for hepatic encephalopathy

PBS status ✔ PBS General Benefit

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Bisacodyl

Dulcolax® · Stimulant laxative (rectal)

Adult dose 10 mg PR (suppository) daily; OR 10–20 mg PO daily (enteric-coated tablet)

Paediatric dose ≥2 years: 5 mg PR daily; 4–10 years: 5–10 mg PO daily

Route / Frequency Rectal (suppository) or oral; once daily

Renal adjustment None required

Hepatic adjustment None required

PBS status ✔ PBS General Benefit

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Key practice point: Senna + docusate (Coloxyl with Senna®) is the recommended first-line combination for opioid-induced constipation in Australian palliative care. It is cheap, well-tolerated, PBS-listed, and available without restriction. Prescribe from the day opioids are started.

Faecal Impaction

Faecal impaction occurs when a hard, immovable mass of stool accumulates in the rectum or sigmoid colon. It is a common complication in palliative care patients, particularly those who are immobile, cognitively impaired, dehydrated, or receiving inadequate laxative prophylaxis. Impaction can cause significant morbidity including:

Paradoxical (overflow) diarrhoea — liquid stool leaking around the impacted mass
Urinary retention and recurrent urinary tract infections
Faecal ulceration and rectal bleeding
Nausea, vomiting, and anorexia
Delirium — particularly in elderly patients
Stercoral perforation — a rare but life-threatening complication

Diagnosis

Diagnosis is clinical, supported by:

Digital rectal examination (DRE): the most important initial investigation — reveals hard faecal mass in the rectal vault. Perform gently to avoid mucosal trauma.
Abdominal examination: palpable faecal mass in the left iliac fossa or sigmoid colon; distension; reduced bowel sounds.
Abdominal X-ray (AXR): if clinical assessment is inconclusive or to assess proximal faecal loading. Useful for differentiating impaction from obstruction.
Note: CT abdomen should be reserved for suspected complications (perforation, obstruction) — not routinely indicated for impaction alone.

Management of Faecal Impaction

Management follows a stepwise approach:

Disimpaction (Day 1–3)

Macrogol 3350 (Movicol®) 1 sachet BD–TDS with adequate fluids. If oral route unavailable or patient obtunded: bisacodyl suppository 10 mg PR daily OR sodium phosphate enema (Fleet®) PR — use cautiously in renal impairment. Manual evacuation under sedation may be required if above measures fail (performed by medical officer or trained nurse).

Clearance (Day 3–7)

Continue macrogol until rectum is clear (confirmed by DRE). Add or continue senna 15–30 mg nocte + docusate 100 mg BD. Ensure adequate hydration where clinically appropriate.

Maintenance (Ongoing)

Establish a regular bowel protocol tailored to the patient's opioid regimen, diet, and mobility. Document bowel chart. Review at each clinical encounter.

⚠️

Avoid in renal impairment: Sodium phosphate enemas (Fleet®) can cause dangerous hyperphosphataemia and hypocalcaemia in patients with eGFR <30 mL/min. Use bisacodyl suppositories or macrogol-based preparations instead.

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Australian context: Phosphate-containing enemas are available OTC in Australia but should be used with caution. Coloxyl with Senna® (combination tablet containing docusate 50 mg + senna 8 mg per tablet; dose: 2 tablets BD) is widely available and PBS-listed, making it the most commonly prescribed first-line agent in Australian palliative care.

Bowel Obstruction

Bowel obstruction in palliative care may be mechanical (tumour, adhesions, hernia) or functional (paralytic ileus). Malignant bowel obstruction (MBO) is the most common cause in patients with advanced cancer, particularly ovarian, colorectal, gastric, and pancreatic malignancies. MBO occurs in approximately 3–15% of patients with advanced cancer and up to 50% of patients with advanced ovarian cancer.

Clinical Presentation

Feature	Small Bowel Obstruction	Large Bowel Obstruction
Onset	Acute	Often gradual
Pain	Colicky, central/periumbilical	Colicky, lower abdomen
Vomiting	Early, may be bile-stained or faeculent	Late (if at all)
Distension	May be minimal initially	Prominent
Flatus/faeces	Absence of flatus and bowel actions	May still pass flatus initially; absolute constipation later
Bowel sounds	High-pitched, tinkling	Reduced or absent

Investigations

Essential Abdominal X-ray (AXR) Erect and supine — dilated loops, air-fluid levels, absent rectal gas. Identifies level of obstruction. Available in all Australian hospitals and most radiology practices.

