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Quinones C, Wilson JP, Kumbhare D, Guthikonda B, Hoang S. Clinical Assessment and Management of Acute Spinal Cord Injury. J Clin Med 2024; 13:5719. [PMID: 39407779 PMCID: PMC11477398 DOI: 10.3390/jcm13195719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 09/09/2024] [Accepted: 09/22/2024] [Indexed: 10/20/2024] Open
Abstract
The information contained in this article is suitable for clinicians practicing in the United States desiring a general overview of the assessment and management of spinal cord injury (SCI), focusing on initial care, assessment, acute management, complications, prognostication, and future research directions. SCI presents significant challenges, affecting patients physically, emotionally, and financially, with variable recovery outcomes ranging from full functionality to lifelong dependence on caregivers. Initial care aims to minimize secondary injury through thorough neurological evaluations and imaging studies to assess the severity of the injury. Acute management prioritizes stabilizing respiratory and cardiovascular functions and maintaining proper spinal cord perfusion. Patients with unstable or progressive neurological decline benefit from timely surgical intervention to optimize neurological recovery. Subacute management focuses on addressing common complications affecting the respiratory, gastrointestinal, and genitourinary systems, emphasizing a holistic, multidisciplinary approach. Prognostication is currently based on neurological assessments and imaging findings, but emerging biomarkers offer the potential to refine outcome predictions further. Additionally, novel therapeutic interventions, such as hypothermia therapy and neuroprotective medications are being explored to mitigate secondary damage and enhance recovery. This paper serves as a high-yield refresher for clinicians for the assessment and management of acute spinal cord injury during index admission.
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Affiliation(s)
| | | | | | | | - Stanley Hoang
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.Q.); (J.P.W.J.); (D.K.); (B.G.)
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Johns J, Krogh K, Rodriguez GM, Eng J, Haller E, Heinen M, Laredo R, Longo W, Montero-Colon W, Korsten M. Management of Neurogenic Bowel Dysfunction in Adults after Spinal Cord Injury Suggested citation: Jeffery Johns, Klaus Krogh, Gianna M. Rodriguez, Janice Eng, Emily Haller, Malorie Heinen, Rafferty Laredo, Walter Longo, Wilda Montero-Colon, Mark Korsten. Management of Neurogenic Bowel Dysfunction in Adults after Spinal Cord Injury: Clinical Practice Guideline for Healthcare Providers. Journal of Spinal Cord Med. 2021. Doi:10.1080/10790268.2021.1883385. J Spinal Cord Med 2021; 44:442-510. [PMID: 33905316 PMCID: PMC8115581 DOI: 10.1080/10790268.2021.1883385] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Jeffery Johns
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Gianna M Rodriguez
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Janice Eng
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emily Haller
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Malorie Heinen
- University of Kansas Health Care System, Kansas City, Kansas, USA
| | | | - Walter Longo
- Department of Surgery, Division of Gastrointestinal Surgery, Yale University, New Haven, Connecticut, USA
| | | | - Mark Korsten
- Icahn School of Medicine at Mount Sinai, Department of Internal Medicine, Division of Gastroenterology, New York, New York, USA
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Mosiello G, Safder S, Marshall D, Rolle U, Benninga MA. Neurogenic Bowel Dysfunction in Children and Adolescents. J Clin Med 2021; 10:1669. [PMID: 33924675 PMCID: PMC8069792 DOI: 10.3390/jcm10081669] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 01/07/2023] Open
Abstract
Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.
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Affiliation(s)
- Giovanni Mosiello
- Department of Surgery, Division of Urology, Bambino Gesù Pediatric and Research Hospital, 00165 Rome, Italy
| | - Shaista Safder
- College of Medicine, Center for Digestive, Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL 32806, USA;
| | - David Marshall
- Department of Pediatric Surgery and Pediatric Urology, Royal Belfast Hospital for Sick Children, Belfast BT97AB, UK;
| | - Udo Rolle
- Department of Pediatric Surgery and Pediatric Urology, Goethe-University Frankfurt, 60596 Frankfurt, Germany;
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
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Johns J, Krogh K, Rodriguez GM, Eng J, Haller E, Heinen M, Laredo R, Longo W, Montero-Colon W, Wilson C, Korsten M. Management of Neurogenic Bowel Dysfunction in Adults after Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers. Top Spinal Cord Inj Rehabil 2021; 27:75-151. [PMID: 34108835 PMCID: PMC8152174 DOI: 10.46292/sci2702-75] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jeffery Johns
- Vanderbilt University Medical Center, Nashville, Tennessee USA
| | | | | | - Janice Eng
- University of British Columbia, Vancouver Canada
| | | | - Malorie Heinen
- University of Kansas Health Care System, Kansas City, Kansas USA
| | | | | | | | - Catherine Wilson
- Diplomate, American Board of Professional Psychology (RP) Private Practice, Denver, Colorado
| | - Mark Korsten
- Icahn School of Medicine @ Mt Sinai, New York, New York USA
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Hoey RF, Hubscher CH. Investigation of Bowel Function with Anorectal Manometry in a Rat Spinal Cord Contusion Model. J Neurotrauma 2020; 37:1971-1982. [PMID: 32515264 DOI: 10.1089/neu.2020.7145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bowel dysfunction after chronic spinal cord injury (SCI) is a common source of morbidity and rehospitalization. Typical complications include constipation, fecal impaction, incontinence, abdominal distention, autonomic dysreflexia, and the necessity of interventions (i.e., suppositories, digital stimulation) to defecate. Numerous surveys have confirmed that the remediation of bowel complications is more highly valued for quality of life than improvements in walking. Much of what is known about bowel function after SCI for diagnosis and research in humans has been gained using anorectal manometry (ARM) procedures. However, ARM has been underutilized in pre-clinical animal work. Therefore, a novel combination of outcome measures was examined in the current study that incorporates functional output of the bowel (weekly fecal measurements), weight gain (pre-injury to terminal weight), and terminal ARM measurement with external anal sphincter electromyography under urethane anesthesia. The results indicate higher fecal output after contusion during the sub-acute period (4-7 days) post-injury, changes in the composition of the feces, and functionally obstructive responses in a specific section of the rectum (increased baseline pressure, increased frequency of contraction, and reduced ability to trigger a giant contraction to a distension stimulus). These results demonstrate significant bowel dysfunction in the rodent SCI contusion model that is consistent with data from human research. Thus, the combined measurement protocol enables the detection of changes and can be used, with minimal cost, to assess effectiveness of therapeutic interventions on bowel complications.
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Affiliation(s)
- Robert F Hoey
- Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Charles H Hubscher
- Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, Louisville, Kentucky, USA.,Kentucky Spinal Cord Injury Research Center, Louisville, Kentucky, USA
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Neurogenic Bowel: Traditional Approaches and Clinical Pearls. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00269-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Predeterminative role of Onuf's nucleus ischemia on mesenteric artery vasospasm in spinal subarachnoid hemorrhage: A preliminary experimental study. Asian J Surg 2019; 42:797-804. [DOI: 10.1016/j.asjsur.2018.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/23/2018] [Accepted: 12/07/2018] [Indexed: 12/11/2022] Open
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Beddar SAM, Holden-Bennett L, Mccormick AM. Development and Evaluation of a Protocol to Manage Fecal Incontinence in the Patient with Cancer. J Palliat Care 2019. [DOI: 10.1177/082585979701300206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Fecal incontinence is an important yet often overlooked clinical problem in the care of patients with cancer. This paper presents a protocol for the assessment and management of this distressing symptom. The objective of the protocol is to regulate bowel motion, thereby minimizing fecal incontinence and improving patients’ physical functioning, self-esteem, dignity, and quality of life. A comprehensive assessment addressing the patient's physical status, previous elimination routines, dietary habits, and medications provides the foundation for successful management. Components of the intervention include dietary modification, Pharmacotherapy with laxatives and suppositories, and attention to routines that capitalize on the normal, involuntary gastrointestinal reflexes. Promotion of normal bowel elimination patterns, positioning, and comprehensive patient teaching and support are also critical components of the intervention. Our experience with this protocol and the outcomes achieved in a small series of patients are discussed.
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Affiliation(s)
- Sandra A. Mitchell Beddar
- Oncology Nurse Practitioner, Albany, New York
- Ontario Cancer Institute/Princess Margaret Hospital and Assistant Professor, Faculty of Nursing, University of Toronto
| | - Lynn Holden-Bennett
- Department of Nursing, Ontario Cancer Institute/Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Anne Marie Mccormick
- Department of Nursing, Ontario Cancer Institute/Princess Margaret Hospital, Toronto, Ontario, Canada
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Reliability, validity and sensitivity to change of neurogenic bowel dysfunction score in patients with spinal cord injury. Spinal Cord 2017; 55:1084-1087. [DOI: 10.1038/sc.2017.82] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/05/2017] [Accepted: 06/07/2017] [Indexed: 12/29/2022]
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Ageing with neurogenic bowel dysfunction. Spinal Cord 2017; 55:769-773. [PMID: 28290468 DOI: 10.1038/sc.2017.22] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 12/19/2022]
Abstract
STUDY DESIGN Longitudinal study with postal survey. OBJECTIVES To describe changes in the patterns of neurogenic bowel dysfunction and bowel management in a population of people with spinal cord injury (SCI) followed for two decades. SETTING Members of the Danish SCI Association. METHODS In 1996, a validated questionnaire on bowel function was sent to the members of the Danish SCI Association (n=589). The same questionnaire was sent to all the surviving members in 2006 (n=284) and in 2015 (n=178). A total of 109 responded to both the 1996 and 2015 questionnaires. RESULTS Comparing data from 2015 with those from the exact same participants in 1996, the proportion of respondents needing more than 30 min for each defaecation increased from 21 to 39% (P<0.01), the use of laxatives increased (P<0.05) and the proportion considering themselves very constipated increased from 19 to 31% (P<0.01). In contrast, the proportion suffering from faecal incontinence remained stable at 18% in 1996 and 19% in 2015. During the 19-year period, there had been no significant change in the methods for bowel care, but 22 (20%) had undergone surgery for bowel dysfunction, including 11 (10%) who had some form of stoma. CONCLUSION Self-assessed severity of constipation increased but quality of life remained stable in a cohort of people with SCI followed prospectively for 19 years. Methods for bowel care remained surprisingly stable but a large proportion had undergone stoma surgery.
