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Neurogenic Bowel

Although all patients with a spinal cord injury will have a neurogenic bowel, the type and symptoms will depend on the level and completeness of the lesion. Individuals with lesions above T10 vertebral or T12 spinal will have a hyperreflexic bowel, while those with lesions below T10 vertebral or T12 spinal will have an areflexic bowel

Stool incontinence has a significant social and emotional impact

Each patient requires an individualised bowel management program that considers timing of bowel movements, diet (e.g., fibre and fluid intake), physical (gastrocolic reflex, abdominal massage) and either a rectal stimulation (hyperreflexic bowel) or a manual evacuation (areflexic bowel) technique

Most patients will be on chronic laxatives (stool softners, stimulant or osmotic laxatives)

If bowel management routine is ineffective, change 1 element of the management plan at a time to help identify cause and do not change more frequently than every 10-14 days

Neurogenic bowel is a common reason patients with spinal cord injury have to go to A&E and a common cause of Autonomic Dysreflexia (AD)

Definitions

Neurogenic Bowel
A life-altering impairment of gastrointestinal and anorectal function resulting from a lesion of the nervous system that can lead to life-threatening complications such as autonomic dysreflexia (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 8).
Areflexic Bowel
A lower motor neuron (LMN) bowel produced by an injury at the sacral segments in which no spinal cord-mediated reflex occurs (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 37).
Reflexic Bowel
An upper motor neuron (UMN) bowel produced by a spinal cord injury above the sacral segments in which defecation cannot be initiated by voluntary relaxation of the external anal sphincter (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 37).

Pathophysiology

Bowel Pathophysiology

Reproduced from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Hyperreflexic Bowel
The upper motor neuron (UMN) bowel syndrome is characterised by increased colonic wall and anal tones. Voluntary (cortical) control of the external anal sphincter is disrupted and the sphincter remains tight, thereby promoting retention of stool. The nerve connections between the spinal cord and the colon, however, remain intact; therefore, there is preserved reflex coordination and stool propulsion. The UMN bowel syndrome is typically associated with constipation and faecal retention at least in part due to external anal sphincter activity (Stiens et al., 1997). Stool evacuation in these individuals occurs by means of reflex activity caused by a stimulus introduced into the rectum, such as an irritant suppository or digital stimulation.

Areflexic Bowel
The lower motor neuron (LMN) bowel syndrome is characterised by the loss of centrally-mediated (spinal cord) peristalsis and slow stool propulsion. LMN bowel syndrome is commonly associated with constipation and a significant risk of incontinence due to the atonic external anal sphincter and lack of control over the levator ani muscle that causes the lumen of the rectum to open. Stool evacuation usually involves manual evacuation.

Completeness of injury
Those with an incomplete injury may retain the sensation of rectal fullness and ability to evacuate bowels so no specific bowel program may be required.
(used with permission from scireproject.com)

Signs and symptoms

  Upper Motor Neuron (UMN) Lesion Lower Motor Neuron (LMN) Lesion
Adapted from Singal, A.K., Rosman, A.S., Bauman, W.A., & Korsten, M.A. (2006). Recent concepts in the management of bowel problems after spinal cord injury. Advances in Medical Sciences, 51, 15-22.
Level of lesion >T10 vertebral or T12 spinal segment <T10 vertebral or T12 spinal segment
Colonic transit time Increased Increased
External anal sphincter (EAS) Spastic paralysis Flaccid paralysis
Sympathetic output Absent with lesions > T6 spinal segment Retained
Symptoms Constipation
Difficulty with evacuation
Incontinence
Constipation
Difficulty with evacuation
Incontinence
Faecal impaction Proximal colon Rectal
Autonomic dysreflexia Common with injuries above T6 level Rare
Reflex defecation Present Not known

Additional symptoms of neurogenic bowel include:

  • Abdominal distension
  • Respiratory compromise
  • Early satiety
  • Nausea
  • Evacuation difficulty
  • Unplanned evacuations
  • Rectal bleeding
  • Diarrhoea
  • Constipation
  • Pain

Management and recommendations

Goals of bowel management

  1. Regular and thorough bowel emptying (every 1-2 days)
  2. Maintain continence
  3. Prevent and treat complications (e.g., constipation, haemorrhoids, faecal impaction, perforation, abscess, Autonomic Dysreflexia (AD))

