Opioid drugs and stercoral perforation of the colon: Case report and review of literature

Safe Management of Adverse Effects Associated with Prescription Opioids in the Palliative Care Population: A Narrative Review

In the palliative care population, prescription opioids are often considered viable pain relief options. However, in this complex patient population, the adverse effects of opioid medications should be identified and managed without delay. Common adverse effects can include constipation, nausea, somnolence, dizziness, vomiting, and pruritus. Less common adverse effects can include potentially lethal respiratory depression and cardiovascular effects. Critical aspects of safe opioid prescribing are recognition of side effects and knowledge of effective management strategies; prompt management is necessary for uninterrupted pain relief. Most complications are managed with general approaches such as dose reduction, opioid rotation, alternate routes of administration, and symptomatic management. The only opioid-induced complication for which US Food and Drug Administration-approved treatments currently exist is constipation. Treating laxative-refractory opioid-induced constipation (OIC) with peripherally acting mu-opioid receptor antagonists (PAMORAs), which block gastrointestinal opioid receptors, can restore gastrointestinal motility and fluid secretion. This narrative review discusses key complications of prescription opioid treatment and their management in the palliative care setting.

Opioid-induced Constipation: Old and New Concepts in Diagnosis and Treatment

Daily use of opioid analgesics has significantly increased in recent years due to an increasing prevalence of conditions associated with chronic pain. Opioid-induced constipation (OIC) is one of the most common, under-recognized, and under-treated side effects of opioid analgesics. OIC significantly reduces the quality of life by causing psychological distress, lowering work productivity, and increasing access to healthcare facilities. The economic and social burden of OIC led to the development of precise strategies for daily clinical practice. Key aspects are the prevention of constipation through adequate water intake and fiber support, avoidance of sedentariness, and early recognition and treatment of cofactors that could worsen constipation. Recommended first-line therapy includes osmotic (preferably polyethylene glycol) and stimulant laxatives. Peripherally acting μ-opioid receptor antagonists, such as methylnaltrexone, naloxegol, or naldemedine, should be used in patients that have not responded to the first-line treatments. The bowel functional index is the main tool for assessing the severity of OIC and for monitoring the response. The paper discusses the recent literature on the pathophysiology, clinical evaluation, and management of OIC and provides a pragmatic approach for its assessment and treatment.

Cumulative Laxation Response with Methylnaltrexone: Implications for Hospitalized Patients with Advanced Illness and Opioid-Induced Constipation

Background

Opioid-induced constipation (OIC) may increase the risk of fecal impaction and mortality in patients with advanced illness. Methylnaltrexone (MNTX) is efficacious for OIC.

Objective

The purpose of this analysis was to evaluate cumulative rescue-free laxation response with repeat MNTX dosing in patients with advanced illness who were refractory to current laxative regimens and to assess the influence, if any, of poor functional status on response to MNTX treatment.

Methods

This analysis included pooled data from patients with advanced illness and established OIC who were on a stable opioid regimen in a pivotal, randomized, placebo (PBO)-controlled clinical trial (study 302 [NCT00402038]) or a randomized, PBO-controlled Food and Drug Administration-required postmarketing study (study 4000 [NCT00672477]). Patients in study 302 received subcutaneous MNTX 0.15 mg/kg or PBO every other day, whereas those in study 4000 received MNTX 8 mg (body weight ≥38 to <62 kg), MNTX 12 mg (body weight ≥62 kg), or PBO every other day. Outcomes included cumulative rescue-free laxation rates at 4- and 24-hours postdose for the first 3 doses of study drug and time to rescue-free laxation. To assess if functional status influenced treatment outcomes, we performed a secondary analysis on the outcomes stratified by baseline World Health Organization/Eastern Cooperative Oncology Group performance status, pain scores, and safety.

Results

One hundred eighty-five patients received PBO and 179 patients received MNTX. The median age was 66.0 years, 51.5% were women, 56.5% had a baseline World Health Organization/Eastern Cooperative Oncology Group performance status score >2, and 63.4% had a primary diagnosis of cancer. Cumulative rescue-free laxation rates were significantly higher with MNTX than PBO 4- and 24-hours after doses 1, 2, and 3 (P < 0.0001), and between-treatment comparisons remained significant (P < 0.0001) regardless of performance status. The estimated time to first rescue-free laxation was shorter for patients receiving MNTX versus PBO. No new safety signals were identified.