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Tulsky DS, Kisala PA, Tate DG, Spungen AM, Kirshblum SC. Development and psychometric characteristics of the SCI-QOL Bladder Management Difficulties and Bowel Management Difficulties item banks and short forms and the SCI-QOL Bladder Complications scale. J Spinal Cord Med 2015; 38:288-302. [PMID: 26010964 PMCID: PMC4445020 DOI: 10.1179/2045772315y.0000000030] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe the development and psychometric properties of the Spinal Cord Injury--Quality of Life (SCI-QOL) Bladder Management Difficulties and Bowel Management Difficulties item banks and Bladder Complications scale. DESIGN Using a mixed-methods design, a pool of items assessing bladder and bowel-related concerns were developed using focus groups with individuals with spinal cord injury (SCI) and SCI clinicians, cognitive interviews, and item response theory (IRT) analytic approaches, including tests of model fit and differential item functioning. SETTING Thirty-eight bladder items and 52 bowel items were tested at the University of Michigan, Kessler Foundation Research Center, the Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital, and the James J. Peters VA Medical Center, Bronx, NY. PARTICIPANTS Seven hundred fifty-seven adults with traumatic SCI. RESULTS The final item banks demonstrated unidimensionality (Bladder Management Difficulties CFI=0.965; RMSEA=0.093; Bowel Management Difficulties CFI=0.955; RMSEA=0.078) and acceptable fit to a graded response IRT model. The final calibrated Bladder Management Difficulties bank includes 15 items, and the final Bowel Management Difficulties item bank consists of 26 items. Additionally, 5 items related to urinary tract infections (UTI) did not fit with the larger Bladder Management Difficulties item bank but performed relatively well independently (CFI=0.992, RMSEA=0.050) and were thus retained as a separate scale. CONCLUSION The SCI-QOL Bladder Management Difficulties and Bowel Management Difficulties item banks are psychometrically robust and are available as computer adaptive tests or short forms. The SCI-QOL Bladder Complications scale is a brief, fixed-length outcomes instrument for individuals with a UTI.
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Affiliation(s)
- David S. Tulsky
- Correspondence to: David S. Tulsky, Professor and Director of the Center on Assessment Research and Translation, STAR Campus, University of Delaware, 540 S. College Ave, Newark, DE 19713, USA.
| | - Pamela A. Kisala
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Denise G. Tate
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
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Coggrave M, Norton C, Cody JD, Cochrane Incontinence Group. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database Syst Rev 2014; 2014:CD002115. [PMID: 24420006 PMCID: PMC10656572 DOI: 10.1002/14651858.cd002115.pub5] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with central neurological disease or injury have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two symptoms, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical, with a limited research base. This is an update of a Cochrane review first published in 2001 and subsequently updated in 2003 and 2006. The review is relevant to individuals with any disease directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injury, cerebrovascular disease, Parkinson's disease and Alzheimer's disease. OBJECTIVES To determine the effects of management strategies for faecal incontinence and constipation in people with a neurological disease or injury affecting the central nervous system. SEARCH METHODS We searched the Cochrane Incontinence Group Trials Register (searched 8 June 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles. SELECTION CRITERIA Randomised and quasi-randomised trials evaluating any type of conservative or surgical intervention for the management of faecal incontinence and constipation in people with central neurological disease or injury were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed the risk of bias of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures. MAIN RESULTS Twenty trials involving 902 people were included. Oral medications There was evidence from individual small trials that people with Parkinson's disease had a statistically significant improvement in the number of bowel motions or successful bowel care routines per week when fibre (psyllium) (mean difference (MD) -2.2 bowel motions, 95% confidence interval (CI) -3.3 to -1.4) or oral laxative (isosmotic macrogol electrolyte solution) (MD 2.9 bowel motions per week, 95% CI 1.48 to 4.32) are used compared with placebo. One trial in people with spinal cord injury showed statistically significant improvement in total bowel care time comparing intramuscular neostigmine-glycopyrrolate (anticholinesterase plus an anticholinergic drug) with placebo (MD 23.3 minutes, 95% CI 4.68 to 41.92).Five studies reported the use of cisapride and tegaserod in people with spinal cord injuries or Parkinson's disease. These drugs have since been withdrawn from the market due to adverse effects; as they are no longer available they have been removed from this review. Rectal stimulants One small trial in people with spinal cord injuries compared two bisacodyl suppositories, one polyethylene glycol-based (PGB) and one hydrogenated vegetable oil-based (HVB). The trial found that the PGB bisacodyl suppository significantly reduced the mean defaecation period (PGB 20 minutes versus HVB 36 minutes, P < 0.03) and mean total time for bowel care (PGB 43 minutes versus HVB 74.5 minutes, P < 0.01) compared with the HVB bisacodyl suppository.Physical interventions There was evidence from one small trial with 31 participants that abdominal massage statistically improved the number of bowel motions in people who had a stroke compared with no massage (MD 1.7 bowel motions per week, 95% CI 2.22 to 1.18). A small feasibility trial including 30 individuals with multiple sclerosis also found evidence to support the use of abdominal massage. Constipation scores were statistically better with the abdominal massage during treatment although this was not supported by a change in outcome measures (for example the neurogenic bowel dysfunction score).One small trial in people with spinal cord injury showed statistically significant improvement in total bowel care time using electrical stimulation of abdominal muscles compared with no electrical stimulation (MD 29.3 minutes, 95% CI 7.35 to 51.25).There was evidence from one trial with a low risk of bias that for people with spinal cord injury transanal irrigation, compared against conservative bowel care, statistically improved constipation scores, neurogenic bowel dysfunction score, faecal incontinence score and total time for bowel care (MD 27.4 minutes, 95% CI 7.96 to 46.84). Patients were also more satisfied with this method.Other interventions In one trial in stroke patients, there appeared to be a short term benefit (less than six months) to patients in terms of the number of bowel motions per week with a one-off educational intervention from nurses (a structured nurse assessment leading to targeted education versus routine care), but this did not persist at 12 months. A trial in individuals with spinal cord injury found that a stepwise protocol did not reduce the need for oral laxatives and manual evacuation of stool.Finally, one further trial reported in abstract form showed that oral carbonated water (rather than tap water) improved constipation scores in people who had had a stroke. AUTHORS' CONCLUSIONS There is still remarkably little research on this common and, to patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other.There was very limited evidence from individual trials in favour of a bulk-forming laxative (psyllium), an isosmotic macrogol laxative, abdominal massage, electrical stimulation and an anticholinesterase-anticholinergic drug combination (neostigmine-glycopyrrolate) compared to no treatment or controls. There was also evidence in favour of transanal irrigation (compared to conservative management), oral carbonated (rather than tap) water and abdominal massage with lifestyle advice (compared to lifestyle advice alone). However, these findings need to be confirmed by larger well-designed controlled trials which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.
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Affiliation(s)
- Maureen Coggrave
- Stoke Mandeville Hospital, Aylesbury and Buckinghamshire New UniversityThe National Spinal Injuries CentreAylesburyBuckinghamshireUKHP21 8AL
| | - Christine Norton
- King's College London & Imperial College Healthcare NHS Trust57 Waterloo RoadLondonUKSE1 8WA
| | - June D Cody
- University of AberdeenCochrane Incontinence Review Group2nd Floor, Health Sciences BuildingHealth Sciences BuildingForesterhillAberdeenUKAB25 2ZD
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Coggrave M, Norton C. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database Syst Rev 2013:CD002115. [PMID: 24347087 DOI: 10.1002/14651858.cd002115.pub4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND People with central neurological disease or injury have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two symptoms, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical, with a limited research base. This is an update of a Cochrane review first published in 2001 and subsequently updated in 2003 and 2006. The review is relevant to individuals with any disease directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injury, cerebrovascular disease, Parkinson's disease and Alzheimer's disease. OBJECTIVES To determine the effects of management strategies for faecal incontinence and constipation in people with a neurological disease or injury affecting the central nervous system. SEARCH METHODS We searched the Cochrane Incontinence Group Trials Register (searched 8 June 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles. SELECTION CRITERIA Randomised and quasi-randomised trials evaluating any type of conservative or surgical intervention for the management of faecal incontinence and constipation in people with central neurological disease or injury were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures. MAIN RESULTS Twenty trials involving 902 people were included.Oral medicationsThere was evidence from individual small trials that people with Parkinson's disease had a statistically significant improvement in the number of bowel motions or successful bowel care routines per week when fibre (psyllium) (mean difference (MD) -2.2 bowel motions, 95% confidence interval (CI) -3.3 to -1.4) or oral laxative (isosmotic macrogol electrolyte solution) (MD 2.9 bowel motions per week, 95% CI 1.48 to 4.32) are used compared with placebo. One trial in people with spinal cord injury showed statistically significant improvement in total bowel care time comparing intramuscular neostigmine-glycopyrrolate (anticholinesterase plus an anticholinergic drug) with placebo (MD 23.3 minutes, 95% CI 4.68 to 41.92).Five studies reported the use of cisapride and tegaserod in people with spinal cord injuries or Parkinson's disease. These drugs have since been withdrawn from the market due to adverse effects; as they are no longer available they have been removed from this review.Rectal stimulantsOne small trial in people with spinal cord injuries compared two bisacodyl suppositories, one polyethylene glycol-based (PGB) and one hydrogenated vegetable oil-based (HVB). The trial found that the PGB bisacodyl suppository significantly reduced the mean defaecation period (PGB 20 minutes versus HVB 36 minutes, P < 0.03) and mean total time for bowel care (PGB 43 minutes versus HVB 74.5 minutes, P < 0.01) compared with the HVB bisacodyl suppository.Physical interventionsThere was evidence from one small trial with 31 participants that abdominal massage statistically improved the number of bowel motions in people who had a stroke compared with no massage (MD 1.7 bowel motions per week, 95% CI 2.22 to 1.18). A small feasibility trial including 30 individuals with multiple sclerosis also found evidence to support the use of abdominal massage. Constipation scores were statistically better with the abdominal massage during treatment although this was not supported by a change in outcome measures (for example the neurogenic bowel dysfunction score).One small trial in people with spinal cord injury showed statistically significant improvement in total bowel care time using electrical stimulation of abdominal muscles compared with no electrical stimulation (MD 29.3 minutes, 95% CI 7.35 to 51.25).There was evidence from one trial with a low risk of bias that for people with spinal cord injury transanal irrigation, compared against conservative bowel care, statistically improved constipation scores, neurogenic bowel dysfunction score, faecal incontinence score and total time for bowel care (MD 27.4 minutes, 95% CI 7.96 to 46.84). Patients were also more satisfied with this method.Other interventionsIn one trial in stroke patients, there appeared to be a short term benefit (less than six months) to patients in terms of the number of bowel motions per week with a one-off educational intervention from nurses (a structured nurse assessment leading to targeted education versus routine care), but this did not persist at 12 months. A trial in individuals with spinal cord injury found that a stepwise protocol did not reduce the need for oral laxatives and manual evacuation of stool.Finally, one further trial reported in abstract form showed that oral carbonated water (rather than tap water) improved constipation scores in people who had had a stroke. AUTHORS' CONCLUSIONS There is still remarkably little research on this common and, to patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other.There was very limited evidence from individual trials in favour of a bulk-forming laxative (psyllium), an isosmotic macrogol laxative, abdominal massage, electrical stimulation and an anticholinesterase-anticholinergic drug combination (neostigmine-glycopyrrolate) compared to no treatment or controls. There was also evidence in favour of transanal irrigation (compared to conservative management), oral carbonated (rather than tap) water and abdominal massage with lifestyle advice (compared to lifestyle advice alone). However, these findings need to be confirmed by larger well-designed controlled trials which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.