Available CT Abdomen/Pelvis with IV contrast Gold standard for identifying cause, level, and complications of obstruction. MBS Item 56100. Use when surgical intervention is being considered.

Available Bloods — FBC, UEC, LFTs, CRP, lactate Assess for dehydration, electrolyte derangement, ischaemia (lactate), and infection. Available at all Australian pathology providers.

Specialist Gastrografin (diatrizoate) swallow study May distinguish complete from partial small bowel obstruction and predict need for surgery. Available at major hospitals. Use under specialist guidance.

Medical Management of Malignant Bowel Obstruction

In patients with advanced cancer and MBO who are not surgical candidates (the majority in palliative care), medical management is the mainstay of treatment. The goal is symptom relief: control of pain, nausea, vomiting, and secretions.

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Hyoscine Butylbromide

Buscopan® · Antispasmodic / Antisecretory

Adult dose 20 mg SC stat then 60–120 mg/24h via CSCI (continuous subcutaneous infusion); titrate to effect

Paediatric dose Not routinely used; specialist guidance required

Route / Frequency SC bolus or CSCI via syringe driver

Renal / Hepatic No specific adjustment

PBS status ✔ PBS General Benefit

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Octreotide

Sandostatin® · Somatostatin analogue / Antisecretory

Adult dose 100–300 µg SC BD or 300–600 µg/24h via CSCI; titrate to effect. More potent antisecretory effect than hyoscine butylbromide.

Paediatric dose Not routinely used; specialist guidance required

Route / Frequency SC BD or CSCI via syringe driver

Renal / Hepatic No specific adjustment required

PBS status Authority Required

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Dexamethasone

Generic · Corticosteroid / Anti-oedema

Adult dose 8–16 mg IV/SC daily for 3–5 days; reduce to 4 mg daily if responding. Reduces peri-tumour oedema and may relieve partial obstruction.

Paediatric dose 0.15–0.3 mg/kg/day IV/SC (max 16 mg)

Route / Frequency IV/SC/PO, once or twice daily

Renal / Hepatic No dose adjustment

PBS status ✔ PBS General Benefit

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Metoclopramide

Maxolon® · Prokinetic / Anti-emetic

Adult dose 10 mg PO/SC TDS or 30–60 mg/24h via CSCI. Use ONLY in partial/functional obstruction — contraindicated in complete mechanical obstruction (increases intraluminal pressure).

Paediatric dose 0.1–0.15 mg/kg PO/SC TDS–QID (max 0.5 mg/kg/day)

Route / Frequency PO/SC, TDS or CSCI

Renal adjustment Reduce dose by 50% if eGFR <10 mL/min

Hepatic adjustment Reduce dose in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Ondansetron

Zofran® · 5-HT₃ antagonist / Anti-emetic

Adult dose 4–8 mg PO/IV/SC BD–TDS or 16–24 mg/24h via CSCI. Second-line anti-emetic for nausea/vomiting in MBO.

Paediatric dose 0.1–0.15 mg/kg IV/PO BD–TDS (max 4 mg/dose <4 years; 8 mg/dose >4 years)

Route / Frequency PO/IV/SC, BD–TDS or CSCI

Renal / Hepatic Max 8 mg/day in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Do NOT use laxatives in complete bowel obstruction. Stimulant and osmotic laxatives increase intraluminal pressure proximal to the obstruction, risking perforation, and cause cramping pain. Nasogastric tube decompression may be required for intractable vomiting.

Surgical Considerations

Surgical intervention (bypass, stenting, resection, or stoma formation) in MBO should be considered only in carefully selected patients with:

Good performance status (ECOG 0–1)
Single-level obstruction
Slowly progressive disease (long interval since primary treatment)
Absence of diffuse peritoneal carcinomatosis
Expected survival >2–3 months

Self-expanding metallic stents (SEMS) for colonic obstruction (via interventional endoscopy or radiology) can be a bridge to surgery or a definitive palliative measure. MBS Item 30474 covers colonic stenting. Access is available at major metropolitan hospitals and some regional centres in Australia.

