Bowel Management
Neurogenicbowel is a syndrome commonly observed in individuals with SCI and defined as colonic dysfunctions due to lack of central nervous control. Bowel dysfunction following spinal cord injury (SCI) is a major source of morbidity (Han et al. 1998; Stone et al. 1990a). Not surprisingly, bowel dysfunctions alone or bladder/bowel dysfunctions were rated among the highest priorities among individuals with SCI in numerous studies (Anderson 2004; Glickman and Kamm 1996;). Depending on the level of injury, a variety of GI problems could arise in these individuals and it has the potential to disrupt almost every aspect of their life. Correa and colleagues found that 27 – 41 % of patients with neurogenic bowel report chronic gastrointestinal GI problems that alter their lifestyle and may require treatment (Correa and Rotter 2000). Fear of bowel accidents is common among individuals with SCI and deters them from participating in social and other outside activities (Correa and Rotter 2000). Severe constipation often follows SCI and chronic constipation has a significant impact on quality of life (Longo et al. 1995). The prevalence of chronic GI symptoms increases with time after injury, suggesting that these problems are acquired and potentially preventable (Rajendran et al. 1992).
Decreased mobility (where constipation is more prevalent) and lack of sensation may partially contribute to GI dysfunction. However, disrupted autonomic control of the GI tract is probably the dominating cause for major bowel dysfunctions observed in this population, leading to delayed gastric emptying (Leduc et al. 2002; Gondim et al. 2001;Menter 1997; Rajendran et al. 1992; Fealey et al. 1984), poor colonic motility (Lynch & Frizelle 2006; Fajardo et al.2003) resulting in prolonged bowel transit time (Brading & Ramalingam 2006; Lynch et al. 2001), constipation (Faaborg et al.2008; Finnerup et al. 2008;Lynch et al. 2000;), and postprandial (after eating a meal) abdominal distension (Stone et al. 1990a). Furthermore, a significant number of bowel dysfunctions following SCI are associated with episodes of autonomic dysreflexia (Furusawa et al. 2007; Cosman and Vu 2005).
The level and severity of SCI are important factors to consider when deciding on bowel management strategies with the goal of re-establishing some level of evacuation control. Clinical experience indicates that a successful bowel program results in predictable, regular and thorough evacuation of the bowels without the occurrence of incontinence and additional complications (i.e. autonomic dysreflexia). An effective bowel program takes into consideration diet and nutritional factors, use of medications when necessary and is consistent with the neurologic condition and needs of the individual with SCI.It is important to emphasize that each person with SCI is unique and that individual bowel programs need to be client-specific. Clinical experience indicates that the procedures used and the need for medications will depend greatly on the level of neurologic injury, the extent of impairment and subsequent effect of the injury on bowel function. The effectiveness of a bowel program should be reevaluated and modified as needed.
Figure 1: Innervation of the gastrointestinal system. Schematic diagram of the autonomic and somatic innervations of the lower GI tract and pelvic floor. The brainstem, spinal cord and sympathetic chain are shown on the left, and the colon, rectum and pelvic floor on the right. Sympathetic innervation (dashed lines) originates from the thoracic and upper lumbar regions; parasympathetic innervation (solid lines) orginates from the vagus nerve (to the upper GI and colon up to the colonic flexture) and from the sacral region of the spinal cord (to areas below the splenic flexture). Dotted lines represent the mixed nerves supplying the somatic innervation to the musculature of the external anal sphincter and the pelvic floor.
(Reprinted from Archives of Physical Medicine and Rehabilitation, 78(3), Steins SA, Biener Bergman S, Goetz LL, Neurogenic bowel dysfunction after spinal cord injury: clinical evaluation and rehabilitative management, S86-S102, Copyright (1997), with permission from Elsevier.)