Guiding principles

  • A systematic and comprehensive evaluation of bowel function and impairments is completed at the onset of injury and continues on an annual basis.
  • Bowel management starts during acute care and is revised as needed.
  • Bowel management program provides predictable and effective elimination and reduces gastrointestinal and evacuation complaints.
  • Knowledge, cognition, motor performance, and function are important assessments in determining the ability of the individual to complete a bowel care program or instruct a carer.
  • Attendant care needs, personal goals, life schedules, role obligations, developmental needs, and self-rated quality of life are to be considered in the development of bowel care programs.
  • Establishing a consistent schedule for defecation, based on factors that influence elimination, preinjury patterns of elimination, and anticipated life demands, is essential when designing a bowel care program.
  • Prescriptions for appropriate adaptive equipment for bowel care should be based on the individual’s functional status and discharge environment.
  • All aspects of the bowel management program are designed to be easily replicated in the individual’s home and community environments.
  • Adherence to treatment recommendations is assessed when evaluating bowel complaints and problems.
  • Effective treatment of common neurogenic bowel complications, including faecal impaction, constipation, and haemorrhoids, is necessary to minimise potential long-term morbidities.

Reproduced from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Neurogenic Bowel Management in Adults with Spinal Cord Injury” Washington, DC: © 1998 Paralyzed Veterans of America.

Designing a management program

Adapted from Multidisciplinary Association of spinal cord injured professionals (MASCIP) guidelines (2012). Guidelines for the management of neurological bowel dysfunction in individuals with central neurological conditions. www.mascip.co.uk and from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Neurogenic Bowel Management in Adults with Spinal Cord Injury” Washington, DC: © 1998 Paralyzed Veterans of America.

Evaluating bowel management

Adapted from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Troubleshooting

If bowel management routine is ineffective and regular bowel emptying does not happen regularly (every 2 days), change one element at a time to help identify the cause and do not change more frequently than every 10-14 days. A change in bowel management takes about 10-14 days to be reflected. Make sure to ask patient about changes in activity as this may impact bowel function (less active = harder stool).

Adapted from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Problem Possible Solutions
Stool too soft
  • Reduce or stop stool softener or laxative
  • Consider adding fibre supplement to bulk up stool
  • Increase dietary insoluble fibre (e.g., prunes)
  • Consider overflow from impaction (rectal exam and/or x-ray to rule out)
  • Check medications (e.g., antibiotics)
  • Check for bacterial infection in colon
  • Consider spacing out bowel routine
  • Inquire about dietary changes (e.g., fatty or spicy foods)
  • Ask about psychological stress
Stool too hard
  • Check fluid intake, if adequate consider fibre supplement
  • Add stool softener
  • Check medications (e.g., anticholinergic, narcotic)
  • Consider using a macrogol e.g. Movicol
Alternating diarrhoea and constipation May be indicative of higher faecal obstruction
Incontinence prior to planned evacuation time If stool is too hard or too soft may be the result of ineffective emptying
Change stimulant laxative to later time (i.e evening)
Ask about adherence to bowel care program
Ask about use of laxatives
Incontinence after evacuation
  • Consider incomplete emptying
  • Change stimulant laxative to earlier time
  • Consider increasing stimulant dose
  • If stool too hard, may have longer transit time
Excessive gas or abdominal bloating Ask about:
  • Chewing gum (increases swallowing of air)
  • Swallowing air while drinking through a straw or eating
  • Snoring
  • Consumption of gas-producing foods (high in sugar), beverages (e.g. carbonated drinks) or medications (e.g. Lactulose)
  • Changes to tube feeding or intake of artificial sweeteners in food or liquid medications
  • Lactose tolerance

Reproduced from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Laxatives

Most patients will be on chronic laxatives, which is OK.

We do not recommend bulk-forming laxatives or phosphate enemas due to the risk of bowel perforation.

