neurogenic bowel definition, pathophysiology, management, medications

1. S.K. NAYAK
DNB PMR- 2ND YR. RESIDENT

2. NEUROGENIC BOWEL
• IT IS PRIMARILY THE FUNCTIONAL CHANGES
IN THE COLON AND PELVIC FLOOR.
• PROBLEM LIST:
PREVENTS WILLFUL CONTINENCE
VOLUNTARY DEFECATION
SELF MANAGEMENT OF CLEAN UP
• WHICH LEADS TO DREAD AND FEAR OF
INCONTINENCE AND FEAR OF COMMUNITY
PARTICIPATION.

3. • SPINAL CORD INJURY IS AMONG THE MOST
COMMMON CONDITIONS CAUSING
NEUROGENIC BOWEL DYSFUNCTION.
• INVOLVES ALL SEGMENTS OF GASTRO-
INTESTINAL SYSTEM

4. THE FOLLOWING CHANGES APPEAR
FOLLOWING SPINAL CORD INJURY(SCI)
APART FROM INVOLVEMENT OF COLON
AND ANORECTUM-
• COMPROMISED ORAL HYGIENE
• DYSPHAGIA
• GASTRIC ULCER AND ESOPHAGEAL DYSMOTILITY
• GALL STONES
• SMA SYNDROME
• NON TRAUMATIC PANCREATITIS

5. CHANGES IN COLON
• ALTERATION IN COLONIC MOVEMENT-
DISTURBED COLONIC PROPULSION
• MAY BE MEDIATED BY COLONIC REFLEXES-
GASTROCOLIC REFLEXES, COLOCOLONIC
REFLEX, RECTOCOLIC REFLEX.

6. ANORECTAL CHANGES
DISTURBANCE IN
• INTERNAL ANAL SPHINCTER ,
• EXTERNAL ANAL SPHINCTER AND
• PUBORECTALIS MUSCLE ACTIVITY

7. GASTROINTESTINAL REGULATION
• INTRALUMINAL CONTENT-
WESTERN DIET- DEFICIENT IN FIBER
FIBER RICH DIET-MOISTURE CONTENT,
MICROBIAL MASS- BILE SALT METABOLISM
• NEURAL REGULATION- INTRINSIC AND
EXTRINSIC
• ENDOCRINE REGULATION- PEPTIDES,
SUBSTANCE P, GRP.

10. NEUROGENIC BOWEL FUNCTIONS
SUPRASPINAL LESIONS- ROSTRAL TO PONS-
• FAILURE TO PERCEIVE RECTAL FULLNESS WITH
OVERFLOW INCONTINENCE AROUND A FECAL
INCONTINENCE
EXAMPLES ARE FRONTAL INCONTINENCE,
PARKINSON’S , MULTIPLE SCLEROSIS

11. UPPER MOTOR NEURON LESION(BETWEEN
PONS AND SACRAL SPINAL CORD- C1-T12)-
• GASTROCOLONIC REFLEX IS PRESERVED
• NO AWARENESS OF RECTAL FULLNESS
• NO SENSATION OF PELVIC FLOOR RETAINING
THE STOOL
• SPASTIC ANAL SPHINCTER

12. LOWER MOTOR NEURON BOWEL- BELOW T12
• INCONTINENCE- BECAUSE OF DENERVATION
OF ANAL SPHINCTER.
• ANAL SPHINCTER IS FLACCID

13. CLINICAL EVALUATION
• HISTORY-
 PREMORBID GI FUNCTION
CURRENT BOWEL PROGRAM WITH PATIENT
SATISFACTION
CURRENT SYMPTOMS- ABD. DISTENSION,
RESPIRATORY COMPROMISE, NAUSEA,
DIFFICULTY IN EVACUATION

14. • PHYSICAL EXAMINATION- COMPLETE
ABDOMINAL ASSESSMENT
• RECTAL EXAMINATION
• ANAL SPHINCTER TONE
• ANOCUTANEOUS AND BULBOCAVERNOSUS
REFLEX
• STOOL TESTING FOR OCCULT BLOOD (AGE
MORE THAN 50 YRS)

15. SPECIAL TESTS
• RECTODYNAMICS

16. GI PROBLEMS FOLLOWING SCI
• DIFFICULT BOWEL EVACUTION:
-REQUIRES MORE THAN 60MINS /DAY FOR
BOWEL CARE OR
- NEEDS MANUAL DISIMPACTION MORE
THAN ONCE IN A WEEK
• POORLY LOCALISED ABDOMINAL PAIN
• INCONTINENCE
• AUTONOMIC DYSREFLEXIA
• VENTILATORY INSUFFICIENCY