ℹ️

Multi-disciplinary approach: Decisions about surgery vs. medical management in MBO should involve the palliative care team, surgical team, oncologist, and the patient/family. Goals of care discussions must be documented. Refer to the Australian Commission on Safety and Quality in Health Care (ACSQHC) framework for shared decision-making.

Stoma Considerations

Stomas — ileostomy or colostomy — may be present as a result of previous surgery or may be fashioned in the palliative setting to relieve bowel obstruction or divert faecal flow. In palliative care, stoma creation is most commonly performed for:

Unresectable distal colonic or rectal obstruction (end colostomy / loop colostomy)
Complex pelvic malignancy causing intractable obstruction or fistulation
Incontinence management in advanced neurological disease (rare)
Pre-existing stomas from prior oncological surgery requiring ongoing management

Pre-Operative Counselling

Patients and families must receive thorough pre-operative counselling, ideally involving a stomal therapy nurse (STN). Key discussion points include:

Type of stoma and expected output (ileostomy: liquid/pasty, high volume; colostomy: formed stool, lower volume)
Appliance selection and fitting
Skin care and peristomal dermatitis prevention
Odour management and dietary adjustments
Impact on body image and psychosocial wellbeing
Expected prognosis and whether the stoma is likely to be permanent

Ongoing Stoma Care in Palliative Patients

Issue	Management
High-output stoma (>1.5 L/day)	Reduce oral fluids that exacerbate output; consider loperamide 2–4 mg PO before meals; consider codeine phosphate 30 mg PO TDS; ensure adequate fluid and electrolyte replacement; consider octreotide if refractory.
Peristomal skin irritation	Ensure correct appliance sizing; use barrier cream/spray (e.g. Cavilon™); treat candidal infection with topical antifungal; referral to STN.
Stomal retraction or prolapse	Convex appliance for retraction; surgical review for significant prolapse if causing symptoms; STN assessment.
Parastomal hernia	Support belt; appliance modification; conservative management preferred in palliative setting unless causing obstruction.
Constipation (colostomy)	Same laxative principles as constipated patients without stomas; senna + docusate or macrogol. Avoid phosphate enemas via stoma.

ℹ️

Stomal therapy nursing in Australia: Stomal Therapy Nurses (STNs) are credentialed through the Australian Association of Stomal Therapy Nurses (AASTN). They provide expert assessment, appliance fitting, skin care, and patient education. Referral to STN should be made for all new stomas and for any stoma complications. STNs are available in most Australian public hospitals and some community palliative care services.

Pharmacological Considerations for Stoma Patients

Modified-release medications: avoid in ileostomy patients — incomplete absorption and risk of obstruction from matrix tablets. Use immediate-release formulations.
Opioid patches: transdermal fentanyl and buprenorphine patches are appropriate if oral absorption is unreliable.
Oral morphine liquid: absorbed in the stomach and proximal small bowel — reliable in ileostomy and colostomy patients.
Loperamide: useful for high-output ileostomy (2–4 mg PO before meals); contraindicated in complete obstruction.

Monitoring

Regular monitoring of bowel function is essential in all palliative care patients. A structured approach ensures early detection of complications and guides laxative titration.

Bowel Chart

A bowel chart should be maintained for all inpatients and recommended for community patients receiving opioid therapy. Document:

Date and time of each bowel action
Stool consistency (Bristol Stool Chart type)
Volume (small / moderate / large)
Colour — note any blood, melaena, or bile-staining
Straining (yes/no)
Passage of flatus (yes/no)
Laxatives administered and response
Abdominal symptoms (pain, distension, nausea)

Review Schedule

Daily

Bowel chart review for inpatients. Assessment for new symptoms (nausea, distension, absence of flatus). Laxative titration as indicated.

Weekly

Community patients — telephone or face-to-face review of bowel function. Review adequacy of laxative regimen. Document and adjust.

Each clinical encounter

Abdominal examination. DRE if constipation or impaction suspected. Review of contributing factors (medication changes, hydration, mobility).