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Affiliation(s)
- Maureen Coggrave
- The National Spinal Injuries Centre, Stoke Mandeville Hospital, Mandeville Road, Aylesbury, Buckinghamshire, UK, HP21 8AL
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Faaborg PM, Finnerup NB, Christensen P, Krogh K. Abdominal Pain: A Comparison between Neurogenic Bowel Dysfunction and Chronic Idiopathic Constipation. Gastroenterol Res Pract 2013; 2013:365037. [PMID: 24159329 PMCID: PMC3789481 DOI: 10.1155/2013/365037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/12/2013] [Indexed: 01/02/2023] Open
Abstract
Introduction. Most spinal-cord-injured patients have constipation. One-third develop chronic abdominal pain 10 years or more after injury. Nevertheless, very little is known about the nature of abdominal pain after spinal cord injury (SCI). It may be neuropathic or caused by constipation. Aim. To compare characteristics of abdominal pain in SCI with able-bodied with chronic idiopathic constipation (CIC). Subjects and Methods. 21 SCI and 15 CIC patients were referred for treatment of bowel symptoms. Constipation-related symptoms were assessed with the Cleveland Constipation Scoring System and the International Spinal Cord Injury Basic Bowel Function Data Set. Characteristics of abdominal pain were described using the Brief Danish Pain Questionnaire. Total gastrointestinal transit times (GITT) were measured by radiopaque markers. Results. Seventeen (81%) SCI and 14 (93%) CIC patients reported abdominal pain or discomfort within the last month (P = 0.38). Pain was considered more intense by CIC than by SCI patients (P < 0.05). Only minor differences were found in patient's qualitative description of abdominal pain or in the location of pain. In neither SCI nor CIC was pain associated with GITT. Conclusion. Most characteristics of abdominal pain among SCI patients resemble those of CIC. This indicates that constipation is a major cause of pain after SCI.
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Affiliation(s)
- Pia Møller Faaborg
- 1Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Dk-8000 Aarhus, Denmark
- 2Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Dk-8000 Aarhus, Denmark
- *Pia Møller Faaborg:
| | - Nanna Brix Finnerup
- 3Danish Pain Research Centre, Aarhus University Hospital, Dk-8000 Aarhus, Denmark
| | - Peter Christensen
- 2Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Dk-8000 Aarhus, Denmark
| | - Klaus Krogh
- 1Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Dk-8000 Aarhus, Denmark
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Fynne L, Worsøe J, Gregersen T, Schlageter V, Laurberg S, Krogh K. Gastric and small intestinal dysfunction in spinal cord injury patients. Acta Neurol Scand 2012; 125:123-8. [PMID: 21428967 DOI: 10.1111/j.1600-0404.2011.01508.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Many patients with spinal cord injury (SCI) suffer from constipation, abdominal pain, nausea, or bloating, and colonic transit times are prolonged in most. Gastric and small intestinal dysfunction could contribute to symptoms but remain to be described in detail. Also, it is obscure whether the level of SCI affects gastric and small intestinal function. AIM To study orocecal transit time and gastric emptying (GE) in patients with SCI. METHODS Nineteen patients with SCI (7 ♀, median age 54 years) and 15 healthy volunteers (9 ♀, median age 32 years) were included. All were referred because of neurogenic bowel problems. Eleven patients had low SCI (located at conus medullaris or cauda equina) affecting only the parasympathetic nerves to the left colon and eight had high SCI (above Th6) affecting parasympathetic and sympathetic innervation. Subjects ingested a small magnetic pill that subsequently was tracked by the Motility Tracking System - MTS-1 (Motilis, Lausanne, Switzerland). RESULTS Orocecal transit time was longer than normal both in individuals with high lesions (P < 0.01) and in individuals with low lesions (P < 0.01). Individuals with high lesions had slower GE than those with conal/cauda equina lesions (P < 0.05). Basic contractile frequencies of the stomach and small intestine were unaffected by SCI. CONCLUSION Surprisingly, upper gastrointestinal transit is prolonged in subjects with SCI suffering from bowel problems, not only in subjects with cervical or high thoracic lesions but also in subjects with conal/cauda equina lesions. We speculate that this is secondary to colonic dysfunction and constipation.
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Affiliation(s)
- L Fynne
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University Hospital, Denmark.
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Bauman WA, Korsten MA, Radulovic M, Schilero GJ, Wecht JM, Spungen AM. 31st g. Heiner sell lectureship: secondary medical consequences of spinal cord injury. Top Spinal Cord Inj Rehabil 2012; 18:354-78. [PMID: 23459498 PMCID: PMC3584784 DOI: 10.1310/sci1804-354] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Persons with spinal cord injury (SCI) have secondary medical consequences of paralysis and/or the consequences of extreme inactivity. The metabolic changes that result from reduced activity include insulin resistance with carbohydrate disorders and dyslipidemia. A higher prevalence of coronary artery calcification was found in persons with SCI than that in matched able-bodied controls. A depression in anabolic hormones, circulating testosterone and growth hormone, has been described. Adverse soft tissue body composition changes of increased adiposity and reduced skeletal muscle are appreciated. Immobilization is the cause for sublesional disuse osteoporosis with an associated increased risk of fragility fracture. Bowel dysmotility affects all segments of the gastrointestinal tract, with an interest in better defining and addressing gastroesophageal reflux disease and difficulty with evacuation. Developing and testing more effective approaches to cleanse the bowel for elective colonoscopy are being evaluated. The extent of respiratory dysfunction depends on the level and completeness of SCI. Individuals with higher spinal lesions have both restrictive and obstructive airway disease. Pharmacological approaches and expiratory muscle training are being studied as interventions to improve pulmonary function and cough strength with the objective of reducing pulmonary complications. Persons with spinal lesions above the 6th thoracic level lack both cardiac and peripheral vascular mechanisms to maintain blood pressure, and they are frequently hypotensive, with even worse hypotension with upright posture. Persistent and/or orthostatic hypotension may predispose those with SCI to cognitive impairments. The safety and efficacy of anti-hypotensive agents to normalize blood pressure in persons with higher level cord lesions is being investigated.
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Affiliation(s)
- William A Bauman
- VA RR&D National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York ; Medical Service, James J. Peters VA Medical Center , Bronx, New York ; Department of Medicine, The Mount Sinai School of Medicine , New York, New York ; Department of Rehabilitation Medicine, The Mount Sinai School of Medicine , New York, New York
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18
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Tong W, Kamiyama Y, Ridolfi TJ, Zietlow A, Zheng J, Kosinski L, Ludwig K, Takahashi T. The role of 5-HT3 and 5-HT4 receptors in the adaptive mechanism of colonic transit following the parasympathetic denervation in rats. J Surg Res 2011; 171:510-6. [PMID: 20691988 PMCID: PMC2978263 DOI: 10.1016/j.jss.2010.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 04/20/2010] [Accepted: 05/04/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Clinical studies show that disturbed colonic motility induced by extrinsic nerves damage is restored over time. We studied whether 5-HT3 and 5HT4 receptors are involved in mediating the adaptive mechanisms following parasympathetic denervation. METHODS Parasympathetic denervation of the entire colon was achieved by bilateral pelvic nerve transection and truncal vagotomy in rats. Colonic transit was measured by calculating the geometric center (GC) of 51Cr distribution. Expression of 5-HT3 and 5HT4 receptor mRNA was determined by real time RT-PCR. RESULTS Parasympathetic denervation caused a significant delay in colonic transit (GC=4.36) at postoperative day (POD) 1, compared with sham operation (GC=6.31). Delayed transit was gradually restored by POD 7 (GC=5.99) after the denervation. Restored colonic transit was antagonized by the administration of 5-HT3 and 5HT4 receptors antagonists at POD 7. 5-HT3 and 5HT4 receptors mRNA expression were significantly increased in the mucosal/submucosal layer at POD 3 or POD 7, whereas no significant difference was observed in the longitudinal muscle layers adherent with the myenteric plexus (LMMP). CONCLUSIONS It is suggested that up-regulation of 5-HT3 and 5-HT4 receptors expression in the mucosal/submucosal layer is involved to restore the delayed transit after the parasympathetic denervation in rats.