17. BOWEL MANAGEMENT- AAN
INTERDISCIPLINARY APPROACH
• BOWEL PROGRAMME
• BOWEL CARE

18. BOWEL PROGRAMME
• DIET AND FLUID INTAKE
• MEDICATIONS
• PHYSICAL ACTIVITY
• A SCHEDULE FOR BOWEL CARE

19. DIET AND FLUID INTAKE
• MINIMUM OF 15GM OF FIBER DAILY SHOULD BE
STARTED FROM DIFFERENT SOURCES OF DIET.
• HIGH FIBRE DIETS SHOULD BE AVOIDED (AS THERE
IS LACK OF EVIDENCE AND NEGATIVE EFFECTS
FROM AMOUNT OF 20-30GM PER DAY)
• SAFE : 15-20GM OF FIBER FROM DIFFERENT
SOURCES PER DAY
• FLUID INTAKE OF 2-3 LITRES PER DAY DEPENDING
ON THE BLADDER STATUS

20. MEDICATIONS
• STOOL SOFTNERS-
DOCUSATE SODIUM(COLACE),
CALCIUM(SURFAK)
-ARE THE SURFACE ACTIVE AGENTS AND LESSEN
THE REABSORPTION OF WATER IN THE COLON.
• PROKINETIC AGENTS (STIMULANTS)-
SENNA(SENOKOT)
METOCLOPRAMIDE(REGLAN)

21. • BULK FORMERS- PSYLLIUM(METAMUCIL,
FIBERALL), METHYL CELLULOSE (CITRUCEL)
• CONTACT IRRITANTS- BISACODYL(DULCOLAX),
GLYCERIN SUPPOSITORIES
• LAXATIVES- SODIUM, POTASSIUM,
MAGNESIUM SALTS, MILK OF MAGNESIA,
• HYPEROSMOLAR LAXATIVES- LACTULOSE,
SORBITOL, PEG(MIRALAX)- ACTION AT SI

22. PHYSICAL ACTIVITY
• NO SPECIFIC EXERCISES.
• FACILITATES GRAVITY TO ACT
• THE PATIENT SHOULD BE TRAINED FOR
TRANSFER TECHNIQUES, STANDING BALANCE.

23. BOWEL CARE
• POSITIONING
• ASSISTIVE DEVICES
• RECTAL STIMULATION OR TRIGGER FOR
DEFECATION
• ASSISTIVE MANEUVERS

24. POSITIONING
• IDEAL IS SITTING POSITION
• IF ON BED THEN SHOULD BE IN RIGHT SIDE
LYING POSITION
• SPECIAL CARE FOR PATIENTS WITH LESION
ABOVE T6- 2% LIGOCAINE JELLY FOR
STIMULATION

25. ASSISTIVE DEVICES
• FINGER,
• THERMOPLASTIC FINGER PROSTHESIS,
• GLOVES.

26. ASSISTIVE TECHNIQUES
• VALSALVA MANEUVER
• ABDOMINAL MASSAGE IN CLOCKWISE DIRECTION
FROM RIGHT LOWER QUADRANT ALONG THE
COURSE OF COLON
• INCREASE IN PHYSICAL ACTIVITIES
• ACTION IN A COMMODE CHAIR RATHER THAN ON
BED

27. BOWEL CARE STEPS
(FOR PATIENT AND CARE GIVER)

28. 3-2-1 PROGRAMME
• A STOOL SOFTNER THRICE A DAY
• TWO PROKINETIC AGENTS 8 HOURS BEFORE
THE SUPPOSITORY
• ONE SUPPOSITORY STARTED ONCE BOWEL
SOUNDS ARE PRESENT.

29. • TO UTILIZE GASTROCOLIC REFLEX THE BOWEL
PROGRAMME SHOULD BE STARTED 20- 30
MINS AFTER EATING
• RECTAL STIMULATION SHOULD BE DONE FOR
15-20 SECS FOR EVERY 10-15 MINS UNTIL
THERE IS CLOSURE OF IAS.
• FREQUENT BOWEL CARE- EVERY 1-2 DAYS

30. • FOR PATIENTS WITH CHRONIC INEFFECTIVE
BOWEL PROGRAM, OTHER OPTIONS ARE
ENEMA CONTINENCECATHETER, TRANS-
COLONIC IRRIGATION, APPENDICO-
CECOSTOMY AND COLOSTOMY.
• FOR UNRESPONSIVE PATIENTS COLOSTOMY
CAN SHORTEN TIME, ENHANCE SELF
EFFICACY AND QUALITY OF LIFE.

31. GI COMPLICATIONS
• ACUTE ABDOMEN
• ILEUS
• SMA SYNDROME
• PANCREATITIS
• HEMORRHOIDS
• CHOLELITHIASIS
• CANCER