Transcript Neurogenic Bowel Management in Adults with Spinal Cord Injury

NEUROGENIC BOWEL
MANAGEMENT IN ADULTS WITH
SPINAL CORD INJURY
Tom Kiser, MD, MPH
Medical Director of Arkansas Spinal Cord Commission
Professor, UAMS Dept of PM&R
Anatomy of the gut
Assessment
• Patient history:
• Premorbid GI function and medical conditions
• Current bowel program and satisfaction
• Current symptoms: abdominal distention, respiratory
compromise, early satiety, nausea, evacuation
difficulty, unplanned evacuations, rectal bleeding,
diarrhea, constipation, and pain.
• Medication use and potential effect on bowels.
Assessment
• Physical Exam
• Complete abdominal assessment including palpation
along the course of the colon.
• Rectal examination
• Assessment of anal sphincter tone.
• Elicitation of anocutaneous and bulbocavernosus
reflexes to determine if the patient has UMN or LMN
bowel.
• Stool testing for occult blood beginning at age 50.
Assessment
• Functional evaluation:
• Ability to learn or direct others
• Sitting tolerance, angle, and balance
• Upper extremity strength, proprioception, and hand
and arm function.
• Spasticity and transfer skills
• Skin risks
• Anthropometric characteristics
• Home accessibility and equipment needs.
Normal Gut
• Stomach and small intestine
function: Mixes and digests
your food supplying the
blood streams with the
needed nutrients to function.
Minimal change after Spinal
cord injury
• Gastrocolic reflex with fatty
or protein food. Starts w/i 15
min and can last up to one
hour.
Designing a Bowel Program
• Encourage appropriate fluids, diet, and activity.
• Chose an appropriate rectal stimulant.
• Provide a stimulant to trigger defecation initially
daily.
• Select optimal scheduling, positioning and
appropriate assistive techniques.
• Evaluate medication and its effect on bowels.
Designing a Bowel Program
• Consistent schedule for defecation based on
factors that influence elimination, pre-injury
pattern, and anticipated life demands.
• Prescribe mechanical and/or chemical rectal
stimulant to predictably and effectively evacuate
stool.
Designing a Bowel Program
• Use of assistive techniques should be individualized with
evaluation of their effectiveness:
• Push-ups,
• abdominal massage,
• Valsalva maneuver,
• deep breathing,
• ingestion of warm fluids
• a seated and forward-learning.
Nutrition
• Should not be placed uniformly on high fiber diets
• Diet history to determine usual fiber intake
• Effect of current fiber intake on stool consistent
and frequency should be evaluated.
• Start with a diet with at least 15 grams of fiber.
• Increase fiber slowly from a variety of sources.
• Symptoms of intolerance should be monitored
and reduced or increased.
Nutrition
• Balance fluid intake for optimal stool consistency
and bladder management.
• Fluid intake approximately 500 ml/day greater
than standard guidelines for general public.
• Standard guidelines
• 1ml fluid/Kcal of energy needs + 500 ml/day
• 40ml/kg body weight + 500 ml/day
Home management of the bowel program
• Appropriate adaptive equipment for functional
status and discharge environment.
• Careful measures to avoid pressure ulcers and
falls.
• Adequate social and emotional support to help
manage disabilities and handicaps.
• Bowel management program should be easily
replicated in the home and community of the
individual.
Monitoring and adjusting Bowel program
• Date and time of day.
• Time from rectal stimulation until completion of
defecation.
• Total time for completion of bowel care
• Mechanical stimulation techniques
• Pharmacological stimulation
• Position/assistive techniques
• Color, consistency, and amount of stool
• Adverse reactions
• Unplanned evacuations
Bowel Program management
• When a bowel program is not effective.
• Ensure a consistent schedule then consider change to the
following:
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Diet
Fluid intake
Level of activity
Frequency of bowel care
Position/assistive techniques
Type of rectal stimulant
Oral medications
Rectal angle and Puborectal sling
Suppository
• Glycerin suppository – mild local stimulus and lubricating
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agent.
Bisacodyl suppository – contact irritant acts directly on
colonic mucosa produces peristalsis throughout the colon.