Red Flags Requiring Urgent Assessment

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Absolute constipation (no bowel action >5 days) with abdominal distension and vomiting — suspect bowel obstruction
Sudden onset of severe abdominal pain — suspect perforation or ischaemia
Melaena or significant rectal bleeding — upper GI source or rectal ulceration from impaction
New-onset confusion or delirium in an elderly patient — consider faecal impaction as a reversible cause
Signs of peritonism (guarding, rigidity, rebound) — emergency surgical assessment required

Special Populations

🤰

Pregnancy

Constipation in pregnancy palliation: If pregnancy coexists with palliative illness, osmotic laxatives (macrogol, lactulose) are preferred. Avoid stimulant laxatives (senna, bisacodyl) in the first trimester if possible — teratogenicity data limited but theoretical concern. Magnesium-containing laxatives (milk of magnesia) can be used short-term.

Opioids: Codeine and morphine are excreted in breast milk; avoid if breastfeeding is desired. Neonatal withdrawal may occur with chronic maternal opioid use.

Involve obstetric team early in palliative care planning for pregnant patients.

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Paediatrics

Paediatric palliative care: Constipation is common in children with life-limiting conditions, particularly those on opioids or with neurological impairment. First-line: macrogol 3350 (dose adjusted by age). Senna may be used in children >6 months. Docusate is safe from infancy.

Rectal interventions: Minimise in children; use only when oral therapy fails. Phosphate enemas are contraindicated in children <2 years due to risk of fatal hyperphosphataemia.

Methylnaltrexone: Limited data in children ≥2 years; use only under specialist guidance.

Consult paediatric palliative care team for complex bowel management in children.

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Elderly

Higher risk: Elderly patients are more susceptible to constipation due to reduced mobility, diminished fluid intake, polypharmacy (anticholinergics, calcium channel blockers), and reduced colonic motility.

Delirium: Faecal impaction is a reversible cause of delirium in the elderly — always perform DRE in the confused elderly palliative patient.

Avoid: Magnesium-containing laxatives in severe renal impairment (common in elderly). Avoid sodium phosphate enemas in CKD. Lactulose may cause bloating and is poorly tolerated — macrogol is generally better tolerated.

Medication review: discontinue contributing drugs (anticholinergics) where possible.

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Renal Impairment

eGFR <30 mL/min: Avoid magnesium-containing laxatives (magnesium hydroxide, magnesium citrate) — risk of hypermagnesaemia. Avoid phosphate enemas (Fleet®) — risk of hyperphosphataemia and hypocalcaemia. Macrogol with electrolytes (Movicol®) requires monitoring of serum sodium and potassium.

Dialysis patients: Constipation is very common due to fluid restriction and phosphate binders. Macrogol without electrolytes or lactulose preferred. Senna and docusate are safe in CKD.

Methylnaltrexone: Reduce dose by 50% if eGFR <30 mL/min.

Refer to nephrology if electrolyte derangement suspected from laxative use.

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Hepatic Impairment

Hepatic encephalopathy: Lactulose is first-line for both constipation and hepatic encephalopathy (titrate to 2–3 soft stools daily). Lactulose reduces ammonia production by promoting acidification of the colonic lumen.

Cautions: Avoid senna in severe hepatic impairment — rare risk of hepatotoxicity with chronic use. Ondansetron: max 8 mg/day in severe hepatic impairment. Dexamethasone: use lowest effective dose.

Monitor for worsening ascites and encephalopathy when adjusting bowel regimen.

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Immunocompromised

Neutropenic patients: Avoid rectal interventions (suppositories, enemas, DRE) if platelet count <50 × 10⁹/L or absolute neutrophil count <0.5 × 10⁹/L due to risk of mucosal trauma, bacteraemia, and bleeding.

Constipation in chemotherapy: Ondansetron and other 5-HT₃ antagonists are significant contributors to constipation. Vincristine causes autonomic neuropathy and severe constipation/ileus. Prophylactic laxatives should accompany all emetogenic chemotherapy regimens.

Autologous/Allogeneic transplant: Constipation is common post-HSCT; bowel management should be included in supportive care protocols.

