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Neurogenic bowel

Colon
 The colon starts in the right lower quadrant as the cecum.
This then connects to ascending, transverse, descending and
sigmoid colon. The rectum and anus mark the termination of
the colon
 Primary function of the ascending colon is to absorb
electrolytes and water, the primary function of the
descending colon is to store fecal material until evacuation
 Secreting mucus, supporting growth of symbiotic bacteria
are other functions of colon
 Normal colonic transit time is 12 to 30 hours
 Fluids up to 30lts/day can be reabsorbed by bowel
Introduction
 Haustrations and mass movements are two types of colonic
motility
 Haustrations: circular muscular contractions of the colon that
cause mixing of colonic contents, generally they do not cause
any forward movement of the stool
 Mass movements: are large areas of muscular contractions
that propel food forwards inside the colon(last 10 to 30 min)
Enteric nervous system
• Myenteric plexus (Auerbach’s) is located between the outer
longitudinal and the inner circular muscle layers, controls
motor activities such as tonic and rhythmic contractions
• Submucosal plexus ( Meissner’s) is located in the submucosa,
controls local intestinal secretion and absorption
• Enteric nervous is functionally independent but is partially
controlled by the autonomic nervous system
• Neurotransmitters include Ach, NA, dopamine,
cholecystokinin, somatostatin
Autonomic nervous system
 In general parasympathetic nervous system(PS) increases
peristalsis, stimulates secretions, relaxes sphincters, and
increases gut motility
 Vagus nerve supplies the PS innervation from esophagus to
mid-transverse colon. There is minimal PS innervation to
small intestine
 Pelvic nerve originates in the lateral anterior gray columns of
spinal cord segments S2, S3, S4 and supplies the
parasympathetic innervation from mid-transverse colon to
the rectum
Autonomic nervous system
 In general, the sympathetic nervous system decreases
peristalsis, inhibits secretions, contracts sphincters, and
decreases gut motility
 The preganglionic fibers originate in the intermediolateral
column of the spinal cord between T5 and L2
 The superior and inferior mesenteric(T9 to T12) and
hypogastric(T12 to L3) nerves contain postganglionic
sympathetic fibers
 Unlike PS, sympathetic nervous system neurons are equally
distributed
Reflexes of gastrointestinal system
 Gastro colic
Increase in colonic activity that occurs 30 to 60min after a meal
Distention of the stomach stimulates evacuation of the colon
Blunted, but still useful after SCI
 Enterogastric
Distention and irritation of the small intestine results in suppression of
secretion and motor activity in the stomach
 Colocolonic
Propels stool caudally by proximal muscle constriction and distal dilatation
Mediated by myenteric plexus
 Recto colic
Colonic peristalsis due to stimulation(mechanical or chemical) of rectum
Mediated by pelvic nerve
 Anorectal
Involuntary relaxation of internal sphincter as stool passes into rectum
Normal defecation
The internal anal sphincter is composed of involuntary smooth
muscle and provides continence in resting state by remaining
tonically contracted
The external sphincter, innervated by the pudendal nerve(S2 to
S4) is composed of striated muscle, provides voluntary
control of defecation and prevents incontinence along with
the puborectalis during cough or valsalva maneuver
Recto sigmoid distention stimulates recto rectal reflex
Bowel proximal to bolus contracts
Bowel distal to bolus relaxes
Normal defecation
• Reflex relaxation of internal anal sphincter( anorectal reflex)
Correlates with the “urge to go”
 The external anal sphincter and puborectalis prevent
defecation( i.e., the holding reflex) if the conditions are not
appropriate, internal anal sphincter relaxation reflex will fade
(within approx 15 sec) and urge will resolve until triggered
again
 Under voluntary control, the EAS and puborectalis relax
allowing defecation
Normal defecation
Neurogenic bowel
 The neurogenic bowel is defined as the loss of direct somatic
sensory or motor control functions, with or without impaired
sympathetic and parasympathetic innervation

 Intrinsic ENS remains intact with most presenting injuries and


illnesses. Most common exceptions being developmental
disorders like Hirschsprungs, autonomic neuropathy like DM

