Transcript Neurogenic Bowel - The Christopher & Dana Reeve Foundation

Spinal Cord Injury and
Bowel Dysfunction
Glen W. White, Ph.D.
Melissa Gard, M.A. and Sam Ho
Research and Training Center on Independent Living
at the University of Kansas
This training
sponsored through a
grant from the
Christopher and Dana
Reeve Foundation
Special thanks to…
• The Christopher and Dana Reeve Foundation
• Centers for Disease Control
• Ann Sullivan Center of Perú
• Dra. Liliana Mayo and Staff members
• Scott Richards, Ph.D. – Spain Rehabilitation
Center, University of Alabama at Birmingham
• Suzanne Groah, M.D., M.S.P.H. – National
Rehabilitation Hospital, Rehabilitation
Research & Training Center on Secondary
Conditions in the Rehabilitation of Individuals
with Spinal Cord Injury
Special thanks to…
• Sam Ho
• Jaime Huerta
• Monica Ochoa
• And special thanks
to Julio Chojeda for
translation of
materials from
English to
Spanish…
Acknowledgement of sources used for this
presentation:
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Yes You Can! (Paralyzed Veterans of America)
SCI: A Manual for Healthy Living (TIRR)
Bowel Dysfunction (RTC/IL & PVA)
Neurogenic Bowel: What You Should Know (by the
Consortium for Spinal Cord Medicine)
Presentation Review
• Discuss significance of the problem
• Define bowel dysfunction
• Describe how the digestive system works
• Discuss neurogenic bowel
• Identify personal risk factors
• Identify environment risk factors
• Autonomic dysreflexia
• Management of bowel programs
• Some cautions about bowel programs
• Other more invasive considerations
• Question and Answer session
Bowel Dysfunction A Serious Problem
• More than 33% of people with SCI state
that bowel problems are major issues
resulting from their injury.
• About 25-30% of people with SCI living
independently say their digestive problems
have changed their lifestyle and has
required medical intervention.
• People with complete SCI that occurred 5 or
more years ago are most likely to experience
problems.
Bowel Dysfunction A Serious Problem
• A source of social embarrassment if an
effective bowel program is not followed
• Limits social participation in the
community in terms of work, and leisure
• Can cause discomfort, pain, and even death
if not managed properly
Bowels
How are they defined?
– The dictionary defines them
as “the seat of the gentler
emotions”
– Anatomically speaking the
bowels is another name for
the intestines or colon
– Also derived from the Old
French “boiel,” which is
taken from the Latin word
“botellus,” which means
“sausage”
Digestive System: How does it Work?
• Food is chewed, swallowed and
goes to stomach
• It then goes to the small
intestine where food is broken
down further and absorbed by
the intestinal walls
• Peristalsis action moves the
waste down the large intestine
or colon, which is shaped like a
large “S.” At the end of the
large intestine is the anus
Digestive System: How does it Work?
• The function of the colon
(large intestine) is to move the
waste or feces out of the
body
• The internal and external
sphincters are the
“gatekeepers” that allow
feces to pass out of the body
through the anus
SCI and the Neurogenic Bowel
• Brain signals are not able
to communicate below the
area of injury
• Many SCI individuals
cannot sense when their
bowel is full or when a
bowel movement is about
to occur
• This loss of sensation and
function is called
“neurogenic bowel”
Upper and Lower Motor Neuron
Bowels: What’s the Difference?
The Spine
• The figure to the left
illustrates the human
spine.
• There are two types
of bowels that are
affected by the level
of the spinal injury.
The dividing point
for these is T-12 or
the 12th thoracic
vertebrae.
High Level SCI: Reflex Bowel
• Those with SCI injury above T12 have
a reflex or upper motor neuron bowel
– Local nerves that connect with rectum
still communicate with one another
– Internal and external anal sphincters
retain tone reducing “accidents” between
regularly scheduled bowel programs
– Person is not usually aware when bowel
is full
– Bowel movements occur every 2-3 days
– Main issue is incomplete bowel emptying
Low Level SCI: Flaccid Bowel
• Those with SCI injury below T11
have a flaccid or lower motor
neuron bowel
– Anal sphincter always relaxed
– The colon does not normally
contract when the bowel is full
– There is greater risk for
incontinence and impaction
– Bowel movements occur almost
every day
Protective factors
against bowel problems
J
J J
N
N
NN
Knowledge
• Does not know how to perform a bowel program
• Knows how, but does not perform it routinely
• Is not aware of medications and other
technology available to help make bowel
management more successful
Health Beliefs
• Does not take personal responsibility for selfhealth
• Believes in fate versus empowered approach to
maintaining health
Personal Risk Factors
Risk Behaviors
• Poor nutrition/eating habits—not eating enough
fiber can lead to constipation
• Doesn’t drink enough water.
