LA MIELOLESIONE ATTUALITA' IN RIABILITAZIONE IX CORSO EMRSS Siracusa Ottobre 2013 Fondazione Sant Angela Merici
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1 LA MIELOLESIONE ATTUALITA' IN RIABILITAZIONE IX CORSO EMRSS Siracusa Ottobre 2013 Fondazione Sant Angela Merici Bowel Management S. Tiberti MD Prof. C. Foti MD Physical and Rehabilitation Medicine Chair Tor Vergata University, Rome 1
2 Digestive System Kong F, Singh RP (June 2008). "Disintegration of solid foods in human stomach". J. Food Sci. 73 (5): R67 80
3 Digestive System IAS smooth muscle EAS striated muscle
4 What influences digestion? Different foods Different speeds Emotional factors
5 What influences digestion? Changes of posture Physical exercise Gastro-colic reflex
6 Bowel Physiology Complete the process of digestion Move stool through peristalsis Form, store and expel faeces
7 Neurological Input
8 Neurogenic bowel Dysfunction of the colon (constipation, faecal incontinence and disordered defaecation) due to loss of normal sensory and/or motor control or both, as a result of central neurological disease or damage. Gastrointestinal symptoms related to autonomic dysfunction following spinal cord injury, Chung, Progress in brain research 2006
9 Neurogenic bowel Neurogenic function may be reflex, areflexic or mixed
10 Reflex bowel Damage to the brain or spinal cord above conus medullaris: sensory perception of the need for defaecation voluntary control of the EAS
11 Reflex bowel Modulation of colonic motor activity is lost and peristalsis movements continue though less effectively Recto-anal dyssynergia
12 Reflex bowel Intact reflex arcs through the conus medullaris maintain tone (reflex activity) in the anorectum Reflex activity could aid in bowel management
13 Areflexic bowel Damage to conus medullaris or cauda equina (below T12) EAS denervated and flaccid INCONTINENCE Autonomic motor nerves are disrupted due to damage to parasympathetic cell bodies
14 Areflexic bowel peristalsis, loss of effective stool transport in the descending and sigmoid colon and rectum (Banwell 1993) colonic transit time through descending colon, sigmoid and rectum (Krogh et al 2000, Leduc et al1997) CONSTIPATION
15 pressure in IAS Areflexic bowel High risk of faecal incontinence through the sphincter, as well as constipation (Steins et al 1997)
16 Bowel Management Programme of interventions designed to achieve effective bowel evacuation at a specific frequency, reducing its impact on quality of life, minimising associated morbidity and facilitating carer input Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions September 2012
17 Bowel Management avoid faecal incontinence minimise or avoid constipation manage evacuation within a reasonable time,generally suggested to be up to one hour (Stone 1990) Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions September 2012
18 Bowel Management optimise comfort, safety and privacy fit management in with the lifestyle of the individual, enabling activity without fear of faecal incontinence Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions September 2012
19 Bowel Management use the minimum necessary physical and pharmacological interventions maintain short and long-term GI health identify appropriate transfer methods, equipment and adaptive devices Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions September 2012
20 Bowel Management evaluate the outcomes of bowel management objectively by recording episodes of faecal incontinence, duration of bowel management episodes and stool form as described by the Bristol Stool Form Scale (Heaton 1992) Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions September 2012
21 Bristol Stool Chart
22 Assessment of Neurogenic Bowel Patient history Physical examination Assessment of function Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
23 Patient history Premorbid gastrointestinal function Medical condition Current symptoms Current bowel program Medication use Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
24 Physical examination Abdominal assessment Assessment of anal sphincter tone Elicitation of anocutaneous and bulbocavernosus reflex Rectal examination Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
25 Assessment of function Ability to learn Upper extremity strenght and proprioception Hand and arm function Spasticity Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
26 Assessment of function Transfer skill Actual and potential risks to skin Home accessibility Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
27 Management of Neurological Bowel Designing a bowel program Nutrition Surgical and Nonsurgical Therapies Managing at home Monitoring program effectiveness Managing complications Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
28 Bowel Program From acute care to through life Minimize unplanned bowel movements Evacuate stool at a regolar time Predictable time 60 minutes of bowel care Minimize GI symptoms Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
29 Bowel Program Same time each day Ingestion of food 30 minutes prior to bowel care At least once every two days Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
30 Reflexic Bowel Program Chemical stimulant onto rectal mucosae Upright or side-lying position Assistive techniques (digital stimulation) Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
