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Bowel management after spinal cord injury.

The neurogenic bowel seldom causes life-threatening problems, but is notorious for the profound effect it has on the quality of life of individuals disabled by spinal cord injury (SCI). The primary functional loss is the loss of voluntary control over defaecation. There are two types of neurogenic bowel. In the upper motor neuron or reflex bowel, the anal sphincter remains tight and bowel movement will occur on a reflex basis. This type of bowel is best managed by reflex emptying, after suppositories or digital stimulation. In the lower motor neuron or flaccid bowel, the anal sphincter tone is relaxed. The flaccid bowel is usually managed by manual evacuation, requiring laxatives, but may be able to empty using abdominal muscles.

What is a bowel programme?

This is a programme that should provide predictable and complete (i.e. no socially embarrassing leaks) elimination and reduce evacuation problems and gastrointestinal complaints. A bowel programme usually requires regular revision within the established parameters of safety and effectiveness. The design should take into account a patient's functional ability, availability of a caregiver/attendant, personal goals, life schedules, role obligations of the individual and self-rated quality of life. It is usually initiated during acute care and while it changes regularly, is continued through life.

Consistency of stool, type of rectal stimulant and frequency of emptying usually differ in reflex and flaccid bowels.

Establishing a bowel programme

The first step is to ensure that the patient is taking adequate fluid, is active and on a balanced fibre-rich diet (at least 30 g per day). Then choose an appropriate rectal stimulant and method to provide rectal stimulation to trigger defaecation. Select optimal scheduling and physical positioning as well as the assistive technique. Evaluate medication that promotes or inhibits bowel function. For example, a laxative could be taken 3 times per week on the night before, in the morning a rectal suppository is inserted followed by a waiting period of approximately 15-20 minutes, preferably on the commode or toilet seat. Programmes vary, are usually required between 3 and 4 times per week to avoid colonic distention and take about 30 - 60 minutes each time; they therefore have to be to be tailored to individual needs and schedules.

A combination of the following is usually used, again individualised to each patient's needs. Increasing stool volumes with regular oral fibre supplementation, together with oral laxatives such as senna preparations given the night before combined with either manual removal, a mini-enema or in well-trained/ experienced patients a colonic lavage (such as Coloplast) are key ingredients of an effective flaccid bowel management programme.

Rectal suppositories such as Bisacodyl (which increases sigmoid peristalsis) or glycerine (which draws fluid into the stools) followed 10-50 minutes later by digital stimulation, which is circular motion with the index finger in the rectum, or with finger extensions or digital stimulators, may result in effective emptying in a reflex bowel.

Push-ups, abdominal massage, Valsalva manoeuvre and deep breathing are some of the adaptive techniques which augment complete emptying of the bowel. A colostomy or iliostomy may be considered when all attempts at bowel management have failed.

What could go wrong?

* Accidents. If this happens often, it may be necessary to re-evaluate the management schedule. It could be due to inadequate emptying during the bowel programme and the method needs to be reviewed. If it is happening consistently after certain foods, these should be avoided.

* Diarrhoea occurs when there is a frequent passage of more than 3 loose watery stools in 24 hours. If the diet is the cause, remove offending food or fluid. Check factors such as alcohol consumption, stool softeners and fibre intake. Rule out impaction. Note any fever as this may be due to a medical illness. Medication, especially antibiotics, may cause diarrhoea--consider adding yoghurt or probiotics.

* Stool too soft--add more fibre, at least 30 g per day. Add constipating foods to diet such as cheese, meat and starches.

* Constipation--unusually long bowel care periods with small results and dry hard stools. Establish a balanced diet with added fibre of at least 30 g per day. Increase fluid intake to 2-3 litre/ day and if possible increase physical activity. Review any medication, e.g. anticholinergics, antacids, antidepressants and analgesics that could be the cause.

* Impaction--this is the collection of hardened faeces in the lower intestine and should be suspected when there has been no bowel movement for 3-5 days. It is probably the most common complication in SCI and can usually be seen on an abdominal X-ray. If the impaction is situated high in the bowel give oral medication and a suppository, e.g. Bisacodyl. If this is unsuccessful then give a mini-enema followed by manual removal. Leakage of a watery stool around impaction may often be interpreted as diarrhoea; an X-ray is the best way to differentiate leakage in an impacted bowel from diarrhoea. A regular bowel plan must then be established every 2 days with an increase in fibre intake. Fluid and lactulose syrup may be added to soften the impaction. If the person is prone to develop autonomic dysreflexia, use topical gel with 2% lidocaine while trying to evacuate the bowel and monitor the blood pressure if there are any signs of sweating, headache, flushed cheeks, etc.

* Rectal bleeding--the most common cause of rectal bleeding in SCI is traumatic superficial mucosal erosion, which manifests as bright red streaks usually on the glove or stool and is usually due to trauma and haemorrhoids, manifesting as blood dripping into the commode or passing of clots. A rectal examination and proctoscopy should be done. This is associated with chronic constipation and may be treated medically; if there is no response, surgical intervention is required. Colorectal cancer should be ruled out in individuals over 45 years who have a positive faecal occult blood test or a change in bowel function that does not respond to corrective intervention.

* Autonomic dysreflexia occurs in patients with injuries above T6. Faecal impaction is the most common cause of autonomic dysreflexia in SCI. Less common causes are massive abdominal distention and digital stimulation. Topical gel containing 2% lidocaine applied rectally can help to prevent this and could be given 1 hour before attempting to clear impaction in persons with SCI known to be prone to dysreflexia. They may complain of distorted vision, goose bumps, sweating above the level of the lesion, feeling flushed and having a blocked nose. Bradycardia and high blood pressure are usually present.

Conclusion

It is evident that in the life of a person with an SCI the bowel has the upper hand and steers life's daily way. Sadly, the importance of 'the bowel' is often grossly neglected and underestimated. It is important to remember that a person with SCI can still present with all the diseases of a person without SCI, but now has the added burden of the complications that may develop due to SCI.

Further reading

Alexander TT, Hiduke J, Stevens KA. Rehabilitation Procedures, 2nd ed. 146-159.

Paralyzed Veterans of America. Neurogenic Bowel Management in Adults with Spinal Cord Injuries. Washington (DC): Consortion for spinal cord medicine, 1998: 39.

ANNA MARX, BMedSc, MB ChB, FCFP (SA)

Rehabilitation Doctor, Life Eugene Marais

Unit, Pretoria
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Title Annotation:More about ... Physical rehabilitation
Author:Marx, Anna
Publication:CME: Your SA Journal of CPD
Geographic Code:6SOUT
Date:Feb 1, 2008
Words:1195
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