Medical Rehabilitation Department

Dr. Cipto Mangunkusumo Hospital / Faculty

of Medicine University of Indonesia
Introduction
• Bowel management : >> spinal cord
injured (SCI) persons
• Medical problem after SCI:
– 41%  bowel dysfunction
– Moderately – severely life limiting problem
Epidemiology
• Neurogenic bowel dysfunction
symptoms result from autonomic and
somatic denervation are common :
– Produces fecal incontinence (FI)
– Constipation
– Difficulty with evacuation (DWE)
Prevalence
• FI and fecal impaction : 0,3% - 5,0% in
the general population
• DWE ranges from : 10% - 50% among
the hospitalized or instituonalized elderly
• Although many gastrointestinal (GI)
disorders can contribute to FI or DWE,
disorders that impair the extrinsic
(sympathetic, parasympathetic, or
somatic) nervous control of the bowel
and anorectal mechanisms are more
common among the patients populations
seen by physiatrics
• Neurogenic bowel difficulties can be a
primary disabling and handicapping
feature for patient with : SCI, stroke,
amyotrophic lateral sclerosis, multiple
sclerosis, diabetes mellitus, myelo-
meningocele, and muscular dystrophy.
• The three primary objectives of the
bowel program that apply to all cases
are :
1. To prevent unplanned bowel movements
2. To promote efficient and effective bowel
care
3. To prevent complications
Bowel Anatomy and
Function
• The colon : the terminal segment of
intestine :
– Fecal formation
– Storage
– Defecation
• The colon and anorectal mechanism :
– Parasympathetic, sympathetic, and somatic
innervation
– The intrinsic enteric nervous system (ENS)
between muscular layers and under the
mucosa.
• Figure 28-1
• The neurogenic bowel : as the loss of
direct somatic sensory or motor control
functions, with or without impaired
sympathetic and parasympathetic
innervation
• The intrinsic ENS remains intact with
most presenting injuries and illnesses
• The most common exceptions are :
– The developmental disorder of
Hirschsprung’s disease
– Acquired autonomic neuropathy from
diabetes mellitus
Physiology : Normal
Function
• The colon :
– A reservoir for food waste until it is
convenient for elimination.
– A storage device as long as the colonic
pressure is less than that of the anal
sphincter mechanism.
– Fecal elimination occurs when colonic
pressure exceeds that of the anal sphincter
mechanism.
– To reasorb fluids (up to 30 L/days can be
reabsorbed from the large and small bowel
walls, with typically only 100 ml of water
loss in feces) and gases (90% of the 7 to
10 l of gases produced by intracolonic
fermentation is absorbed rather than
expelled).
– Also provides and environment for the
growth of bacteries needed to assist in
digestion, and serves to absorb certain
bacterial break down products as well.
• Figure 28.2 : The layers of the
colon wall
– The ENS is the key to proper functioning of
the entire GI tract.
– There are two primary layers:
• The submucosal (Meissner’s) plexus.
• The intramuscular myenteric (Auerbach ’s)
plexus.
- The sympathetic and parasympathetic
nervous systems seem to modulate the ENS.
- Sympathetic nervous systems stimulation
tends to promote the storage function by
enhancing anal tone and inhibiting colonic
contractions.
- Parasympathetic activity enhances colonic
motility, and its loss is often associated with
DWE, including impactions and functional
obstructions, such as Ogilvie’s pseudo-
obstructive syndrome.
- The rectum is usually empty until just
prior to defection .
- The resting anal canal pressure is
largely determined by the angulation
and pressure of the anorectal junction
by the puborectalis sling and smooth
muscle internal sphincter tone.
- Continence is maintained by the anal
sphincter mechanism consist of :
• The internal anal sphincter (IAS)
• The externaL anal sphincter (EAS)
• The puborectalis muscle.
- The EAS is innervated by the S 2
through S4 nerve roots via the
pudendal nerve.
- The puborectalis muscle is
innervated by direct branches from
the S1 to S5 roots.
- Normal defection begins with reflexes
triggered by the rectosigmoid distention ( Fig.
28-3).
PATHOPHISIOLOGY : NEUROGENIC
BOWEL DYSFUNCTION