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MESH Headings
- Adaptation, Physiological/physiology
- Animals
- Colon/innervation
- Colon/physiology
- Gastrointestinal Motility/drug effects
- Gastrointestinal Motility/physiology
- Intestinal Mucosa/innervation
- Intestinal Mucosa/physiology
- Male
- Myenteric Plexus/physiology
- Nerve Regeneration/physiology
- Parasympathectomy
- Parasympathetic Nervous System/physiology
- RNA, Messenger/metabolism
- Rats
- Rats, Sprague-Dawley
- Receptors, Serotonin, 5-HT3/genetics
- Receptors, Serotonin, 5-HT3/physiology
- Receptors, Serotonin, 5-HT4/genetics
- Receptors, Serotonin, 5-HT4/physiology
- Serotonin 5-HT3 Receptor Antagonists/pharmacology
- Serotonin 5-HT4 Receptor Antagonists/pharmacology
- Up-Regulation/physiology
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Affiliation(s)
- Weidong Tong
- Department of Surgery, Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, Wisconsin 53295, USA
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Joo MC, Kim YS, Choi ES, Oh JT, Park HJ, Lee MY. Changes in the muscarinic receptors on the colonic smooth muscles of rats with spinal cord injury. Ann Rehabil Med 2011; 35:589-98. [PMID: 22506180 PMCID: PMC3309258 DOI: 10.5535/arm.2011.35.5.589] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 05/22/2011] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate changes in (1) the colonic response to acetylcholine (Ach), (2) the muscarinic (M) receptors in the colon, and (3) the levels of colonic contraction-related proteins after a spinal cord injury (SCI). Method We divided 16 Sprague-Dawley rats into 2 groups: the control group and the SCI group. A spinal cord transection was performed surgically at the T10 vertebral level. After 1 week, the entire colon was divided into 2 segments, the proximal and distal colon. Each segment was mounted in a longitudinal or circular muscle direction in a 10-ml organ bath. We determined the intergroup differences as percentage changes in contractility after Ach treatment alone, Ach treatment with M2 receptor antagonist (AQ-RA741) pretreatment, and Ach treatment with M3 receptor antagonist (4-DAMP) pretreatment. Western blot analyses were performed to determine the expression level of RhoA, and heat shock protein 27 (HSP27). Results Compared to the control rats, the SCI rats showed an increased response to Ach along both the directions in the proximal colon (p<0.05). Compared to the control group, in the SCI group, the Ach response was significantly different in the proximal segment under AQ-RA741 pretreatment (p<0.05) and in the distal segment under 4-DAMP pretreatment (p<0.05). Findings of the western blot analyses showed a significant decrease in the level of protein gene product 9.5 in the proximal and distal colon and a significant increase in the level of RhoA and HSP27 in the proximal colon of the SCI rats. Conclusion Our results suggest that changes in colonic contractility after SCI are partly attributable to changes in the M receptor subtypes.
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Affiliation(s)
- Min Cheol Joo
- Department of Rehabilitation Medicine and Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan 570-749, Korea
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20
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SmartPill technology provides safe and effective assessment of gastrointestinal function in persons with spinal cord injury. Spinal Cord 2011; 50:81-4. [DOI: 10.1038/sc.2011.92] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ridolfi TJ, Tong WD, Kosinski L, Takahashi T, Ludwig KA. Recovery of colonic transit following extrinsic nerve damage in rats. Scand J Gastroenterol 2011; 46:678-683. [PMID: 21561284 DOI: 10.3109/00365521.2011.560682] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Injury to pelvic sympathetic and parasympathetic nerves from surgical and obstetrical trauma has long been cited as a cause for abnormal colorectal motility in humans. Using a rat model, acute transaction of these extrinsic nerves has been shown to effect colorectal motility. The aim of this study is to determine in a rat model how transection of these extrinsic nerves affects colonic transit over time. METHODS Eighty-two Sprague-Dawley rats underwent placement of a tunneled catheter into the proximal colon. Bilateral hypogastric, pelvic nerves (HGN and PN) or both were transected in 66 rats. The remaining 16 rats received a sham operation. Colonic transit was evaluated at postoperative days (PODs) 1, 3, and 7 by injecting and calculating the geometric center (GC) of the distribution of (51)Cr after 3 h of propagation. RESULTS At POD 1, transection of PNs significantly delayed colonic transit (GC = 4.9, p < 0.05), while transection of HGNs (GC = 8.5, p < 0.05) or transection of both nerves (GC = 7.8, p < 0.05) significantly accelerated colonic transit, when compared with sham operation (GC = 6.0). A significant trend toward recovery was noted in both the HGN and PN transection groups at POD 7. CONCLUSIONS Damage to the extrinsic sympathetic and/or parasympathetic PNs affects colonic transit acutely. These changes in large bowel motor function normalize over time implicating a compensatory mechanism within the bowel itself.
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Affiliation(s)
- Timothy J Ridolfi
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Hitzig SL, Eng JJ, Miller WC, Sakakibara BM, SCIRE Research Team. An evidence-based review of aging of the body systems following spinal cord injury. Spinal Cord 2011; 49:684-701. [PMID: 21151191 PMCID: PMC3181216 DOI: 10.1038/sc.2010.178] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To systematically review evidence on aging of the body systems after spinal cord injury (SCI). SETTING Toronto, Ontario and Vancouver, British Columbia, Canada. METHODS Electronic databases (MEDLINE/PubMed, CINAHL, EMBASE and PsycINFO), were searched for studies published between 1980 and 2009. The search was augmented by reviewing the reference lists of relevant papers. Non-intervention studies that were longitudinal or cross-sectional with able-bodied controls that were at minimum matched on chronological age were included for review. Levels of evidence were assigned to the study design using a modified Sackett scale. RESULTS Of the 74 studies selected for inclusion, 16 were longitudinal in design. The hypothesis that SCI represents a model for premature aging is supported by a large proportion of level 5 evidence for the cardiovascular and endocrine systems, level 2, 4 and 5 evidence for the musculoskeletal system, and limited level 5 evidence for the immune system. Only a few level 4 and 5 studies for the respiratory system were found. The evidence on the genitourinary system, gastrointestinal system, and for skin and subcutaneous tissues provide level 4 and 5 evidence that premature aging may not be occurring. The evidence on the nervous system does not provide evidence of premature aging as a result of SCI. CONCLUSIONS Premature aging appears to occur in some systems after SCI. Additional longitudinal studies are required to confirm these findings.
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Affiliation(s)
- S L Hitzig
- Lyndhurst Centre, Toronto Rehabilitation Institute, Toronto, Ontario, Canada.
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Juul T, Bazzocchi G, Coggrave M, Johannesen IL, Hansen RBM, Thiyagarajan C, Poletti E, Krogh K, Christensen P. Reliability of the international spinal cord injury bowel function basic and extended data sets. Spinal Cord 2011; 49:886-91. [PMID: 21445082 DOI: 10.1038/sc.2011.23] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN This study was designed as an international validation study. OBJECTIVE The objective of this study was to assess the inter-rater reliability of the International Spinal Cord Injury Bowel Function Basic and Extended Data Sets. SETTING Three European spinal cord injury centers. METHODS In total, 73 subjects with spinal cord injury and a history of bowel dysfunction, out of which 77% were men and median age of the subjects was 49 years (range 20-81), were studied. The inter-rater reliability was estimated by having two raters complete both data sets on the same subject. First and second tests were separated by 14 days. Cohen's kappa was computed as a measure of agreement between raters. RESULTS Inter-rater reliability assessed by kappa statistics was very good (≥0.81) in 5 items, good (0.61-0.80) in 11 items, moderate (0.41-0.60) in 20 items, fair (0.21-0.40) in 11 and poor (<0.20) in 5 items. CONCLUSION Most items within the International Spinal Cord Injury Bowel Function Data sets have acceptable inter-rater reliability and are useful tools for data collection in international clinical practice and research. However, minor adjustments are recommended.
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Affiliation(s)
- T Juul
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.
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Do gastrointestinal transit times and colonic dimensions change with time since spinal cord injury? Spinal Cord 2010; 49:549-53. [PMID: 21102573 DOI: 10.1038/sc.2010.162] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Long-term follow-up study. OBJECTIVES To determine whether gastrointestinal transit times (GITTs) and colonic dimensions change during the first or subsequent decades after spinal cord injury (SCI). SETTING Aarhus University Hospital, Denmark. METHODS GITT and colonic dimensions were evaluated by means of radio-opaque markers. Group A (n=12) was investigated 1 year after SCI and again 13 (range 11-14) years later. Group B (n=10) was studied 19 (range 9-36) years after injury and again 12 (range 11-12) years later. All had been treated with conservative bowel management. RESULTS In group A, the median GITT 1 year after injury was 4.3 (range 1.1-6.5) days and 13 years later, it was 3.2 (range 1.3-6.5) days, P=0.96. In group B, the median GITT 19 year after injury was 3.4 (range 0.6-5.9) days and 12 years later, it was 3.2 (range 1.9-5.5) days, P=0.77. None of the two groups experienced a significant change in the diameter of the caecum/ascending colon, transverse colon, descending colon or the sigmoid during long-term follow-up. Megacolon was present in four patients at baseline and in five at follow-up. CONCLUSION GITTs and colonic dimensions did not change, neither during the first decade nor long after SCI.