 ENS continues to modulate and integrate bowel function, even


without autonomic and somatic nervous system input, and can
be neurological substrate for bowel habit training
 Anal sphincter tone is directly related to SCI level. SCI
occurring above conus medullaris (T12) results in spastic
anal tone
 Voluntary control is lost but reflex activity is preserved. This
situation is commonly referred to as upper motor
neuron bowel
 In lesions above T1 there is prolonged mouth to cecum
transit time. In addition patients may have delayed left
colon and rectal transit times as compared to controls
 When SCI occurs below T12 level, the anal sphincter is
denervated and is therefore flaccid
 Voluntary and reflex activity is lost, and a rounder stool
shape is produced
 This situation is commonly referred to as lower motor
neuron bowel
 Decreased colonic motility, especially of the descending
colon, leading to constipation or ileus commonly occurs after
SCI
 Other factors include loss of normal autonomic control, use
of narcotics, immobility, loss of abdominal musculature,
increased anal sphincter tone (in UMN B), loss of peristalsis
in descending colon, Sigmoid, Rectum(in LMN B) may all
contribute to decreased stool evacuation
 Impact of bowel dysfunction
Decreases return to home after SCI
Increases nursing home costs
Embarrassment and humiliation result in vocational and
social handicap
 An effective and successful bowel program implies the
predictable, regular, and thorough evacuation of bowels
without the occurrence of incontinence and prevention of
complications
 An effective bowel management regimen takes into
consideration of proper evaluation, diet and nutritional
factors, use of pharmacological agents when necessary, and a
well developed, appropriate individualized bowel program
that is consistent with the neurological condition and needs
of the patient
 Other factors such as availability of caregiver assistance, use
and need of adaptive equipment, home accessibility, activity
level and lifestyle and return to work or school, must also be
considered
Impact of bowel dysfunction
Decreases return to home after SCI
Increases nursing home costs
Embarrassment, humiliation, social stigma and loss of self
esteem resulting in vocational, social and psychological
handicap
May predispose to complications like pressure ulcers, AD,
hemorrhoids, abdominal distension, intestinal obstroction,
perforation etc.
Evaluation
 Proper and detailed clinical history to be taken
• Pre morbid bowel pattern
• Defecation frequency
• Typical times of day
• Bowel medication
• Stool consistency
• Techniques
• Food intake
 Other factors to be considered are G I sensations or pain,
warning sensations for defecation, sense of urgency, ability to
prevent stool loss during valsalva activities: sneezing,
coughing, transfers.
Physical examination
Routine Per abdominal examination
Inspection of anus- Gaping, Patulous. Hemorrhoids, fissures etc
Perianal cutaneous sharp sensation
Checked by tugging perianal hair.
Anocutaneous reflex
To be checked in all four quadrants
Anal sphincter tone, and deep anal sensation
Diagnostic testing
• Colonoscopy
• Manometry
• Measures pressure and volume
• Radiography
• Structural defects
• Colonic transit time via serial radiographs
• EMG :To assess motor nerve supply to pubo rectalis,
anococcygeus, levator ani external anal sphincter
bulbocavernous reflex.
• Intraluminal catheter : research tool to assess colonic smooth
muscle electric potential activity
Bowel program
 An effective bowel program should result in complete bowel
evacuation within one hour of routine.
 The time of day that the program is performed should be
consistent to facilitate predictable and complete evacuation
 It should be instituted early during the acute phase, in doing
so, common complications such as abdominal distension,
obstruction, impaction or diarrhoea may be avoided
Approach to UMN bowel
 Getting ready and washing hands: Empty bladder.
 Setting up and positioning: Transfer to a toilet or commode. If
patient cannot sit up, make him lie on right side.(gravity assisted)
 Checking for stool: Remove any stool that would interfere with
inserting a suppository or minienema.
 Inserting stimulant medication: Using a gloved and lubricated
finger or assistive device, place the medication right next to the
rectal wall.
 Waiting: Wait about 5 to 15 minutes for the stimulant to work.
Approach to UMN bowel
 Starting and repeating digital rectal stimulation: To keep stool
coming, repeat digital rectal stimulation every 5 to 10
minutes as needed, until all stool has passed.
 Recognizing when bowel care is completed:You'll know that
stool flow has stopped if (a) no stool has come out after two