Upper Motor Neurogenic Bowel (UMNB)

 UMNB pattern of dysfunction :
- destructive CNS process above the
conus
- SCI
- dementia
 Spinal cortical sensory pathway deficits to
decreased ability to sense the urge to
defecate
 SCI :
• Sense a vague discomfort when
excessive rectal or colonic
distention occurs.
• 43% have chronic complaints of
vague abdominal distention
discomfort that eases with bowel
evacuation.
LOWER MOTOR NEUROGENIC BOWEL
(LMNB)

 Patients with LMNB dysfunction

have decreased anal tone due to
the smooth muscle internal
sphincter.
• TABLE 28-1
• FIGURE 28 - 4
EVALUATION
- The GI history ( patient’s general
neromuscular and GI function).
- The patient’s bowel programs includes an
assessment of fluids, diet, activity,
medications and aspects of bowel care.
- The history should include premobid bowel
pattern information such as defecation
frequency, typical time (s) of the day,
associated predefectory activities, bowel
medications and techniques or trigger foods
and stool consistency.
- History of premorbid GI disease or
dysfunction
- The presence of GI sensations or pain,
warning sensations for defection, sense
of urgency and ability to prevent stool
loss during Valsava activities such as
laughing, sneezing, coughing, or
transfers should be noted.
- The physical examination : The GI systems
and the associated parts of the
musculoskeletal and nervous systems
required for independent management of the
bowel program.
- The examination should be completed at the
onset and then annually for SCI.
- The purpose of the examination is to detect
functional changes, screen for complications
and identity any new masses or lesions.
- The abdomen should be inspected for
distention, hernia and other abnormalities.
- Percussion and auscultation should precede
palpation for masses and tenderness.
- Physical examination continues with
inspection of the anus.
- A normal and buttock contour suggest an
infact EAS muscle mass, where as its loss
results in a flattened, fanned-out “scalloped”-
appearing and region.
- Checked for anocutaneous reflex.
- Checked for bulbocavernosus reflex.
DIAGNOSTIC TESTING

- Additional objective laboratory testing can be

helpful when :
- The cause of FI or DWE is obscure.
- The history appears doubt ful.
- Conservative interventions fail
- Surgical interventions are contemplated.
- Basic laboratory tests complement the
physical examinations.
- A stool guaiac test is helpful to rule out the
presence of blood in the stool.
- False positives are common after SCI
because of hemorrhoids, as well as from and
trauma secondary to bowel care.
- A flat plate radiograph of the abdomen can be
helpful to rule out impaction, megacolon,
obstruction and a perforated viscus.
• TABLE 28-2 : Laboratory Test of
Colonic and Rectoanal Function
Management
General Principles
- A bowel progress is a comprehensive
individualized patient centered treatment plan
focused on preventing incontinence, achieving
effective and efficient colonic evacuation, and
preventing the complications of neurogenic
bowel dysfunction.
- The subcomponents of a bowel program
address diet, fluids, exercise, medications and
scheduled bowel care.
- Interdisceplinary teams :
- primary nurse
- physiatrist
- occupational therapist
- Dietary Consideractions
- Neurogenic bowel training (Table. 28-3)
- Biofeedback training
- Surgical options
COMPLICATIONS
- Significant bowel complication requiring
medical treatment or lifestyle alterations are
reported by 27% of SCI persons.
- 80% of persons with SCI had bowel
impactions.
- 20% had chronic bowel impaction and DWE
problems.
- Other late SCI complication reported by SCI
patients include gartroesophageal reflex,
premature diverticulosis and autonomic
dysreflexia occurs in SCI patients with lesions
at or above the midthoracc region.
- Hemorrhoids are more symptomatic when
patients have intact sensations.
- Bloating and abdominal distention are
common complaints of patients with
neurogenic bowel dysfunction.
THANK YOU