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Ancha HR, Fajardo NR, Bauman WA, Rosman AS, Galea M, Creasey G, Korsten MA. Absence of high amplitude propagating contractions in subjects with chronic spinal cord injury. World J Gastroenterol 2010; 16:5435-9. [PMID: 21086560 PMCID: PMC2988235 DOI: 10.3748/wjg.v16.i43.5435] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the presence or absence of high amplitude propagating contractions (HAPC), as well as the other measures of colonic motility, in persons with spinal cord injury (SCI).
METHODS: Prolonged colonic ambulatory manometric studies were performed on 14 male volunteers: 8 with SCI (mean age, 59 ± 13 years; mean duration of injury, 13 ± 4 years) and 6 healthy able-bodied controls (mean age, 57 ± 10 years). A solid-state manometry catheter was endoscopically clipped to the splenic flexure. Recording was performed for > 24 h after manometric catheter placement.
RESULTS: HAPC were absent in individuals with SCI during pre-sleep, sleep, and post-sleep phases. HAPC were significantly increased after awakening in non-SCI controls (0.8 ± 0.2 HAPC/h vs 10.5 ± 2.0 HAPC/h, P < 0.005). The motility index was lower in those with SCI than in controls pre- and post-sleep (SCI vs non-SCI: Pre-sleep, 2.4 ± 0.4 vs 8.8 ± 1.9, P < 0.01; Post-sleep, 4.3 ± 0.8 vs 16.5 ± 4.5, P < 0.05). However, a sleep-induced depression of colonic motility was observed in both the SCI and non-SCI groups (Pre-sleep vs Sleep, non-SCI: 8.8 ± 1.9 vs 2.1 ± 0.9, P < 0.002; SCI: 2.4 ± 0.4 vs 0.2 ± 0.03, P < 0.001), with the motility index of those with SCI during sleep not significantly different than that of the controls.
CONCLUSION: HAPC were not observed in individuals with SCI pre- or post-sleep. A sleep-induced depression in general colonic motility was evident in SCI and control subjects.
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Tong W, Kamiyama Y, Ridolfi TJ, Zietlow A, Zheng J, Kosinski L, Ludwig K, Takahashi T. The role of 5-HT3 and 5-HT4 receptors in the adaptive mechanism of colonic transit following the parasympathetic denervation in rats. THE JOURNAL OF SURGICAL RESEARCH 2010. [PMID: 20691988 DOI: 10.1016/j.jss] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical studies show that disturbed colonic motility induced by extrinsic nerves damage is restored over time. We studied whether 5-HT3 and 5HT4 receptors are involved in mediating the adaptive mechanisms following parasympathetic denervation. METHODS Parasympathetic denervation of the entire colon was achieved by bilateral pelvic nerve transection and truncal vagotomy in rats. Colonic transit was measured by calculating the geometric center (GC) of 51Cr distribution. Expression of 5-HT3 and 5HT4 receptor mRNA was determined by real time RT-PCR. RESULTS Parasympathetic denervation caused a significant delay in colonic transit (GC=4.36) at postoperative day (POD) 1, compared with sham operation (GC=6.31). Delayed transit was gradually restored by POD 7 (GC=5.99) after the denervation. Restored colonic transit was antagonized by the administration of 5-HT3 and 5HT4 receptors antagonists at POD 7. 5-HT3 and 5HT4 receptors mRNA expression were significantly increased in the mucosal/submucosal layer at POD 3 or POD 7, whereas no significant difference was observed in the longitudinal muscle layers adherent with the myenteric plexus (LMMP). CONCLUSIONS It is suggested that up-regulation of 5-HT3 and 5-HT4 receptors expression in the mucosal/submucosal layer is involved to restore the delayed transit after the parasympathetic denervation in rats.
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Affiliation(s)
- Weidong Tong
- Department of Surgery, Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, Wisconsin 53295, USA
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Vallès M, Mearin F. Pathophysiology of bowel dysfunction in patients with motor incomplete spinal cord injury: comparison with patients with motor complete spinal cord injury. Dis Colon Rectum 2009; 52:1589-97. [PMID: 19690487 DOI: 10.1007/dcr.0b013e3181a873f3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Bowel dysfunction is a major problem in patients with spinal cord injury. Previous work has provided partial information, particularly about motor incomplete lesions. The purposes of this study were to evaluate the pathophysiologic features of neurogenic bowel in patients with motor incomplete spinal cord injury and to compare them with those in patients with motor complete lesions. METHODS Fifty-four patients (59% men; mean age, 43 years) with chronic spinal cord injury and fecal incontinence and/or constipation were evaluated; 32 had motor incomplete lesions, and 22 had motor complete lesions. Clinical assessment, colonic transit time, and anorectal manometry were performed. RESULTS Colonic transit time was delayed similarly in patients with motor complete lesions and those with motor incomplete lesions. Anal squeeze pressure was present in most patients with motor incomplete lesions and absent in all patients with motor complete lesions. The cough-anal reflex was less frequent in patients with motor complete lesions with a neurologic level above T7 (P < 0.05). Rectal sensitivity was less severely impaired in those with motor incomplete lesions (P < 0.05). Most patients in both groups did not show anal relaxation during defecatory maneuvers. Rectal contractions and anal sphincter activity during distention of the rectum were detected more often in patients with motor complete lesions (P < 0.05). CONCLUSION Many severe pathophysiologic mechanisms are involved in neurogenic bowel, affecting patients with motor incomplete spinal cord injury similarly to those of patients with motor complete lesions with spinal sacral reflexes. The pathophysiologic mechanisms of constipation are obstructed defecation, weak abdominal muscles, impaired rectal sensation, and delayed colonic transit time; the mechanisms of fecal incontinence are impaired external anal sphincter contraction, uninhibited rectal contractions, and impaired rectal sensation. However, specific evaluation is required in individual cases.
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Affiliation(s)
- Margarita Vallès
- Unit of Functional Digestive Rehabilitation, Institut Guttmann (affiliated with the Autonomous University of Barcelona), Badalona, Spain
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Rectal evacuation and antegrade colonic luminal transport by sacral anterior root stimulation in pigs. Dis Colon Rectum 2009; 52:1650-6. [PMID: 19690496 DOI: 10.1007/dcr.0b013e3181a872fb] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Electrical sacral anterior root stimulation with a selective anodal block may relieve difficulties with bowel evacuation by selective colorectal activation and anal sphincter suppression. This study compares rectal evacuation induced by anodal block with that induced by unselective stimulation. METHODS The sacral anterior roots were stimulated with cuff electrodes in seven chloralose-anesthetized minipigs. Anodal block and unselective stimulation were applied in random order and compared by anorectal manometry and by the obtained colorectal evacuation. Evacuation was quantified scintigraphically after retrograde radioactive paste installation. RESULTS Unselective stimulation evoked sphincter activation which obstructed rectal evacuation during the 30-second stimulation period, after which poststimulation evacuation occurred (mean, 13%; P < 0.05). Anodal block reduced the anal canal pressure by median 83% compared with unselective stimulation. With unrestrained evacuation, a different evacuation pattern (mean, 18%; P < 0.05) occurred within the first ten seconds of the stimulation period and evacuated volume was higher (P = 0.08). Colonic evacuation reached a mean of 17% with unselective stimulation and 11% with anodal block. CONCLUSION Anodal block and unselective sacral root stimulation induce rectal evacuation and colonic luminal transport in pigs. However, anodal block may improve stimulation-induced defecation by enabling a near-physiologic defecation pattern.
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Abstract
Constipation and faecal incontinence are common symptoms among patients with spinal cord injury (SCI), myelomeningocoele (MMC), multiple sclerosis (MS), Parkinson's disease (PD) and stroke. Faecal incontinence in SCI, MMC and MS is mainly due to abnormal rectosigmoid compliance and rectoanal reflexes, loss of rectoanal sensibility and loss of voluntary control of the external anal sphincter. Constipation in SCI, MMC and MS is probably due to immobilisation, abnormal colonic contractility, tone and rectoanal reflexes or side effects from medication. In PD, dystonia of the external anal sphincter causes difficult rectal evacuation and the loss of dopaminergic neurons in the enteric nervous system probably causes slow-transit constipation. Changes after stroke remain to be studied. Though dietary adjustments, oral laxatives, suppositories and other conservative treatment modalities are commonly used, evidence for their use in patients with central neurological disorders is scarce. For patients with severe symptoms trans-anal irrigation, the Malone appendicostomy or a colostomy can be recommended.
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Affiliation(s)
- Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University Hospital, Norrebrogade 2, 8000 Aarhus C, Denmark.
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Abstract
STUDY DESIGN International expert working group. OBJECTIVE To develop an International Bowel Function Extended Spinal Cord Injury (SCI) Data Set presenting a standardized format for the collection and reporting of an extended amount of information on bowel function. SETTING Working group consisting of members appointed by the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS). METHODS A draft prepared by the working group was reviewed by Executive Committee of the International SCI Standards and Data Sets and later by the ISCoS Scientific Committee and the ASIA Board. Relevant and interested scientific and professional organizations and societies (around 40) were also invited to review the data set and it was posted on the ISCoS and ASIA websites for 3 months to allow comments and suggestions. The ISCoS Scientific Committee, ISCoS Council and ASIA Board received the data set for final review and approval. RESULTS The International Bowel Function Basic SCI Data Set includes 26 items providing a thorough description of bowel-related symptoms as well as clinical assessment of anal sphincter function and description of total gastrointestinal or segmental colorectal transit times. CONCLUSION An International Bowel Function Extended SCI Data Set has been developed. This Data Set is mainly for research purposes and it should be used in combination with the information obtained from the International SCI Core Data Set and the International Bowel Function Basic SCI Data Set.