Use oral laxatives preferentially; avoid rectal interventions in severely immunocompromised patients.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander peoples experience a disproportionate burden of cancer, chronic kidney disease, and other conditions requiring palliative care. Gastrointestinal cancers (colorectal, oesophageal, gastric, liver) are among the most commonly diagnosed malignancies. Despite this, access to palliative care services — particularly in remote and very remote communities — remains significantly lower than for non-Indigenous Australians.

Access to palliative care services

Many Aboriginal and Torres Strait Islander peoples live in regional, remote, or very remote areas where specialist palliative care services are limited or absent. The Australian Government's National Palliative Care Strategy 2018 recognises this gap. Community-controlled health services (ACCHSs) play a vital role in providing culturally safe palliative care.

Cultural sensitivity around bowel care

Bowel function, rectal examination, and stoma care are deeply personal topics. Some Aboriginal and Torres Strait Islander patients may feel shame or discomfort discussing these issues, particularly with non-Indigenous clinicians. Same-gender clinicians should be offered where possible. Health workers from the local community can facilitate culturally safe communication.

Stomal therapy services

Access to stomal therapy nurses is extremely limited in remote areas. Telehealth consultations with metropolitan STN services should be utilised (MBS Items 99212, 99213, 99215 for telehealth). Basic stoma care education for community health workers and family members is essential. Ensure adequate supplies (appliances, skin care products) are available through remote area pharmacies or postal supply services.

Medication access

PBS-listed laxatives (senna, docusate, macrogol, lactulose) are generally available through Remote Area Aboriginal Health Services under Section 100 arrangements. Ensure adequate stock at remote health clinics. Methylnaltrexone may require Special Access Scheme (SAS) and specialist prescription — arrange supply pathways proactively.

Health literacy and education

Patient education materials about bowel care, laxative use, and stoma management should be available in plain English and, where possible, in relevant First Nations languages. Visual aids and pictorial guides enhance understanding. Use the "teach-back" method to confirm comprehension.

Social determinants and sorry business

Housing overcrowding, limited sanitation facilities in some remote communities, and the disruption of sorry business (bereavement practices) can all impact bowel management and palliative care delivery. Flexible, community-based care models that respect cultural obligations are essential. Advance care planning should be undertaken early, with input from Elders and family where the patient wishes.

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Closing the Gap: The Australian Government's National Agreement on Closing the Gap (2020) includes Outcome 1 (Aboriginal and Torres Strait Islander people enjoy long and healthy lives) and Outcome 4 (Aboriginal and Torres Strait Islander people have high-quality, culturally safe health services). Culturally safe bowel management in palliative care contributes directly to these outcomes. Engage local Aboriginal Health Workers and Liaison Officers (AHWLOs) in all aspects of bowel care planning.

📚 References

1. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Australian Government Department of Health; 2018.
2. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Consensus Statement: Essential Elements for Safe and High-quality End-of-life Care. Sydney: ACSQHC; 2015.
3. Larkin PJ, Cherny NI, La Carpia D, et al. Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Ann Oncol. 2018;29(Suppl 4):iv111–iv125.
4. Candy B, Jones L, Goodman ML, et al. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011;(1):CD003448.
5. Thomas J, Karver S, Cooney GA, et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med. 2008;358(22):2332–2343.
6. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Cat. no. HWV 79. Canberra: AIHW; 2023.
7. Feuer DJ, Broadley KE. Systematic review and meta-analysis of corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancers. Ann Oncol. 2000;11(5):535–541.
8. Mercadante S, Ferrera P, Villari P, et al. Aggressive pharmacological treatment for reversing malignant bowel obstruction. J Pain Symptom Manage. 2004;28(4):412–416.
9. Australian Association of Stomal Therapy Nurses (AASTN). Standards of Care: Colostomy, Ileostomy and Urostomy. 4th ed. Melbourne: AASTN; 2018.
10. Palliative Care Outcomes Collaboration (PCOC). National Outcomes and Casemix Report. Wollongong: University of Wollongong; 2023.
11. Australian Government Department of Health. National Agreement on Closing the Gap. Canberra: Commonwealth of Australia; 2020.
12. Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ. 2003;327(7414):523–528.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).