May be compounded with vegetable oil (dulcolax) or
polyethylene glycol (magic bullet)
Carbon dioxide generating suppository causes reflex
defecation in response to colonic dilatation.
Enemeze (Therevac) – 4 cc liquid docusate, glycerin,
and liquid soap base (polyethylene glycol)
Mini soap/shampoo enema.
Bowel Program
House JG, Steins SA. Arch of PMR 78: Oct ‘97
Bowel Program management
• Any change to a bowel program should be
maintained for 3 to 5 cycles prior to considering
possible modifications.
• Change only one element at a time.
• Adherence and compliance to recommendations
should be assessed.
• Colorectal cancer should be ruled out if older
than 50 years of age.
Digital Stimulation
• Insert gloved (non-latex suggested), lubricated finger into
rectum and slowly rotated finger in circular motion until
relaxation of bowel wall is felt and flatus and stool passes
or internal sphincter contracts.
• Usually takes 15 to 20 seconds, and repeated q 5 to 10
minutes is complete.
Manual evacuation
• Insertion of one or two fingers
• Break up or hook stool and pull it out.
• Method of choice in areflexic bowel
• Also may be needed to remove stool prior to suppository
insertion to ensure it is against the rectal mucosa for
reflexic bowel
Managing Complications of the
Neurogenic bowel
• Constipation – unusually long bowel care periods,
small results, dry hard stool.
• Chronic constipation – treat with balanced diet,
adequate fluid and fiber intake, increased daily
activity, reduce/eliminate constipating medication.
• No response w/i 24 hours of scheduled
evacuation a trial of bulk-forming agent or one or
more of the following laxative agents: lubricants,
osmotics and stimulant cathartics (ingest at least
8 hrs before planned bowel care)
Common complications
• Fecal impaction
• Hemorrhoids
• Prokinetic medication (Reglan, amitiza, zelnorm)
reserved for use with:
• Severe constipation
• Difficult evacuation
• Resistant to modification of bowel program
Surgical and Nonsurgical Therapies
• Biofeedback is not likely to be an effective
treatment modality for individuals with SCI.
• Decision about a colostomy or ileostomy is based
on specialized screening and individual
expectations. A permanent stoma is the best
option.
• Discussion should include anesthesia, surgical,
postoperative risks, body image, independence in
self manage, the permanence of the procedure.
Education of Bowel Program
• Anatomy and process of defecation
• Effect of SCI on bowel function
• Description, goals, and rationale of successful
bowel program
• Role of regularity, timing and postion and
assistive device/equipment use.
• Techniques for manual evacuation, digital
stimulation, and suppository insertion
Education of Bowel Program
• Prescription bowel medications
• Prevention and treatment of common bowel
problems: constipation, impactions, diarrhea,
hemorrhoids, incontinence and Autonomic
Dysreflexia.
• When and how to make changes in medications
and schedules.
• Management of emergencies.
• Long term implications of neurogenic dysfunction.
Surgical Options
• MACE (Malone Anterograde continence
enema)
• Appendix is constructed into a continent
stoma in the right lower quadrant.
• Paper at ASIA 2007 meeting suggests this
may be a preferable method based on
mathematical modeling of risks and
benefits.
Antegrade Continence enema
• One case report, by post
op 12 weeks. Daily
program with 200 cc tap
water/glycerin via 10 fr
catheter, then 15-20 min
later - digital stimulation
over a commode. Total
time 50 minutes.
• Yang CC. Arch Phys Med
Rehabil 81, May 2000.
Colostomy
• A diverting colostomy is often used to assist with
pressure sore healing due to soiling of the
wound. However, permanent stoma is the best
option.
• Choose a site on abdomen the will maximize
function and body image.
• In a VA study no statistical difference in
satisfaction with the bowel program between
colostomies and those without colostomies. Luther
Sl et al. J SCM 28(5), 2005.
Vocare Bladder
• Extradural stimulation of S2 and S3 nerves
• stimulates bladder and sphincter contraction
• stimulates descending bowel contraction
• Dorsal rhizotomy of Sacral nerves
• allows the bladder to fill
• eliminates autonomic dysreflexia due to
bladder
• loss of perineal sensation in incomplete SCI