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Abstract
STUDY DESIGN International expert working group. OBJECTIVE To develop an International Bowel Function Basic Spinal Cord Injury (SCI) Data Set presenting a standardized format for the collection and reporting of a minimal amount of information on bowel function in daily practice or in research. SETTING Working group consisting of members appointed by the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS). METHODS A draft prepared by the working group was reviewed by Executive Committee of the International SCI Standards and Data Sets, and later by ISCoS Scientific Committee and the ASIA Board. Relevant and interested scientific and professional (international) organizations and societies (approximately 40) were also invited to review the data set and it was posted on the ISCoS and ASIA websites for 3 months to allow comments and suggestions. The ISCoS Scientific Committee, Council and ASIA Board received the data set for final review and approval. RESULTS The International Bowel Function Basic SCI Data Set includes the following 12 items: date of data collection, gastrointestinal or anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, awareness of the need to defecate, defecation method and bowel care procedures, average time required for defecation, frequency of defecation, frequency of fecal incontinence, need to wear pad or plug, medication affecting bowel function/constipating agents, oral laxatives and perianal problems. CONCLUSION An International Bowel Function Basic SCI Data Set has been developed.
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Affiliation(s)
- Maureen Coggrave
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire and the Burdett Institute of Gastrointestinal Nursing, St Mark’s Hospital, Harrow, and Lecturer, King’s College London
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Reproducibility and validity of radiographically determined gastrointestinal and segmental colonic transit times in spinal cord-injured patients. Spinal Cord 2008; 47:72-5. [PMID: 18645578 DOI: 10.1038/sc.2008.88] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Total gastrointestinal transit times (GITT) and segmental colonic transit times (CTT) are commonly used to describe bowel function in individuals with spinal cord injury (SCI). STUDY DESIGN Reproducibility study. OBJECTIVES To describe inter- and intrasubjective as well as interobserver variations in GITT and segmental CTT in patients with SCI. Furthermore, to study associations between GITT or segmental CTT and colorectal symptoms. SETTING Spinal Cord Unit, Viborg Hospital, Denmark. METHODS Thirty SCI patients took 10 radio-opaque markers on 6 consecutive days and an abdominal X-ray was taken on day 7. The same procedure was repeated after 3 months. GITT and CTT were computed from the number of markers in the entire colorectum and in the left and the right colon. Intra- and interobserver variations were described as dispersion (numerical difference/mean). RESULTS Intersubjective variation was large for GITT (range: 0.6-6.3 days), right CTT (range: 0.1-5.5 days) and left CTT (range: 0-4.9 days). Intrasubjective variation was acceptable for GITT (dispersion: 0.28) but less good for right (dispersion: 0.63) and left CTT (dispersion: 0.68). Interobserver variation was very small. No correlations were found between GITT, right or left CTT and colorectal symptoms. CONCLUSION GITT and right and left CTT are of limited value for clinical decision-making in individual patients but may be useful for comparison of groups of patients with SCI.
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Bracci F, Badiali D, Pezzotti P, Scivoletto G, Fuoco U, Di Lucente L, Petrelli A, Corazziari E. Chronic constipation in hemiplegic patients. World J Gastroenterol 2007; 13:3967-72. [PMID: 17663511 PMCID: PMC4171169 DOI: 10.3748/wjg.v13.i29.3967] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the prevalence of bowel dysfunction in hemiplegic patients, and its relationship with the site of neurological lesion, physical immobilization and pharmacotherapy.
METHODS: Ninety consecutive hemiplegic patients and 81 consecutive orthopedic patients were investigated during physical motor rehabilitation in the same period, in the same center and on the same diet. All subjects were interviewed ≥ 3 mo after injury using a questionnaire inquiring about bowel habits before injury and at the time of the interview. Patients’ mobility was evaluated by the Adapted Patient Evaluation Conference System. Drugs considered for the analysis were nitrates, angiogenic converting enzyme (ACE) inhibitors, calcium antagonists, anticoagulants, antithrombotics, antidepressants, anti-epileptics.
RESULTS: Mobility scores were similar in the two groups. De novo constipation (OR = 5.36) was a frequent outcome of the neurological accident. Hemiplegics showed an increased risk of straining at stool (OR: 4.33), reduced call to evacuate (OR: 4.13), sensation of incomplete evacuation (OR: 3.69), use of laxatives (OR: 3.75). Logistic regression model showed that constipation was significantly and independently associated with hemiplegia. A positive association was found between constipation and use of nitrates and antithrombotics in both groups. Constipation was not related to the site of brain injury.
CONCLUSION: Chronic constipation is a possible outcome of cerebrovascular accidents occurring in 30% of neurologically stabilized hemiplegic patients. Its onset after a cerebrovascular accident appears to be independent from the injured brain hemisphere, and unrelated to physical inactivity. Pharmacological treatment with nitrates and antithrombotics may represent an independent risk factor for developing chronic constipation.
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Affiliation(s)
- F Bracci
- Dipartimento Scienze Cliniche (2(0) Cl. Medica), Policlinico "Umberto I" V.le del Policlinico 155, Rome 00161, Italy.
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Soler JM, Denys P, Game X, Ruffion A, Chartier-Kastler E. Chapitre B - L’incontinence anale et les troubles digestifs et leurs traitements en neuro-urologie. Prog Urol 2007; 17:622-8. [PMID: 17622100 DOI: 10.1016/s1166-7087(07)92378-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Anal incontinence and gastrointestinal disorders are one of the major causes of impaired quality of life in patients with neurological disease. Patients are very often too embarrassed to spontaneously talk about these problems and problems of chronic constipation can lead to microbial maceration, a known risk factor for urinary tract infection. In this article, the authors review the physiology of defecation and describe the main disorders observed in the various neurological diseases and their management.
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Affiliation(s)
- J M Soler
- Centre de médecine physique et de réadaptation du cap Peyrefitte, Cerbère, France.
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36
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Coggrave M, Burrows D, Durand MA. Progressive protocol in the bowel management of spinal cord injuries. ACTA ACUST UNITED AC 2007; 15:1108-13. [PMID: 17170659 DOI: 10.12968/bjon.2006.15.20.22295] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Research into bowel management in spinal cord injury is sparse. Specifically, the use of laxatives in this group, while widespread, is not supported by research evidence. A prospective study in which baseline and intervention data were collected from each subject was undertaken with 17 individuals. The baseline was the routine method of bowel management in the study unit. The intervention was the use of a progressive protocol which allowed the use of physical interventions and rectal stimulants prior to the use of laxative therapy if required. Though the response of individuals varied, the number of successful bowel management episodes employing laxatives was significantly less in the intervention phase, the proportion of glycerine suppository uses which were successful was significantly greater, the use of manual evacuation was significantly reduced and the duration of bowel management episodes was significantly less. These findings suggest that use of laxatives in bowel management is not essential for all newly spinal cord injured individuals, while the use of physical interventions in this population may be beneficial. The variable response of individuals to the progressive protocol highlights the need for individual assessment in the area of bowel. The findings of this small study must be validated by a larger study.
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Vallès M, Vidal J, Clavé P, Mearin F. Bowel dysfunction in patients with motor complete spinal cord injury: clinical, neurological, and pathophysiological associations. Am J Gastroenterol 2006; 101:2290-9. [PMID: 17032195 DOI: 10.1111/j.1572-0241.2006.00729.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Abnormal bowel function is a key problem in patients with spinal cord injury (SCI). Previous works provided only partial information on colonic transit time (CTT) or anal dysfunction but did not identified a comprehensive neurogenic bowel pattern. AIM To evaluate clinical, neurological, and pathophysiological counterparts of neurogenic bowel in patients with motor complete SCI. METHODS Fifty-four patients (56% men, mean age 35 yr) with chronic motor complete SCI (mean evolution time 6 yr) were evaluated: 41% with injuries above T7 (> T7) and 59% with injuries below T7 (< T7); patients were also classified according to the presence or not of sacral spinal reflexes. Clinical assessment, total and segmental CTT quantification, anorectal function evaluation by manometry, intrarectal balloon distension, and surface electromyography were performed. RESULTS Three different neuropathophysiological patterns were observed: Pattern A, present in > T7 injuries, characterized by very frequent constipation (86%) with significant defecatory difficulty and not very severe incontinence (Mean Wexner score 4.5); it was related to moderate delay in CTT (mainly in the left colon and recto-sigma), incapacity to increase the intra-abdominal pressure, and the absence of anal relaxation during the defecatory maneuvre; Pattern B, present in < T7 injuries with preserved sacral reflexes, characterized by not so frequent constipation (50%) but very significant defecatory difficulty and not very severe incontinence (Wexner 4.8); the pathophysiological counterpart was a moderate delay in CTT, capacity to increase intra-abdominal pressure, increased anal resistance during the defecatory maneuver, and presence of external anal sphincter (EAS) contraction when intra-abdominal pressure increased and during rectal distension; Pattern C, present in < T7 injuries without sacral reflexes, characterized by not very frequent constipation (56%) with less defecatory difficulty and greater severity of incontinence (Wexner 7.2); this was associated with severe delay in CTT (mainly in the left colon), capacity to increase intra-abdominal pressure, absence of anal resistance during the defecatory maneuver, and absence of EAS contraction when intra-abdominal pressure increased and during rectal distension. CONCLUSION In patients with motor complete SCI, we were able to define three different neuropathophysiological patterns that are associated with bowel function abnormalities and clinical complaints; this might be of help when designing therapeutic strategies.
