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Neurogenic Bowel and SCI

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Abdul Hamad

on 18 November 2012

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Transcript of Neurogenic Bowel and SCI

Fecal contents are propelled in the large intestine by periodic mass movements, as opposed to the more continuous peristalsis of the small intestine.
One predictable mass movement is the gastrocolic reflex, which occurs in association with filling of the stomach. Refers to increased colonic activity, which occurs in the first 30-60 min after a meal.
Modulated by:
Hormonal effects.
Mechanical reflexes. HAMA-SYRIA Complains and complications.
Bowel Function and dysfunction.
Bowel management in neurological cases.
Investigations.
Medications frequently used in bowel management.
Bowel care. contents Complications related to neurogenic bowel Hemorrhoids
Impaction.
Colonic diverticuli,
Rectal prolapse,
Perirectal abscess,
Megalocolon, Complications related to neurogenic bowel 7. Colonic cancer.
8. Gastroesophageal reflux results from chronic overdistention.
9. Increased spasticity ,and
10. Autonomic dysreflexia. INNERVATION Important neural pathways include:
-parasympathetic,
- sympathetic, and
- somatic innervation to the colon, rectum,
and anus.
The intrinsic nervous system, also known as the enteric nervous system ENS, is composed of the submucosal (ie, Meissner) and myenteric (ie, Auerbach) plexuses, which largely regulate segment-to-segment movement of the GI tract. The vagus nerve innervates the upper segments of the GI tract up to the splenic flexure.
The pelvic splanchnic nerves (nervi erigentes) carry parasympathetic fibers from the S2-S4 spinal cord levels to the descending colon and rectum.
The hypogastric nerve sends out sympathetic innervation from the L1, L2, and L3 spinal segments to the lower colon, rectum, and sphincters. The pudendal nerve (S2-S4) provides somatic innervation to the external anal sphincter and pelvic floor.. RECTODYNAMICS
To understand the effects of SCI on bowel evacuation, we designed a test to measure the opposing expulsive and resistive forces at work in the anorectum. We call the test rectodynamics because of its similarity to urodynamics, the study of bladder emptying (Fig. 76-10). Rectodynamics is performed by placing a triple-lumen catheter through the anus so that one pressure-measuring sideport is in the rectum and another is in the high-pressure zone of the anal canal. The third lumen is used to fill a balloon located in the rectum. A concentric EMG needle is placed in the EAS. Rectal and anal pressures, along with external sphincter EMG, are measured at rest and during stimulation of the anorectum by digital stimulation, the Valsalva maneuver, rapid rectal distention (i.e., air is rapidly injected and removed from rectal balloon to elicit the rectoanal inhibitory reflex), and slow, continuous filling of the rectal balloon with saline. To understand the effects of SCI on bowel evacuation,
we do a test to measure the opposing expulsive and resistive forces at work
in the anorectum. THE OBJECTIVE OF MANAGEMENT The goal of bowel care is to train the bowel to evacuate at a
set time each day or,
most commonly every-other-day; thereby preventing constipation or fecal incontinence. Bowel Care Red signals Diarrhea
Increased spasticity
Autonomic dysreflexia THANK you Rehab Medicine Club April 5,2012 Neurogenic Bowel
and
Spinal Cord Injury Dr. Abdulhamid Hamad MD, Physiatrist. PM&R. KFSH-D
Definition Neurogenic bowel:

is a term that relates
colon dysfunction to
lack of nervous control.
COMPLAINS result from FECAL INCOTENENCE(FI)
DIFICULTY WITH EVACUATION(DWE)
FECAL IMPACTION
PREVENTION

of this complications =

BOWEL MANAGEMENT contents Complains and complications.
Bowel Function and dysfunction.
Bowel management in neuropathic patients.
Investigations.
Medication frequently used in bowel management. “This is a fundamental principle of
medicine, that whenever the stool is
withheld or is extruded with difficulty,
grave illness result”. Maimonides (1135-1204 ) The rectum stores stool until it is full.
Then reflex relaxation of the usually tonically contracted internal anal sphincter occurs.

In response to the impending bolus of stool, the external sphincter contracts until voluntarily relaxed to permit defecation. Fecal Continence contents Complains and complications.
Bowel function and dysfunction.
Bowel management in neurological cases. Pharmacologic Colonic Stimulants (eg, bisacodyl),tab or supp, also (senna).
Hyperosmolar Agents (sodium phosphate), for short term treatment of constipation.
Osmotic Agents, promote bowel movement by osmotic action that hold water in the small intestine and colon. polyethylene glycol “Mirax”, Lactolose. Pharmacologic Bulking Agents (eg, psyllium), absorb water in intestine to form viscous liquid,
reduce transit time ,and
Stool Softeners, help keep stools soft for easy passage (eg, docusate sodium, surface active agent(. Suggested protocol
Bowel clean out if stool is present by multiple enemas.

Maintain the stool bulky by using fibers
(diet, tablets) and soft by using stool softener (docusate). Suggested protocol
3. Stimulate the defecation by:
Glycerin (or Dulcolax) supp. 20-30 min. after a major meal,
10 min later send to toilet, less than 40 min. reliving skin pressure
4. digital stimulation_ 20 min post supp. every 5 min. 3 times. Good outcome indicators NO Fecal impaction or difficulty with evacuation (DWE).
NO Fecal incontinence (FI). SURGURY Bowel Perforation
is a surgical emergency resulting from fecal impaction with eventual distention, then perforation
Muscle Transposition
with innervated adductor longus, gluteus maximus, or other free muscle grafts to replace the puborectalis sling. Use this technique in patients with incomplete motor lesions with some sensation. This technique can lead to some degree of restoration of fecal continence.
Rectal Dyssynergia,
consider myotomy since incomplete relaxation of the internal anal sphincter leads to functional outlet obstruction and may cause dysreflexia in susceptible patients.
Colostomy/ileostomy
may be considered in highly refractory cases or when stool incontinence complicates other problems such as pressure sore management.
Appendicocecostomy
(antegrade continence enema [ACE] procedure): The appendix is used as a conduit between the skin and cecum. Enema fluid can be introduced using a catheter. This procedure is used in chronic refractory neurogenic bowel when there is insufficient rectal tone to allow use of rectal enemas.
Appendicocecostomy is used most often in children with spina bifida. SUMMARY Neurogenic bowel dysfunction deeply reduces quality of life and community re-integration.
The objective of bowel program is
(diaper-free status).
Achieved by establishing a regular defecation program (bowel care). References Spinal Cord Medicine
PM&R Secrets.
PM&R Handbook, by S. Garrison
PM&R by R. Braddom
PM&R by Delisa, and B. Gans
Rehabilitation Medicine, by A. Chamberlin
Emedicine Website.
Net-doctor Website. ######### management of this problem presents many challenges for both patients and healthcare professionals.
These challenges include the limited evidence available to assist with the development of a satisfactory bowel management programme for individuals, and the small range of available options where conservative approaches are unsuccessful.
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