• Low activity levels—can lead to a sluggish bowel
• Does not perform regular routine to empty bowel
to avoid incontinence.
• Stress and mood—affects people differently; some
become more constipated, others not.
Personal Risk Factors
• Aging
– Increased risk for bowel dysfunction
– Why?
• The lining of the bowel is not as lubricated as
it was in young adulthood
• There is decreased motility or peristalsis of
the intestine
• Sphincter muscles may not be as tight and
toned
• Medications
• Some medications can make the stool softer
(Colace or Surfak)
• Some medications can make stool more firm
(Imodium)
• Narcotics can also lead to constipation.
• Some antibiotics (Augmentin) can kill all
bacteria (good and bad) and can result in
diarrhea, unless good bacteria is re-introduced
into the digestive system (acidophilus, cultured
yogurt)
Environmental Risk Factors
• Availability of foods that are a good
source of fiber
• Opportunity and place to increase
physical activity
• Availability of materials needed to
perform bowel program (gloves,
lubricant, suppositories)
• Personal assistance, if needed, to help
perform bowel program
Potential Problems with
the Neurogenic Bowel
• Involuntary bowel movements
• Constipation
• Fecal Impaction
• Diarrhea
• Hemorrhoids
• Autonomic Dysreflexia
Potential Problems with
the Neurogenic Bowel
• Involuntary bowel movements
– Can occur after you eat certain foods
• Caffeine, chocolate, and spicy foods stimulate
the bowels
– Evaluate entire bowel program
• Is the program frequent enough?
• Is it thorough and complete?
– Plan for unanticipated “events”
Potential Problems with
the Neurogenic bowel
• Constipation
– Not eating proper diet
• Low intake of fluid
• Low intake of fiber
• Not using laxatives to assist
– Medication side effects
– Incomplete emptying of bowel
Dietary Effects on Bowel Management
FOOD
GROUP
FOODS THAT HARDEN
STOOLS
FOODS THAT SOFTEN
STOOLS
Milk
Milk, cheese, cottage
cheese, ice cream
Yogurt with seeds or fruit
Bread and
Cereal
White bread or rolls,
pancakes, white rice
Whole grain breads and
cereals
Fruits and
Vegetables
Strained fruit juice, apple
sauce, potatoes without
skins
All vegetables except
potatoes without the skin
Meat
Any meat, fish, poultry
Nuts, dried beans, peas,
seeds, lentils, chunky
peanut butter
Fats
None
Any
Desserts
and Sweets
Any without seeds or fruit
Anymade with cracked
wheat, seeds or fruit
Soups
Any creamed or brothbased with nothing else
Soups with vegetables,
beans, or lentils
Potential Problems with
the Neurogenic Bowel
• Fecal Impaction
– Chronic constipation can lead to
impaction
– Occurs when hardened feces
collects in the colon
– Laxatives and manual removal
of stool may be required
– In serious cases, surgery may be
needed to remove impaction and
possible damaged colon
Potential Problems with
the Neurogenic Bowel
• Diarrhea
– Can be caused by medications
such as antibiotics
– Overuse of laxatives
– If using antibiotics, does not reintroduce healthy bacteria in
colon (e.g., yogurt with live
culture or acidophilus)
– May be the result of a fecal
impaction (leaking around the
impacted area)
Potential Problems with Neurogenic Bowel
Hemorrhoid Facts:
• Similar to vericose veins seen
on the legs
• When irritated, tends to swell
causing pain, itching,
discomfort, burning and
bleeding.