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Affiliation(s)
- Margarita Vallès
- Unit of Functional Digestive Rehabilitation, Institut Guttmann, Barcelona, Spain
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Christensen P, Bazzocchi G, Coggrave M, Abel R, Hultling C, Krogh K, Media S, Laurberg S. A randomized, controlled trial of transanal irrigation versus conservative bowel management in spinal cord-injured patients. Gastroenterology 2006; 131:738-47. [PMID: 16952543 DOI: 10.1053/j.gastro.2006.06.004] [Citation(s) in RCA: 171] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Accepted: 05/18/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Bowel dysfunction in patients with spinal cord injury often causes constipation, fecal incontinence, or a combination of both with a significant impact on quality of life. Transanal irrigation improves bowel function in selected patients. However, controlled trials of different bowel management regimens are lacking. The aim of the present study was to compare transanal irrigation with conservative bowel management (best supportive bowel care without irrigation). METHODS In a prospective, randomized, controlled, multicenter trial involving 5 specialized European spinal cord injury centers, 87 patients with spinal cord injury with neurogenic bowel dysfunction were randomly assigned to either transanal irrigation (42 patients) or conservative bowel management (45 patients) for a 10-week trial period. RESULTS Comparing transanal irrigation with conservative bowel management at termination of the study, the mean (SD) scores were as follows: Cleveland Clinic constipation scoring system (range, 0-30, 30 = severe symptoms) was 10.3 (4.4) versus 13.2 (3.4) (P = .0016), St. Mark's fecal incontinence grading system (range, 0-24, 24 = severe symptoms) was 5.0 (4.6) versus 7.3 (4.0) (P = .015), and the Neurogenic Bowel Dysfunction Score (range, 0-47, 47 = severe symptoms) was 10.4 (6.8) versus 13.3 (6.4) (P = .048). The modified American Society of Colorectal Surgeon fecal incontinence scores (for each subscale, range is 0-4, 4 = high quality of life) were: lifestyle 3.0 (0.7) versus 2.8 (0.8) (P = .13), coping/behavior 2.8 (0.8) versus 2.4 (0.7) (P = .013), depression/self perception 3.0 (0.8) versus 2.7 (0.8) (P = .055), and embarrassment 3.2 (0.8) versus 2.8 (0.9) (P = .024). CONCLUSIONS Compared with conservative bowel management, transanal irrigation improves constipation, fecal incontinence, and symptom-related quality of life.
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Affiliation(s)
- Peter Christensen
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.
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Coggrave M, Wiesel PH, Norton C. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database Syst Rev 2006:CD002115. [PMID: 16625555 DOI: 10.1002/14651858.cd002115.pub3] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND People with neurological disease have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two conditions, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical with a limited research base. OBJECTIVES To determine the effects of management strategies for faecal incontinence and constipation in people with neurological diseases affecting the central nervous system. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Trials Register (searched 26 January 2005), the Cochrane Central Register of Controlled Trials (Issue 2, 2005), MEDLINE (January 1966 to May 2005), EMBASE (January 1998 to May 2005) and all reference lists of relevant articles. SELECTION CRITERIA All randomised or quasi-randomised trials evaluating any types of conservative or surgical measure for the management of faecal incontinence and constipation in people with neurological diseases were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered. DATA COLLECTION AND ANALYSIS Two reviewers assessed the methodological quality of eligible trials and two reviewers independently extracted data from included trials using a range of pre-specified outcome measures. MAIN RESULTS Ten trials were identified by the search strategy, most were small and of poor quality. Oral medications for constipation were the subject of four trials. Cisapride does not seem to have clinically useful effects in people with spinal cord injuries (three trials). Psyllium was associated with increased stool frequency in people with Parkinson's disease but did not alter colonic transit time (one trial). Prucalopride, an enterokinetic did not demonstrate obvious benefits in this patient group (one study). Some rectal preparations to initiate defaecation produced faster results than others (one trial). Different time schedules for administration of rectal medication may produce different bowel responses (one trial). Mechanical evacuation may be more effective than oral or rectal medication (one trial). There appears to be a benefit to patients in one-off educational interventions from nurses. The clinical significance of any of these results is difficult to interpret. AUTHORS' CONCLUSIONS There is still remarkably little research on this common and, to patients, very significant condition. It is not possible to draw any recommendation for bowel care in people with neurological diseases from the trials included in this review. Bowel management for these people must remain empirical until well-designed controlled trials with adequate numbers and clinically relevant outcome measures become available.
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Affiliation(s)
- M Coggrave
- Stoke Mandeville Hospital, National Spinal Injuries Centre, Mandeville Road, Aylesbury, Buckinghamshire, UK, HP21 8AL.
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Lynch AC, Frizelle FA. Colorectal motility and defecation after spinal cord injury in humans. PROGRESS IN BRAIN RESEARCH 2006; 152:335-43. [PMID: 16198711 DOI: 10.1016/s0079-6123(05)52022-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Following spinal cord injury, colorectal problems are a significant cause of morbidity, and chronic gastrointestinal problems remain common with increasing time after injury. Although many cord-injured patients achieve an adequate bowel frequency with drugs and manual stimulation, the risk and occurrence of fecal incontinence, difficulties with evacuation, and need for assistance remain significant problems. The underlying physiology of colorectal motility and defecation is reviewed, and consequences of spinal cord injury on defecation are reported. A discussion of present management techniques is undertaken and new directions in management and research are suggested. There is need for more intervention in regard to bowel function that could improve quality of life, but there is also a need for more research in this area.
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Affiliation(s)
- A C Lynch
- Colorectal Unit, Department of Surgery, Christchurch Hospital and Burwood Spinal Unit, Christchurch, New Zealand
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Chung EAL, Emmanuel AV. Gastrointestinal symptoms related to autonomic dysfunction following spinal cord injury. PROGRESS IN BRAIN RESEARCH 2006; 152:317-33. [PMID: 16198710 DOI: 10.1016/s0079-6123(05)52021-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The impact of spinal cord injury on an individual's gastrointestinal tract function is often poorly understood by the general public and also by those involved with persons with spinal cord injury. This chapter reviews the anatomy, physiology and function of the gastrointestinal tract, with particular emphasis on neurological control mechanisms. In turn, it relates the effect that spinal cord injury has on the neurological control of the gastrointestinal tract. The symptoms that are encountered by patients in the acute phase following injury, and by individuals in the months/years after injury, with particular reference to the effect of altered autonomic nervous system control of the gastrointestinal tract, are discussed. Together with a following summary of current bowel management regimens and techniques, this chapter aims to provide an overall view of the effect that autonomic dysfunction due to spinal cord injury has on gastrointestinal function.
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Affiliation(s)
- Eric A L Chung
- St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, UK
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Abstract
STUDY DESIGN Cross-sectional questionnaire study. OBJECTIVES To develop and validate a symptom-based score for neurogenic bowel dysfunction (NBD): NBD score. SETTING University Hospital of Aarhus, Denmark. METHODS A questionnaire including questions about background parameters (n=8), faecal incontinence (n=10), constipation (n=10), obstructed defecation (n=8), and impact on quality of life (QOL) (n=3) was sent to 589 Danish spinal cord injured (SCI) patients. The reproducibility and validity of each item was tested in 20 and 18 patients, respectively. Associations between items and impact on QOL were determined by logistic regression analysis. The NBD score was constructed from items with acceptable reproducibility and validity that were significantly associated with impact on QOL. Based on odds ratios for associations between items and impact on QOL, each item was given a corresponding number of points in the NBD score. RESULTS A total of 424 SCI patients responded. The following 10 items met the criteria above: frequency of bowel movements (0-6 points), headache, perspiration or discomfort before or during defecation (0-2 points), tablets and drops against constipation (0-2 points each), time used for each defecation (0-7 points), frequency of digital stimulation or evacuation (0-6 points), frequency of faecal incontinence (0-13 points), medication against faecal incontinence (0-4 points), flatus incontinence (0-2 points) and perianal skin problems (0-3 points). Differences in NBD score among patients reporting no, little, some or major impact on QOL were statistically significant (all P<0.001). CONCLUSION Based on valid and reproducible questions, we have constructed a score for NBD that is correlated to impact on QOL.
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Affiliation(s)
- K Krogh
- Surgical Research Unit, Department of Surgery L, Section THG, University Hospital of Aarhus, Aarhus, Denmark
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Corazziari E, Staiano A, Miele E, Greco L. Bowel frequency and defecatory patterns in children: a prospective nationwide survey. Clin Gastroenterol Hepatol 2005; 3:1101-6. [PMID: 16271341 DOI: 10.1016/s1542-3565(05)00848-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Very little is known about several aspects of bowel habits in the general pediatric population and the aim of this nationwide survey was to assess bowel frequency and modalities of defecation in children. METHODS The survey was conducted by 58 pediatricians who were selected randomly and distributed evenly throughout Italy. The following items were reported by each pediatrician in a standardized questionnaire: sociodemographic data, frequency and modalities of bowel evacuation, and anorectal disorders. RESULTS The response rate of available completed questionnaires was distributed evenly for the 1-year age group and was 94% (number of patients, 2680; 1-2 years, 442; females, 49.8%). Mean bowel frequency did not vary in the first 2 years of life, it decreased (P = .00001) after the second year, and remained stable until the 12th year; it did not differ between sexes. Mean bowel frequency was reduced significantly in children, both in those younger or older than 2 years, with a positive history of constipation in the parents (P = .00002). Bowel frequency was inversely correlated with the number of persons living and the number of rooms in the child's house (P < .05, P = .008, respectively). Stool consistency, duration of evacuation, and frequency of episodes of painful defecation showed an inverse relationship (P < .001) with bowel frequency. Bowel frequency was significantly lower (P < .001) in children with anorectal disorders. CONCLUSIONS In Italian children, bowel frequency does not differ between sexes but it differed between the first 2 years of life and age older than 2. Anorectal disorders increase as bowel frequency decreases.