Conclusions

Repeated use of MNTX represents a safe and effective treatment for OIC in patients with advanced illness regardless of baseline performance status. ClinicalTrials.gov identifier: NCT00672477. (Curr Ther Res Clin Exp. 2023; 84:XXX-XXX)© 2023 Elsevier HS Journals, Inc.

Non-perforated Stercoral Colitis patients with septic shock have a higher mortality than their perforated counterparts. A case report and review of literature

Introduction and importance

Stercoral colitis is an inflammatory condition caused by fecal impaction; it involves the colonic or rectal wall. It occurs most commonly in nursing home patients, chronic opioid users, and patients with mental impairment.

Case presentation

We present the case of a 36-year-old, obese, African American male with a history of intellectual disability, bipolar disorder, and chronic constipation. Patient presented to the emergency room after an episode of syncope, confusion, 24-hour abdominal pain, nausea, and vomiting. On admission to the ED the patient was found to be in sepsis; within 4 h he developed septic shock. CT scan of the abdomen showed impacted fecal matter in a significantly distended left and sigmoid colon. This was associated with colitis, extensive fat stranding and free fluid, without pneumoperitoneum. The patient was taken to the operating room for exploration where he underwent an extended left colectomy and Hartmann's procedure. Pathology showed acute focal colitis with transmural necrosis. There were no signs of perforation or inflammatory bowel disease. The patient recovered and was discharged home on post-operative day 8. Upon follow up on post-operative day 22, he was doing well.

Clinical discussion

This case illustrates a very rare and challenging scenario. Complications of stercoral colitis include: stercoral ulcer, perforation, ischemic colitis, sepsis and death. Peritonitis, sepsis and bowel necrosis without perforation is extremely rare with very few cases reported in the literature. Colectomy with diversion is the mainstay of therapy.

Conclusion

It is of paramount importance for ED providers and general surgeons to be aware of this condition. It presents a diagnostic challenge and carries an elevated mortality. Elderly patients on chronic opioids and those with mental impairment are at a higher risk.

•

Stercoral colitis induced sepsis is a challenging diagnosis.

•

Stercoral colitis induced sepsis has a mortality close to 60 %.

•

Source control is paramount to avoid fatal outcomes.

First-Dose Efficacy of Methylnaltrexone in Patients with Severe Medical Illness and Opioid-Induced Constipation: A Pooled Analysis

BACKGROUND

Opioid-induced constipation (OIC) is a frequent consequence of opioid analgesia that may increase patient risk for emergency department visits and hospitalization. Methylnaltrexone is a peripherally acting µ-opioid receptor antagonist indicated for the treatment of OIC.

OBJECTIVE

To assess the safety and efficacy of a single methylnaltrexone dose.

METHODS

Results were pooled from three randomized, placebo-controlled methylnaltrexone (MNTX) studies in opioid-treated patients with advanced illness and OIC, despite treatment with conventional laxatives. Baseline assessments included demographics, disease/treatment characteristics, and functional levels. Efficacy endpoints included rescue-free laxation (RFL) rates within 4 and 24 h, time to first RFL, pain score change, and adverse events (AEs) after a single MNTX dose or placebo.

RESULTS

The analysis included 281 patients receiving MNTX and 237 receiving placebo. Mean age was 66.2 years for MNTX and 65.8 for placebo; ∼50% were men. The most frequent primary diagnosis was cancer (MNTX = 70.5%; placebo = 66.2%) and most (∼98%) were receiving at least one laxative at baseline. RFL occurred in 61.4% vs. 16.0%, and 72.1% vs. 40.1% MNTX vs. placebo patients, within 4 and 24 h of the initial dose, respectively. Relative to placebo, MNTX use reduced the time to first RFL, with most MNTX-treated patients achieving RFL within 2 h. Baseline and posttreatment pain scores were similar (p = 0.9556 vs. placebo for current and worst pain change from baseline), demonstrating that MNTX did not negatively affect opioid analgesia. Most AEs were gastrointestinal related and dissipated by the second dose.

