Transcript Spinal Cord Injury and Bowel Dysfunction

Spinal Cord Injury and Bowel
Dysfunction
Presented by Angela Stancil
January 10 , 2014
Epidemiology of SCI
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200,000 - 273,000 people in U.S. have SCI
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Estimated 12,000 – 20,000 new cases in U.S. annually
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Average age at time of injury 42.6 y/o
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80.7% males
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76.8% Caucasian
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Alcohol implicated in 25% of cases
A&P of the Spinal Column
SCI Classifications
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Complete or
Incomplete
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Quadraplegia
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Tetraplegia
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Paraplegia
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Monoplegia
Complications of SCI
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Lack of bladder control
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Bowel Dysfunction
Spacisity
Altered or missing skin
sensation
Flaccidity
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Problems with circulatory
control
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Orthostatic hypotension
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Autonomic Hyperreflexia
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Edema
Respiratory problems
Altered muscle tone
Muscle atrophy
Weight loss (new injury)
Loss of Mobility
Sexual Dysfunction
Depression
Pain
Autonomic Hyperreflexia
Neurogenic Bowel
Problems with storing, removing, or moving stool from the
intestines resulting from nerve damage
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Classifications
–
Reflexic Bowel
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Areflexic Bowel
Symptoms of Neurogenic Bowel
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Trouble having a bowel movement
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Repeated bowel accidents
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Swollen abdomen
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Feeling full (not hungry) quickly
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Loose stools or very hard stools
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Bleeding from the rectum
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Abdominal pain
Treatment/Bowel Training
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Dietary changes
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Exercise/PA program
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Specific times, assistance, and positions for BMs
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Medications (stool softeners, laxatives, colonic
stimulants, bulking agents)
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Digital Stimulation (mechanical, enemas, suppositories)
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Surgery (Colostomy or Ileostomy)
Rationale and Study Objectives
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Moisture content of stool remains 70-75%
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Low fiber intake does not = constipation
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Symptoms may increase with increased fiber intake
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Other treatments (i.e. lactulose) may be more beneficial
than fiber
Patients with constipation already have high fiber intake
Objective: to study the effect of decreasing fiber in patients
with constipation
Hypothesis: Reducing dietary fiber reduces fecal bulk
making defecation easier
Study Design
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Prospective longitudinal case study
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Inclusion criteria:
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Straining to expel bulky stools
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Bowel frequency <1 per 3 days over 3 months
Exclusion criteria:
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Colorectal cancer, previous colonic surgery,
melanosis coli, thyroid disorders, anal problems
63 subjects enrolled in the study
Methods
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Each patient acted as their own control
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No dietary intake of fiber for 2 weeks
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Normal CHOs and protein
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No laxatives
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Sieved juices and clear vegetables soups
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Low fiber diet
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F/U at 1 month and 6 months
Methods
Data Collection:
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Age & sex
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Fiber intake
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Frequency of BMs
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Straining difficulty
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Evacuation difficulty
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Abdominal pain and bloating
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Anal Bleeding
Statistical analysis
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Paired t tests using SPSS software
Results
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16 males, 47 females
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Median age 47 years
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High fiber diet + fiber supplement
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At 6 months:
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41 no fiber, 16 reduced fiber, 6 high fiber
Results - Demographics
No significant difference in age or sex between groups
Results – BM Frequency
Group
Baseline
6 months
P value
1 motion/ 3.75 days
(+/- 1.59 days)
1 motion/ 1.0 days
(=/- 0.00 days)
P < 0.001
Reduced Fiber
(n = 16)
1 motion/ 4.19 days
(+/- 2.09 days)
1 motion / 1.9 days
(+/- 1.21 days)
P <0.001
High Fiber (n = 6)
1 motion/6.83 days
(+/- 1.03 days)
1 motion/6.83 days
(+/- 1.03 days)
P <1.00
No Fiber (n=41)
Net Effect: Increase in frequency in No Fiber and Low Fiber
groups, no change in High Fiber group
Results – Associated Symptoms
Net Effect: Reduction in associated symptoms in Reduced
and No Fiber groups
Conclusions
Authors' Conclusions:
Removing dietary fiber improves constipation and
associated symptoms
Study Limitations
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Small sample size
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No baseline symptoms by group
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P values
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Results not generalizable
Rationale
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IBS is a functional bowel disorder characterized by abdominal
pain and discomfort related to bowel disturbances
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Probiotics are a safe candidate for controlling IBS symptoms
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Dietary fiber is commonly used in the treatment of IBS
Objective: Evaluate the effect of probiotics on patients with IBS
and determine if dietary fiber has an additive effect
Study Design
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Single center, randomized, control trial
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Recruited volunteers ages 18 – 70 y/o
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Exclusion criteria:
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Severe liver, lung, renal, hematological, or major psychiatric
disorder
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Adults > 50 y/o who had not had colonoscopy or
sigmoidoscopy in past 5 years
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Abnormal thyroid function, blood counts, serum chemistry
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Antipsychotics or anticholergenics in past month
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Pregnant or lactating
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Receiving medications for IBS
Methods
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142 participants
Each participant received a
fermented milk product taken
2x/day for 4 weeks
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Control group: 150 ml milk +
Probiotics
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Test group: same + 3.15 g
dietary fiber
Questionnaire
Primary endpoint: difference in
defecation frequency, duration,
and VAS score
Statistical Analysis
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Shapiro-Wilk test
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Student t tests
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Paired t tests
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P < 0.05
Results
Results
Results
Results
Authors' Conclusions:
Plain probiotic milk and probiotic milk containing fiber are
safe and effective. Probiotic milk containing fiber was more
effective for the constipation dominant subtype of IBS
Study Limitations:
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No placebo group
Mr. W
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57 y/o AAM w/ C4 quadreplegia
PMH: neurogenic bowel and bladder w/ chronic indwelling catheter,
ventilator dependent respiratory failure s/p trach (capped),
osteomyelitis, migraines, anemia, keratoderma, and VRE
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BT: Digital Stimulation, Mini enema
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Skin: Braden 10, Severe risk of HAPU
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Stage 4 PU to clavicle and R. ischeal
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Stage 3 PU to Sacrum
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Unstageable PU to R. heel
Mr. W
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Laboratory Data: No new lab data
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Previously, low pre – albumin (17.39)
Anthropometrics
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HT: 74 in.