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Affiliation(s)
- Enrico Corazziari
- Department of Pediatrics, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
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Korsten MA, Rosman AS, Ng A, Cavusoglu E, Spungen AM, Radulovic M, Wecht J, Bauman WA. Infusion of neostigmine-glycopyrrolate for bowel evacuation in persons with spinal cord injury. Am J Gastroenterol 2005; 100:1560-5. [PMID: 15984982 DOI: 10.1111/j.1572-0241.2005.41587.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Defecatory complications are common after spinal cord injury (SCI) and have been attributed, in part, to an imbalance of the autonomic nervous system between parasympathetic and sympathetic effects on the colon. Because parasympathetic (i.e., cholinergic) input to the bowel may be downregulated after SCI, it was hypothesized that neostigmine, a medication that increases cholinergic tone by blocking the metabolism of acetylcholine, might promote bowel evacuation in these persons. Since neostigmine is known to cause bradycardia and bronchoconstriction, we also assessed whether these side-effects could be prevented by coadministration of neostigmine with glycopyrrolate, an anticholinergic agent that has limited activity on the muscarinic receptors of the colon. The hypothesis was tested in 13 persons with SCI in whom videofluoroscopy was carried out after instillation of a barium oatmeal paste into the rectum and descending colon. On separate days, subjects received, in a randomized, blinded design, one of three intravenous infusates (normal saline, 2 mg neostigmine, or 2 mg neostigmine + 0.4 mg glycopyrrolate). The effect of these infusates on bowel evacuation of the barium paste, heart rate, and airway resistance was determined. Both neostigmine and neostigmine + glycopyrrolate resulted in prompt bowel evacuation. The nadir heart rate was lower after neostigmine alone than with the combination. Neostigmine administration increased both total and central airway resistance, an effect that was not observed with the coadministration of glycopyrrolate. Other side-effects of neostigmine and the combination of drugs included muscle fasciculations and dry mouth, both of which were mild and short-lived. Abdominal cramping was noted in subjects with spinal cord lesions below thoracic level 10. These results indicated that neostigmine/glycopyrrolate administration is safe and well tolerated in persons with chronic SCI.
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Chang SM, Yu GR, Diao YM, Zhang MJ, Wang SB, Hou CL. Sacral anterior root stimulated defecation in spinal cord injuries: An experimental study in canine model. World J Gastroenterol 2005; 11:1715-8. [PMID: 15786558 PMCID: PMC4305962 DOI: 10.3748/wjg.v11.i11.1715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether there was a dominant sacral root for the motive function of rectum and anal sphincter, and to provide an experimental basis for sacral root electrically stimulated defecation in spinal cord injuries.
METHODS: Eleven spinal cord injured mongrel dogs were included in the study. After L4-L7 laminectomy, the bilateral L7-S3 roots were electrostimulated separately and rectal and sphincter pressure were recorded synchronously. Four animals were implanted electrodes on bilateral S2 roots.
RESULTS: For rectal motorial innervation, S2 was the most dominant (mean 15.2 kPa, 37.7% of total pressure), S1 (11.3 kPa, 27.6%) and S3 (10.9 kPa, 26.7%) contributed to a smaller part. For external anal sphincter, S3 (mean 17.2 kPa, 33.7%) was the most dominant, S2 (16.2 kPa, 31.6%) and S1 (14.3 kPa, 27.9%) contributed to a lesser but still a significant part. Above 85% L7 roots provided some functional contribution to rectum and anal sphincter. For both rectum and sphincter, the right sacral roots provided more contribution than the left roots. Postoperatively, the 4 dogs had electrically stimulated defecation and micturition under the control of the neuroprosthetic device.
CONCLUSION: S2 root is the most dominant contributor to rectal pressure in dogs. Stimulation of bilateral S2 with implanted electrodes contributes to good micturition and defecation in dogs.
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Affiliation(s)
- Shi-Min Chang
- Department of Orthopedic Surgery, Tongji Hospital, Tongji University, Shanghai 200065, China.
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Fajardo NR, Pasiliao RV, Modeste-Duncan R, Creasey G, Bauman WA, Korsten MA. Decreased colonic motility in persons with chronic spinal cord injury. Am J Gastroenterol 2003; 98:128-34. [PMID: 12526948 DOI: 10.1111/j.1572-0241.2003.07157.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In persons with spinal cord injury (SCI), several studies have shown that large bowel transit is decreased at the level of the left colon and rectum, and that postprandial colonic response to food is absent. To define these parameters further, the effects of food on colonic motility in persons with SCI were studied and compared to those of spinally intact (SI) individuals. METHODS The study was conducted in eight subjects with SCI (four paraplegic and four quadriplegic) and six age-matched SI subjects. After routine bowel preparation, colonoscopy was performed with the proximal end of a solid state pressure transducer catheter (four sensors each separated by 10 cm) tethered to the splenic flexure using endoclips (Olympus). The subjects were then allowed to carry out their usual daily activities. Two phases were compared: 1 h before breakfast, designated as the "resting phase," and 1 h during breakfast, designated as the "food-ingestion phase." RESULTS Baseline colonic activity of the SCI group was significantly less than in SI subjects. During meals, the motility index, mean amplitude of the waves, percent activity, and number of waves was significantly less in the SCI group. In both the SI and SCI groups, a postprandial colonic response was observed. However, in the SCI group, the response was seen only in the descending colon and not in the rectosigmoid region. CONCLUSIONS SCI decreases colonic motility, and this alteration may relate to difficulty with evacuation. The postprandial colonic response in SCI is present but is suboptimal and confined to the descending colon.
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Affiliation(s)
- Noel R Fajardo
- VA RR&D Center of Excellence, SCI Services, VA Medical Center, Bronx, New York 10468, USA
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47
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Abstract
Hippocrates noted that "it is a general rule, that intestines become sluggish with age", though the precise mechanisms for this association remains uncertain even today.
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Affiliation(s)
- K Winge
- Department of Neurology, Bispebjerg University Hospital, DK-2400 Copenhagen, Denmark.
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48
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Abstract
AbstractThe purpose of this article is to review the literature related to the effects of spinal cord injuries on genitourinary, gastrointestinal, and sexual function. These important areas of function are profoundly affected by spinal cord injuries, with the effects of injury being dependent on the specific level and degree of neurologic dysfunction. Our ability to manage neurogenic bladder dysfunctions and neurogenic bowel dysfunctions has improved over the past few years; however, in general the techniques used have not significantly changed. In contrast, a significant amount of new information has been made available regarding the effects of specific neurologic injuries on sexual response, particularly female sexual response. Moreover, techniques to remediate erectile dysfunction and infertility in the male have vastly improved the fertility potential of men with spinal cord injuries. Further research is warranted in all of these areas.
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49
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Orendácová J, Cízková D, Kafka J, Lukácová N, Marsala M, Sulla I, Marsala J, Katsube N. Cauda equina syndrome. Prog Neurobiol 2001; 64:613-37. [PMID: 11311464 DOI: 10.1016/s0301-0082(00)00065-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Single or double-level compression of the lumbosacral nerve roots located in the dural sac results in a polyradicular symptomatology clinically diagnosed as cauda equina syndrome. The cauda equina nerve roots provide the sensory and motor innervation of most of the lower extremities, the pelvic floor and the sphincters. Therefore, in a fully developed cauda equina syndrome, multiple signs of sensory disorders may appear. These disorders include low-back pain, saddle anesthesia, bilateral sciatica, then motor weakness of the lower extremities or chronic paraplegia and, bladder dysfunction. Multiple etiologies can cause the cauda equina syndrome. Among them, non-neoplastic compressive etiologies such as herniated lumbosacral discs and spinal stenosis and spinal neoplasms play a significant role in the development of the cauda equina syndrome. Non-compressive etiologies of the cauda equina syndrome include ischemic insults, inflammatory conditions, spinal arachnoiditis and other infectious etiologies. The use of canine, porcine and rat models mimicking the cauda equina syndrome enabled discovery of the effects of the compression on nerve root neural and vascular anatomy, the impairment of impulse propagation and the changes of the neurotransmitters in the spinal cord after compression of cauda equina. The involvement of intrinsic spinal cord neurons in the compression-induced cauda equina syndrome includes anterograde, retrograde and transneuronal degeneration in the lumbosacral segments. Prominent changes of NADPH diaphorase exhibiting, Fos-like immunoreactive and heat shock protein HSP72 were detected in the lumbosacral segments in a short-and long-lasting compression of the cauda equina in the dog. Developments in the diagnosis and treatment of patients with back pain, sciatica and with a herniated lumbar disc are mentioned, including many treatment options available.
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Affiliation(s)
- J Orendácová
- Institute of Neurobiology, Slovak Academy of Sciences, 040 01 Kosice, Slovak Republic.
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50
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Böhmer CJ, Taminiau JA, Klinkenberg-Knol EC, Meuwissen SG. The prevalence of constipation in institutionalized people with intellectual disability. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2001; 45:212-218. [PMID: 11422645 DOI: 10.1046/j.1365-2788.2001.00300.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Constipation is a common problem in people with intellectual disability (ID). Laxatives are frequently prescribed with disappointing results. The prevalence of constipation was investigated in a random population of 215 people with ID (IQ < 50) and constipation was correlated with clinical symptoms. All subjects were scored for bowel habits. Constipation was defined as having a bowel movement less than three times a week or the necessity of using laxatives more than three times a week. Further possible accompanying factors were evaluated. The control subjects were defined as individuals who did not use laxatives. Subjects with constipation were defined as patients and were compared to subjects without constipation (controls). One hundred and forty-nine out of 215 cases (69.3%) showed constipation. Constipation was significantly correlated with non-ambulancy, cerebral palsy, the use of anticonvulsive medication or benzodiazepines, H2-receptor antagonists or proton pump inhibitors, food refusal, and an IQ < 35. Fifty-eight per cent of the patients used bisacodyl or magnesium oxide, 39% lactulose, 13% sodiumlaurylsulphoacetate/sodium citrate/sorbitol and only 10% were given sodium phosphate enemas. Faecal soiling was found in 15% of subjects, while manual evacuation of faeces was performed in nearly 7% of cases. Constipation was randomly demonstrated in almost 70% of the population with ID. Subjects with the above-mentioned accompanying factors are especially at risk for constipation. Contrary to the general population, constipation in people with ID is associated with little use of phosphate enemas, microlax, a low incidence of faecal soiling and manual evacuation of faeces, suggesting an aetiology without distal faecal impaction. The regimen and effect of therapy has to be studied to define adequate treatment schedules.
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Affiliation(s)
- C J Böhmer
- Academic Hospital Vrije Universiteit, Department of Gastroenterology, 1007 MB Amsterdam, the Netherlands.
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