digital stimulations at least 10 minutes apart, (b) mucus is
coming out without stool, or (c) the rectum is completely
closed around the stimulating finger.
 Cleaning up - wash and dry the perianal area
General considerations
 Diet and nutrition
 Adequate fluid intake (at least 2 to 3 lts/day)
 Moderate fibre diet (15gm/day)
 Avoiding food that have propensity to produce flatulence or
significantly affect stool consistency
 Avoid using medication that decrease bowel motility such as
Narcotics, Tricyclic antidepressants and Anticholinergics
Pharmacological agents
 These include
 Stool softeners
 Bulk formers
 Peristaltic stimulants and prokinetic agents
 Contact irritants
 Laxatives
Pharmacological agents
 Stool softeners
indicated when fluid management and dietary alterations are
not effective in keeping stool soft
Docusate sodium, Docusate calcium can be used. These are
surface active agents that act to emulsify fat in GI tract, and
decrease water reabsorption from gut thus increasing water
content of stools and making them softer
Appropriate fluid intake is necessary for these agents to be
effective
Pharmacological agents
 Bulk formers
these agents act to increase the bulk of the stool by the
absorption of water and expansion of volume
Increased bulk of the stool stimulates peristalsis.
Excessive intake may cause diarrhea and inadequate intake of
water may lead to obstruction
Agents include Psyllium, Calcium polycarbophil, Methylcellulose
Pharmacological agents
 Peristaltic stimulants and prokinetic agents
Unlike bulk formers, these agents enhance bowel peristalsis
and colonic transit by direct stimulation of the intramural
plexus
Senna is commonly used oral drug in UMN bowel, starts its
action after 6 to 12 hours of ingestion. Long term
complication includes melanosis coli, cathartic colon
Cisapride is commonly used in GERD, DM gastro paresis
Metaclopramide is used in patients with slow gastric
emptying
Pharmacological agents
 Contact irritants
These agents increase peristalsis of colon by direct irritation or
stimulation of colonic mucosa
For these agents to be fully effective, the rectal vault within the reach of
inserted finger should be clear of as much as stool as possible
Theoretically not effective in LMN bowel.
Bisacodyl one of the most commonly used agents
vegetable oil based(dulcolax)
polyethylene glycol based( magic bullet)
Bisacodyl + benzocaine preparation for those predisposed for AD
Glycerin suppositories
Carbon dioxide suppositories
Pharmacological agents
 Laxatives
many oral agents are available. Saline laxatives include salts of
magnesium, sodium, potassium.
they act by drawing fluid into gut, stimulating motility
Hyper osmolar agents like lactulose, sorbitol, polyethylene
glycol preparations are also available
Side effects include cramping, flatulence
 For patients with an ineffective bowel program, there are
options available, including Enema Continence Catheters
( antegrade and retrograde) or surgical approach
 ECC is a specially designed catheter that is inserted into the
rectum. A balloon is inflated to keep catheter in place and
enema is given. Once completed balloon is deflated and
catheter is removed; bowel contents then empty
 Malone procedure: an antegrade continence enema
procedure, uses a segment of intestine, usually appendix to
create a tunnel into ascending colon to administer enema.
These procedures are described for children, rarely used in
adults
SURGICAL OPTIONS
 Transposition of innervated gracilis, adductor longus, gluteus
maximus to replace puborectalis function & restore acute
anorectal junction angle sensory deficits are not improved
but continence is restored.
 Prolonged transit time does improve with IAS & partial EAS
myotomy relieves constipation but may result in F I
 By Electro stimulation of anterior sacral roots S2 S3 S4
defecations has been obtainable by sacral root stimulation
in50% of patients.
Surgical options
 Colostomy
Indications include
• When conservative medical measures fail
• Intrinsic bowel deficits like Hirschsprungs disease, Chagas disease,
Cathartic colon
• Pressure ulcers( colostomy is reversed after PU heals)
When performed in candidates who understand the limitations
(e.g., body image), colostomies enhance the quality of life and
reduce the time needed for bowel care
High placement of stoma has been reported to allow best
visualization and self-management
Complications
 Acute and chronic fecal impaction. May even lead to bowel
perforation and death
 Abdominal distension. May even lead to respiratory distress
 Autonomic dysreflexia esp in patients with lesion above T6
 Anal fissures
 Hemorrhoids
 Rectal prolapse esp in patients with LMN bowel + stool
softeners and bulk formers
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