CONCLUSIONS

Methylnaltrexone provides early RFL without compromising analgesia in patients receiving chronic opioid therapy.

Prognostic Factors of Patients with Stercoral Perforation of the Colon

Background/Aims

The incidence of stercoral perforation of the colon (SPC) is expected to rise, given the increased life expectancy and the aging population. On the other hand, the prognostic factors of mortality after surgery for SPC remain unclear. This study examined the prognostic factors of patients with SPC after surgery.

Methods

The medical records of 145 patients who underwent surgery for colonic perforation between April 2010 and May 2019 were reviewed retrospectively. In 145 patients, 22 patients who underwent SPC surgery were categorized into the following two groups according to in-hospital survival after surgery: alive (group A, n=15) and dead (group B, n=7).

Results

In all enrolled patients, the mean age was 75.7±9.0 years, with a female predominance (female patients, n=19, 86.4%). Sixteen patients (72.7%) had chronic constipation with medications, and five patients (22.7%) were bedridden. The rate of preoperative bedridden status was significantly higher in group B than group A (6.7% vs. 57.1%; p=0.021). Univariate analysis revealed immobility, a sequential organ failure assessment (SOFA) score, and lactate levels of more than 2.0 mmol/L to be factors associated with increased mortality rates in the postoperative period. Multivariate analysis revealed abnormal lactate levels to be the only factor related to mortality (hazard ratio 16.50, 95% CI 1.48-183.07, p=0.022).

Conclusions

Preoperative abnormal serum lactate levels may be a risk factor for mortality after surgery in patients with stercoral perforation. Further research will be needed to identify the postoperative prognostic SPC factors.

Management of Opioid-Induced Constipation and Bowel Dysfunction: Expert Opinion of an Italian Multidisciplinary Panel

The prescribing and use of opioid analgesics is increasing in Italy owing to a profusion in the number and types of opioid analgesic products available, and the increasing prevalence of conditions associated with severe pain, the latter being related to population aging. Herein we provide the expert opinion of an Italian multidisciplinary panel on the management of opioid-induced constipation (OIC) and bowel dysfunction. OIC and opioid-induced bowel dysfunction are well-recognised unwanted effects of treatment with opioid analgesics that can profoundly affect quality of life. OIC can be due to additional factors such as reduced mobility, a low-fibre diet, comorbidities, and concomitant medications. Fixed-dose combinations of opioids with mu (μ) opioid receptor antagonists, such as oxycodone/naloxone, have become available, but have limited utility in clinical practice because the individual components cannot be independently titrated, creating a risk of breakthrough pain as the dose is increased. A comprehensive prevention and management strategy for OIC should include interventions that aim to improve fibre and fluid intake, increase mobility or exercise, and restore bowel function without compromising pain control. Recommended first-line pharmacological treatment of OIC is with an osmotic laxative (preferably polyethylene glycol [macrogol]), or a stimulant laxative such as an anthraquinone. A second laxative with a complementary mechanism of action should be added in the event of an inadequate response. Second-line treatment with a peripherally acting μ opioid receptor antagonist (PAMORA), such as methylnaltrexone, naloxegol or naldemedine, should be considered in patients with OIC that has not responded to combination laxative treatment. Prokinetics or intestinal secretagogues, such as lubiprostone, may be appropriate in the third-line setting, but their use in OIC is off-label in Italy, and should therefore be restricted to settings such as specialist centres and clinical trials.

Rare but relevant: a systematic review of stercoral perforation

BACKGROUND/AIMS

Knowledge of the aetiologies of large bowel perforation are fundamental to its management. Stercoral perforation is a rare cause associated with high mortality. Owing to the paucity of coverage of this condition in the literature, this review raises awareness of stercoral perforation among clinicians.

METHOD

A literature search of PubMed, Embase, MEDLINE, CINAHL, Ovid and Cochrane was performed. Key search terms included 'stercoral, perforation', 'perforated', 'perforat*' and 'stercoral perforation'. Only literature published between December 2011 and July 2020 was included to avoid duplication.