31 Reflexic Bowel Program Soft-formed stool consistency that can be readily evacuated with rectal stimulation Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
32 Areflexic Bowel Program Upright or side-lying position Valsalva maneuvers Manual evacuation Twice daily bowel care Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
33 Areflexic Bowel Program Firm-formed stool that can be retained between bowel care sessions and easily manually evacuated Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
34 Nutrition Fibers High doses are not for all patients with SCI >15 grams of fibers daily initially increases of fibers should be done gradually Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
35 Nutrition Water Balanced with bladder management 500 ml/day more than general public Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
36 Nutrition Water and fibers intake depend on the consistency of the stool and is therefore a factor strictly individual Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
37 Mechanical stimulation Alone or with chemical agents Digital stimulation (increases peristalsis relaxes EAI) Manual evacuation (method of choice in areflexic bowel) Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
38 Chemical rectal agents Bisacodyl suppository Glycerin suppository Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
39 Transanal irrigation constipation after 10 weeks compared to the conservative Bowel treatment improve fecal continence and quality of life A randomized, controlled trial of transanal irrigation versus conservative bowel management in SCI patients. Christensen P, et all. Gastroenterology. 2006; 131:
40 Sacral anterior root stimulator II III IV sacral anterior nerve roots high voltage short stimulation several times daily colonic activity, reduced constipation implantations are rare (Coggrave et al 2009) Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions September 2012
41 Colostomy After failure of other techniques independence in bowel care (Coggrave 2012, Kelly 1999) time spent on bowel management (Coggrave 2012, Stone et al 1990) quality of life for some individuals (Coggrave et al 2012, Rosito et al 2002) Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions September 2012
42 Managing Bowel at Home Appropriate adaptive equipment Careful measures to avoid pressure ulcers Emotional support Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
43 Bowel Problem 27-61% individuals with SCI rank bowel dysfunction as a major life-limiting problem Unplanned evacuations Prolunged bowel care Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
44 Managing complications Constipation Balanced diet Adequate fluid and fiber intake Increased daily acitivities Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
45 Managing complications Fecal impaction 7% individuals with SCI Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
46 Managing complications Hemorrhoids Autonomic dysreflexia Neurogenic bowel management in adults with SCI Consortium for Spinal Cord Medicine, March 1998
47 Bowel Management KIT
48 Bowel Management sleeper diaper
49 Bowel Management sirup tablets suppositories
50 Bowel Management rectal probe lube
51 Bowel Management micro-enema sterilized gauze
52 Case Report 1 25 years old Man Paraplegia following multiple trauma with vertebral fracture T10-T11 Constipation with absence of evacuation
53 Case Report 1 Sennosidi 2 cp by os at 7 am Enema at 2 pm 2 times weekly Discrete management, but the patient wishes to avoid enema
54 Case Report 1 Sennosidi 2cp/die 7 am Bisacodile 2 suppositories/die 1 pm 2 times weekly Good management, patient is satisfied, no complications
55 Bowel Management Usually is not so easy!!!
56 Case Report 2 38 years old Man July 2012 weakness in the lower limbs with bowel and bladder s alterations September 2012 MR vertebral column: injury D8 to D10 and edema at D8 attributable to acute-subacute myelitis
57 Case Report 2 Solumedrol 1 gr intravenous/die for 5 days October 2012 patient discharged April 2013 progressive worsening May 2013 laminectomia D8 - D10, excision of intramedullary lesion
58 Case Report 2 May 2013 admitted to rehabilitation center June 2013 MR vertebral column Constipation with absence of evacuation
59 Case Report 2 Bowel Management - Sennosidi 1 cp by os at 7 am - Enema at 2 pm - 2 times weekly
60 Case Report 2 Bowel Management Bloating widespread Rectal probe 2 h/die after some days Bloating persists Simeticone 2 cp x3/die
61 Case Report 2 Bowel Management Macrogol 1 sachet daily July evacuation on comfortable chair Bisacodile 2 cp
62 August 2013 start training using transanal irrigation Sennosidi 2 cp the night before irrigation Case Report 2 Bowel Management
63 Case Report 2 Bowel Management After 1 month suspends transanal irrigation for discontent and mismanagement evacuative Macrogol 1 sachet x3 daily Sennosidi 6 cp the evening before the Enema
64 Case Report 2 Bowel Management Positive outcome Sennosidi 4 cp 3 months after the hospitalization patient is dissatisfied, we too TO BE CONTINUED..
65 Bowel Management Take home messages Level of SCI is crucial Reflex Areflexic bowel Strictly individual Residual capacity Avoid complications
66 66
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