• Can be internal or external
• Internal hemorrhoids cause
fewer problems than external
hemorrhoids
Potential Problems with Neurogenic Bowel
Hemorrhoid Causes:
• Constipation and chronic
straining
• Diet low in vegetables, fruits,
and other fiber sources
• Genetic factors
• Pregnancy and childbirth
• Aging
• Chronic diarrhea and/or
chronic coughing
• Sitting for long periods of
time
Potential Problems with
the Neurogenic Bowel
Autonomic Dysreflexia
• Over-activity of autonomic nervous system
leading to high-blood pressure
• Potentially life-threatening
• High risk if SCI at upper back or neck
– T6 level or higher
Autonomic Dysreflexia
Frequent causes
– Bowel
• Full of stool or gas
• Impaction
• Any stimulus to the rectum
• Develops suddenly
• Triggered by anything causing pain
– e.g., bowel over-stretching
• Untreated can lead to stroke, seizure, and
ultimately, death
www.sci-info-pages.com/uti.html
Autonomic Dysreflexia
• How it starts
– Uncomfortable or irritating stimulus
• Example: Over-stretched bowel
• Nerve impulse sent to spinal cord from
stimulus
• Impulse stopped at injury level
• Nerve impulse unable to reach brain
• Reflex activated increasing activity in
sympathetic nervous system
www.sci-info-pages.com/uti.html
Autonomic Dysreflexia
• Warning signs
– Sweating on face, arms or chest above injury
– Bad headache
– Red, blotchy skin above level of injury
– Sudden high blood pressure
– Blurry vision or spots
– Goosebumps on arms or chest above injury
– Slow pulse
– A feeling of doom
Autonomic Dysreflexia
• If experiencing symptoms
– Remove tight clothing or pressure
immediately
– Sit up in bed
• Keep head elevated
– Empty bowel
– Go to hospital emergency
room
• REMOVE THE STIMULUS SOURCE
Managing a Bowel Program
The word SELF can remind you of the
elements of a successful bowel program
•S = Schedule
•E = Exercise
•L = Liquids
•F = Fiber
Managing a Bowel Program
S = Schedule
• Establish a regular time to do your program
– Time of day
– Times per week
– When to take laxatives
– When to insert suppository
Managing a Bowel Program
E = Exercise
• Significant increases or decreases in
exercise can affect the movement of the
bowels (peristalsis)
• Long periods of bedrest can cause
constipation
• Regular exercise helps keep you regular
Managing a Bowel Program
L = Liquids
• How much you drink is as important as
what you drink
• Liquids containing caffeine or alcohol will
help stimulate bowel activity
• Prune juice or apricot nectar promotes
bowel regularity, but too much can cause
diarrhea
• Drinking at least 2400 cc’s per day helps
keep stool soft
Managing a Bowel Program
F = Fiber
• Fiber adds bulk to the diet and
improves regularity
• 15 grams of fiber daily is
recommended to maintain
regularity
• Examples of Fiber:
Cereals/Breads Fruits Vegetables
Bran, oats,
wheat, rye,
oatmeal,
granola
Raisins,
orange,
apple,
tangerine
Spinach,
broccoli,
squash,
lettuce
How to do a Bowel Program
• Start your program after a meal or hot drink (this
stimulates peristalsis)
• Check your rectal area to see if there is any loose
stool in it, if so remove
• Insert well-lubricated suppository high up into
your rectum with gloved finger and place next to
intestinal wall
• If possible, transfer to toilet or commode as
gravity helps the evacuation process
• Wait 20-30 minutes after insertion
How to do a Bowel Program
• Then do digital stimulation
using a lubricated gloved
finger placed into your
rectum
• Using a circular motion,
massage the anal muscle
until it becomes relaxed
• Repeat the process every 510 minutes, to allow stool
to pass through the rectum
• Once rectum is clear of any
stool, wash and dry area
Cautions when doing
a Bowel Program
• Enemas are used to flush
out the contents of the
lower intestines. Enemas
should NEVER be
considered the only
solution to emptying the
bowels.
• Repeated enemas can make
the bowel dependent and
not respond to the body’s
own way of moving stool
through the intestines.
Colostomy: A Treatment of Last Choice?
Colostomy may be an option if:
• There are repeated bowel
complications
– Infections
– Chronic leakage
– Bloating
– Extensive limitation of social life
– Skin problems with the buttocks
due to chronic bowel incontinence
Colostomy: A Treatment of Last Choice?
• To perform a colostomy, a
cut is made in the colon and
connected to another opening
in the abdominal wall (called
a “stoma”). The lower end of
the colon is sewn shut.
• Instead of proceeding to the
rectum, stool exits out of the
stoma into a colostomy pouch
attached to the outside of the
body to collect the stool.
Stoma
Future Possibilities
for Bowel Management
• This picture displays an
electronic device that
activates an artificial
sphincter that opens
and releases the
intestines at times when
the user chooses.
• This device is adapted
from a similar device
used to treat urinary
incontinence.
• Research in this area is
still basic and
expensive.
Future Possibilities
for Bowel Management
(Experimental Research)
• Electrostimulation
therapy may become
a viable treatment
option in the future
• Stimulation of the
anterior sacral root
is most likely
candidate
• This technique is
already used to
empty bladder in
some patients
Review of Today’s Session
Today we:
• Discussed the significance of the problem
• Defined bowel dysfunction
• Described how the digestive system works
• Discussed neurogenic bowel
• Identified personal and environmental risk
factors
• Discussed autonomic dysreflexia
• Outlined options for bowel programs
• Mentioned other more invasive treatments