RESULTS

Twenty-nine papers were obtained giving an overall cohort of 58 patients. The median age was 58 years (range 2-83 years) and 72.4% (n=42) were female. Constipation was reported in 69% (n=40) and 20.7% (n=12) reported chronic opioid use. A computed tomography scan was performed in 94.8% (n=55) of cases and typically a Hartmann's procedure (n=40, 72.2%) was performed. The mortality rate was 17.2% (n=10).

CONCLUSIONS

The median age of patients with stercoral perforation has decreased from that found in previous studies and the mortality rate has improved. Chronic opioid users have also emerged as an important cohort. Early recognition, diligent decision making and focused perioperative care form the backbone of the definitive management of stercoral perforation.

Stercoral re-perforation after colostomy takedown: a case report

Background

Stercoral perforation (SP) is a rare surgical condition that is associated with high morbidity and mortality. Most of these patients undergo emergent surgery, including colostomy, and some undergo colostomy takedown after recovery. Stercoral re-perforation after colostomy takedown followed by colostomy for SP has not yet been reported.

Case presentation

A 79-year-old woman presented with abdominal pain for one day. Abdominal-pelvis computed tomography revealed pneumoperitoneum with diffuse mesenteric fat haziness of the left abdomen. During laparoscopic exploration, a 3-cm-sized perforated site was found at the sigmoid-descending colon, with fecal material and reactive fluid outside the colon. Loop colostomy formation was performed, and a takedown was completed after 3 months. Two years 4 months after the initial procedure, the patient was re-admitted to our hospital with abdominal pain. She underwent a second laparoscopic colostomy formation and was discharged, although the postoperative clinical course was poorer than that after the first surgery.

Conclusions

This case of stercoral re-perforation after colostomy takedown followed by colostomy formation for SP has important clinical implications and can be a reference for physicians. When the first colostomy formation was performed for SP, the decision on performance of a colostomy takedown should be made after carefully considering several factors.

Stercoral perforation of the colon: a mortal consequence of chronic constipation in the elderly (a case report)

The stercoral perforation is a mortal condition. It affects elderly patients who have a long history of chronic and severe constipation as well as constitutes a surgical emergency whose prognosis, often grim, depends on the early diagnosis and treatment. We report the case of a stercoral colon perforation which occurred in an 89-year-old patient. The clinical symptomatology was that of an acute peritonitis evolving for four days. The diagnosis was only made intraoperatively and the surgical gesture was a resection of the involved left colon segment and Bouilly Volkmann colostomy. The consequences were unfortunately marked by a resistant septic shock resulting in the death of the patient on the 1st postoperative day. The diagnosis of stercoral colon perforation, which is often difficult and delayed, must be known by all physicians who manage an increasingly older patient population.

Stercoral Perforation of Sigmoid Colon in Systemic Lupus Erythematosus: A Rare Cause of Peritonitis

Stercoral perforation (SP) is a rare cause of peritonitis. It is caused by pressure necrosis of the colonic wall by fecaloma. SP is a lethal condition that is associated with high morbidity and mortality, therefore early diagnosis and treatment are of paramount importance. Herein, we describe a case of SP in a systemic lupus erythematosus (SLE) patient.

A 44-year-old female, known case of SLE, presented with severe abdominal pain, fever, and hypotension. CT scan showed features of perforated sigmoid. The patient underwent exploratory laparotomy which revealed perforation of sigmoid, fecalomas in the peritoneal cavity, and colon loaded with fecal matter. The patient underwent Hartmann's operation with successful control of her intra-abdominal sepsis. Her postoperative course was complicated by SLE flare and wound dehiscence which was probably due to long term steroid use.

Even though SP is rare, it carries a worse prognosis especially if the patients are immunocompromised. The key to successfully manage such cases is early diagnosis, aggressive resuscitation, antibiotics, and prompt surgical intervention. A multidisciplinary approach is often helpful in such cases.

Opioid Use in Patients With Inflammatory Bowel Disease

Background

Data on opioid use in patients with inflammatory bowel disease and the relationship between disease, opioid use, and healthcare resource utilization are needed.