Class Mechanism of Action Onset of Action Available Products Adverse Effects
Hyperosmotic Increases bowel water retention, which stimulates peristalsis 2-24h Lactulose 15-30ml OD-BID Bloating, flatulence, cramps, diarrhoea
Osmotic Increases bowel water retention, which stimulates peristalsis 0.5-6h (mag hydroxide) 24-48h (mag sulfate)
  • Macrogols (Movicol) ½ -2 sachets OD-BD
  • Magnesium sulfate (Epsom salts) 10-30g OD (dissolve in 240ml water)
  • Sodium phosphates (oral or rectal (Fleet)) 120ml PO OD (dilute in 120ml of water) or 120ml PR
  • Nausea, cramping, diarrhoea
  • Magnesium: risk of hypermagnesemia in renal failure
  • Phosphates: risk of hyperphosphatemia in renal failure; decrease absorption of quinolones and tetracyclines (administer at separate times), phosphate enema risk of perforation
Stimulant Irritate bowel wall which stimulate colonic peristalsis 0.5h (bisacodyl) 6-12h (senna)
  • Senna (Senokot) 2-4 tabs PO QHS
  • Bisacodyl (Dulcolax) 5-10mg PO OD or 10mg PR OD
  • Abdominal cramping
  • Melanosis coli (Senna)
Softeners Surfactant, keeps stool soft 12-72h
  • Docusate sodium (100-200mg OD-BD)
  • Nausea, cramping
Lubricants Coat stool to prevent colon from reabsorbing water 6-8h
  • Glycerin 4-8g PR OD
  • Leakage from rectum can cause irritation and pruritus
  • Decreases absorption of fat-soluble vitamins

Adapted from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Follow-up

  • Yearly review of bowel management program
  • If examination indicated should include: Abdominal palpation, rectal exam to check for tone and anocutaneous and bulbocavernous reflexes
  • Consider colorectal cancer screening for patients >50 years of age (FOB test may be very unreliable in this population)
  • Provide patient with education/resources (e.g. LSCIC Education pack)
References

Branagan, G., Tromans, A., & Finnis, D.(2003). Effect of stoma formation on bowel care and quality of life in patients with spinal cord injury. Spinal Cord, 41(12), 680-3.

Consortium for Spinal Cord Medicine. (1998). Neurogenic Bowel management in adults with spinal cord injury. Washington, DC: Paralyzed Veterans of America.

The Canadian Continence Foundation

Frisbie, J.H., Tun, C.G., & Nguyen, C.H. (1986). Effect of enterostomy on quality of life in spinal cord injury patients. Journal of the American Paraplegia Society, 9(1-2), 3-5.

Heaton, K. W., & Lewis, S. J. (1997). Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, 32(9), 920-4.

House JG, Stiens SA. (1997). Pharmacologically initiated defecation for persons with spinal cord injury: effectiveness of three agents. Archives of Physical Medicine and Rehabilitation, 78(10), 1062-1065.

Kelly, S.R., Shashidharan, M., Borwell, B., Tromans, A.M., Finnis, D., & Grundy, D.J. (1999). The role of intestinal stoma in patients with spinal cord injury. Spinal Cord, 37(3), 211-4.

Multidisciplinary Association of spinal cord injured professionals (MASCIP) guidelines (2012). Guidelines for the management of neurological bowel dysfunction in individuals with central neurological conditions.

Munck, J., Simoens, Ch., Thill, V., Smets, D., Debergh, N., Fievet, F., & Mendes da Costa, P. (2008). Intestinal stoma in patients with spinal cord injury: a retrospective study of 23 patients. Hepatogastroenterology, 55(88), 2125-9.

Ontario Neurotrauma Foundation. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. eprimarycare.onf.org/NeurogenicBowel.html

Rosito, O,. Nino-Murcia, M., Wolfe, V.A., Kiratli, B.J., & Perkash, I. (2002). The effects of colostomy on the quality of life in patients with spinal cord injury: a retrospective analysis. Journal of Spinal Cord Medicine, 25(3), 174-83.

Stiens, S.A., Bergman, S.B., & Goetz, L.L. (1997). Neurogenic bowel dysfunction after spinal cord injury: Clinical evaluation and rehabilitative management. Archives of Physical Medicine and Rehabilitation, 78, S86-S102.

Stone, J.M., Wolfe, V.A., Nino-Murcia, M., & Perkash, I. (1990). Colostomy as treatment for complications of spinal cord injury. Archives of Physical Medicine and Rehabilitation, 71(7), 514-8.

Wathen, N., Watson, G., Caldwell, S., & Lewis, N. (2007). Research summary: Improving continence care in complex continuing care. Ontario Women’s Health Council.

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