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WT: 130.1 lbs (12/8/13)
130.2 lbs (11/21/13)
126 lbs. (11/15/13)
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DBW: 162 – 171 lbs. (adjusted 5-10% for tetraplegia)
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%DBW: 80%
Pertinent Medications:
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Omeprazole, Acidophilus, Docusate, Tizanidine, Baclofen
Nutrition Assessment
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Estimated Nutrition Needs
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Calories: 1776 – 2072 kcals/day (30-35 kcals/kg)
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Protein: 74 – 89 g (1.25 – 1.5 g/kg)
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Fluid: 1 ml/kcal + 500 ml or per PCP
Diet Hx:
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PO: Liberal diet
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EN: TwoCal @ 60 ml/hr x 12 hrs
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Free water @ 250 ml/hr q4h
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Prostat supplement
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10 am: orange/mango applesauce (meds only)
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8pm snack: PB &J, 1 choc milk, 1 cookie
Nutrition Assessment
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Nutrition Assessment
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Appetite: “so so”
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No V/C/D
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Tolerating TF w/o problems
Physical Assessment
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Moderate deficits in temples and OFP
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24 hour calorie count: 381 kcals, 16.1 g protein
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Nitrogen Balance: + 2.57 (PO + EN+ Prostat)
Mr. W
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Nutrition Dx:
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Increased protein/energy needs related to malnutrition and
wound healing as evidenced by presence of multiple PUs
and Braden of 9.
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Inadequate oral intake related to poor appetite as evidenced
by ongoing need for nutrition support and results of 24 hour
calorie count.
Nutrition Prescription:
Increase intake by 10% by next visit utilizing supplements,
snacks, and select menus thereby decreasing dependence on
EN
Mr. W
Nutrition Interventions
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Continue Liberal diet
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Continue Prostat and evening snack
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Continue EN : TwoCal @ 60 ml/hr from 7p - 7a
Nutrition Monitors
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Wound healing
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Tolerating TF
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Prevent Unintentional Weight loss
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Lab values WNL
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Consume >80% nutrition needs
Mr. W
Nutrition Evaluation
Patient's PO intake remains suboptimal. With EN,
patient's nitrogen balance is positive. Recommend
continuing Liberal diet and EN. Encourage PO
intake to decrease dependence on nutrition
support. Will continue to follow while admitted.
Prognosis: ??
References
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The University of Alabama at Birmingham NSCISC National Spinal Cord Injury Statistical Center. Spinal Cord
Injuries Facts and Figures at a Glance. Updated February 2013.Accessed January 5, 2014. Available at
https://www.nscisc.uab.edu/.
The Centers for Disease Control and Prevention. Spinal Cord Injury (SCI): Fact Sheet. CDC's Injury Center
webpage. Updated November 4, 2010. Accessed January 5, 2014. Available at
http://www.cdc.gov/traumaticbraininjury/scifacts.html.
The Mayo Clinic. Spinal Cord Injury. Diseases and conditions webpage. Updated Oct. 22, 2011 . Accessed
January 5,2014. Available athttp://www.mayoclinic.org/diseases-conditions/spinal-cordinjury/basics/definition/con-20023837.
National Institutes of Health Clinical Center. Managing Bowel Dysfunction patient education handout.
Accessed January 5, 2014. Available at http://www.cc.nih.gov/ccc/patient_education/pepubs/bowel.pdf.
NYU Langone Medical Center. Neurogenic Bowel. Diseases and conditions webpage. Updated March 2013.
Accessed January 5, 2014. Available at http://medicine.med.nyu.edu/conditions-wetreat/conditions/neurogenic-bowel. http://medicine.med.nyu.edu/conditions-we-treat/conditions/neurogenicbowel.
Ho, K, Tan, CY, Daud MA, Seow-Choen, F. Stopping or reducing dietary fiber intake reduces constipation and
its associated symptoms. World J Gastroenterology. 2012;18(33):4593-4596.
Choi,SC, Kim BJ,Rhee P, et al. Probiotic fermented milk containing dietary fiber has additive effects in IBS
with constipation compared to plain probiotic fermented milk. Gut and Liver; 2011.(5):22 – 28.