Methods

This analysis of real-world data from IBM Watson Health Commercial Claims and Encounters Database included patients with the first claim of inflammatory bowel disease (IBD) between 2007 and 2014.

Results

Opioid use was higher in patients with IBD than in the matched non-IBD cohort. Adjusted for age, gender, and Charlson Comorbidity Index score, inpatient and emergency room visits risk was higher in opioid users than non-users in both IBD cohorts.

Conclusions

Opioid use could be a potential surrogate for inadequate disease control manifested by increased inpatient and emergency room visit risks. These results suggest a need exists for better disease management and the development of an outcomes measurement tool for IBD pain.

Opioid-induced bowel dysfunction: suggestions from a multidisciplinary expert Board

Constipation, one of the adverse effects of opioid therapy with a major impact on quality of life, is still an unmet need for cancer patients, particularly those with an advanced and progressive disease, and for non-cancer patients chronically treated with opioids. The awareness of this condition is poor among healthcare providers, despite the recent publication of guidelines and consensus conferences. An early multidisciplinary approach of opioid-induced bowel dysfunction (OIBD), based on available therapies of proven effectiveness, could support clinicians in managing this condition, thus increasing patients’ adherence to pain therapy. Several Italian experts involved in the management of patients suffering from pain (anaesthesia pain therapy, oncology, haematology, palliative care, gastroenterology) joined in a Board in order to draw up an expert opinion on OIBD. The most frequent and still unsolved issues in this field were examined, including a more comprehensive definition of OIBD, the benefits of early intervention to prevent its occurrence and the most appropriate use of peripherally acting mu-opioid receptor antagonists (PAMORAs). The use of the recently introduced PAMORA naloxegol was analysed, in light of the current literature. The Board proposed a solution for each open issue in the form of recommendations, integrated with the contribution of representatives from different disciplines and often accompanied by procedural algorithms immediately usable and applicable in daily clinical practice. Safety and quality of life of the patient suffering from pain and from the adverse effects of pain therapies have been the mainstays of this expert opinion, in cooperation with general practitioners and caregivers.

Pathophysiology and management of opioid-induced constipation: European expert consensus statement

Background

Opioid-induced bowel dysfunction is a complication of opioid therapy, in which constipation is the most common and problematic symptom. However, it is frequently under-recognised and thus effective management is often not instituted despite a number of treatment options.

Objective

The central objective of this study is to provide a summary of the pathophysiology and clinical evaluation of opioid-induced constipation and to provide a pragmatic management algorithm for day-to-day clinical practice.

Methods

This summary and the treatment algorithm is based on the opinion of a European expert panel evaluating current evidence in the literature.

Results

The pathophysiology of opioid-induced constipation is multi-faceted. The key aspect of managing opioid-induced constipation is early recognition. Specific management includes increasing fluid intake, exercise and standard laxatives as well as addressing exacerbating factors. The Bowel Function Index is a useful way of objectively evaluating severity of opioid-induced constipation and monitoring response. Second-line treatments can be considered in those with recalcitrant symptoms, which include gut-restricted or peripherally acting mu-opioid receptor antagonists. However, a combination of interventions may be needed.

Conclusion

Opioid-induced constipation is a common, yet under-recognised and undertreated, complication of opioid therapy. We provide a pragmatic step-wise approach to opioid-induced constipation, which should simplify management for clinicians.

Focus on current and future management possibilities in inflammatory bowel disease-related chronic pain

INTRODUCTION

Visceral pain is a symptom reported by over 70% of inflammatory bowel disease (IBD) sufferers. So far, a single, specific cause of this debilitating state has not been established. Chronic pain is one of the most important factors decreasing the quality of life in IBD course. Concurrently, management of pain is the most challenging issue encountered by clinicians in IBD treatment.

AREAS COVERED

This review focuses on pathophysiology of inflammatory bowel disease-caused visceral pain and explores currently available approaches to its management. We also covered recent pharmacological developments in the field.

CONCLUSIONS

Pain-related disability has major effects on quality of life and on functional and social outcomes in IBD patients. Currently, there is no one standardized method of managing chronic visceral pain in IBD. Therefore, future development, focusing primarily on alleviating the pain, but also on reducing inflammation, is essential.