Neurogenic Bowel UpdateDr. Karen M. SmithDr. Karen M. Smith

Associate ProfessorAssociate ProfessorQueenQueen’’s Universitys University

Disclosure

Have received an honorarium from Have received an honorarium from Coloplast for speaking on one occasionColoplast for speaking on one occasion

Expenses paid to attend a training session Expenses paid to attend a training session on the use of transanal irrigationon the use of transanal irrigation

Provided with free supplies to trial TAI with Provided with free supplies to trial TAI with first 10 patientsfirst 10 patients

2

Objectives

Present a treatment paradigm for neurogenic Present a treatment paradigm for neurogenic bowel dysfunction to include transanal bowel dysfunction to include transanal irrigationirrigation

Begin a discussion of the opportunities for Begin a discussion of the opportunities for research including quality improvement in research including quality improvement in neurogenic bowel managementneurogenic bowel management

3

4

Compare and contrast the two main types of neurogenic bowel dysfunction Areflexia or LMN bowelAreflexia or LMN bowel

Damage to the parasympathetic nerves, no spinal cord Damage to the parasympathetic nerves, no spinal cord mediated reflex defecation nor reflex peristalsis. mediated reflex defecation nor reflex peristalsis. Levator ani and EAS are denervated and lax.Levator ani and EAS are denervated and lax.

Reflexic or UMN bowelReflexic or UMN bowel No volitional control of defecation. Spinal mediated No volitional control of defecation. Spinal mediated

reflexes intact. Colon and EAS are spastic. Decreased reflexes intact. Colon and EAS are spastic. Decreased number of propogating waves after food intake. number of propogating waves after food intake.

5

6

Standard neurogenic bowel care

Standard neurogenic bowel management Standard neurogenic bowel management according to CPG from the Consortium for according to CPG from the Consortium for Spinal Cord Medicine by PVASpinal Cord Medicine by PVA

Bowel program addressing fluids,diet,meds Bowel program addressing fluids,diet,meds and regular bowel care addressing position, and regular bowel care addressing position, digital stimulation and other techniquesdigital stimulation and other techniques

7

Nonsurgical adjunctive measures

Transanal irrigation Level 1 evidence of Transanal irrigation Level 1 evidence of reduced UTI and constipation, and reduced UTI and constipation, and improved fecal continenceimproved fecal continence

Colonic irrigation Level 4 removing stoolColonic irrigation Level 4 removing stool

Electrical stimulation of the abdominal wall Electrical stimulation of the abdominal wall Level 1Level 1

Functional magnetic stimulation Level 4Functional magnetic stimulation Level 48

Transanal Irrigation

9

Transanal irrigation

LongLong--term results show improvement in 41term results show improvement in 41--75% 75% of patients with fecal incontinence and 40of patients with fecal incontinence and 40--65% 65% with constipationwith constipation

Scintigraphic studies show emptying of the Scintigraphic studies show emptying of the rectosigmoid and descending colon (nonSCI)rectosigmoid and descending colon (nonSCI)

CostCost--effectiveness analysis shows higher product effectiveness analysis shows higher product related costs but reduced attendant costs, related costs but reduced attendant costs, clothes/garments and UTI costsclothes/garments and UTI costs

Christensen et al Gastro 2006; Spinal Cord 2009Christensen et al Gastro 2006; Spinal Cord 200910

Before defecation After ”normal” defecation

Non injured person

SCI patient

Christensen P et al. Dis Colon Rectum 2003; 46: 68-76. Figures 2 & 3 pages 70-71: Reproduced with kind permission of Springer Science and Business Media.

Colonic scintigraphy

11

Scintigraphy – pre and post irrigation with Peristeen in SCI individual

12

13

Colonic Irrigation

14

Colonic Irrigation

15

Colonic irrigation Level 4 evidence shown in 31 patients with SCI that this Level 4 evidence shown in 31 patients with SCI that this

was effective in removing stoolwas effective in removing stool

LongLong--term safety shown in four patients using the term safety shown in four patients using the procedure an average of 3.5 times weekly for av 6.7 yearsprocedure an average of 3.5 times weekly for av 6.7 years

Published results in nonSCI subjects show safety and Published results in nonSCI subjects show safety and efficacy in short and long term useefficacy in short and long term use

Puet et al Spinal Cord 1997;35:694Puet et al Spinal Cord 1997;35:694--699699 Gramlich et al Dig Dis Sci 1998;43:1831Gramlich et al Dig Dis Sci 1998;43:1831--18341834 Kososka et al Dis Colon Rectum 1994;37:161Kososka et al Dis Colon Rectum 1994;37:161--164164 Gilger et al J Ped 1994;18:92Gilger et al J Ped 1994;18:92--9595 Chang et al Gastro Endosc 1991;37:444Chang et al Gastro Endosc 1991;37:444--448448

16

Surgical strategies

Based on systematic reviews (including 29 Based on systematic reviews (including 29 original articles), utilities catalogues and original articles), utilities catalogues and life table analysis Furlan et al ranked 4 life table analysis Furlan et al ranked 4 surgical strategies for neurogenic bowel surgical strategies for neurogenic bowel managementmanagement

Primary outcome qualityPrimary outcome quality--adjusted life adjusted life expectancyexpectancy

Furlan et al Br J Surgery 2007;94:1139Furlan et al Br J Surgery 2007;94:1139--1150115017

Ranking based on primary outcome

MACEMACE

SARS implantationSARS implantation

ColostomyColostomy

IleostomyIleostomy

18

19

MACE Malone Antegrade Continence Enema picturepicture

20

Clinical Assessment Tools

Bowel Function Basic and Extended Data Sets; Bowel Function Basic and Extended Data Sets; contain data allows computation of the St Marks contain data allows computation of the St Marks and Wexner score for fecal incontinence, and Wexner score for fecal incontinence, Cleveland Constipation Score and Neurogenic Cleveland Constipation Score and Neurogenic Bowel Dysfn ScoreBowel Dysfn Score

Total gastrointestinal or colonic transit time, right Total gastrointestinal or colonic transit time, right colonic or left colonic transitcolonic or left colonic transit

Anorectal manometryAnorectal manometry

21

Optimal conservative neurogenic bowel care

Targeted implementation strategies improve Targeted implementation strategies improve provider adherence to Clinical Practice Guidelinesprovider adherence to Clinical Practice Guidelines

Overall Level 4 evidence of reduced GI transit Overall Level 4 evidence of reduced GI transit time, incidence of difficult evacuations and duration time, incidence of difficult evacuations and duration of time requiredof time required

Level 1 evidence preferring polyethylene glycolLevel 1 evidence preferring polyethylene glycol--based suppositoriesbased suppositories

22

Neurogenic Bowel Care Optimize conservative neurogenic bowel care and donOptimize conservative neurogenic bowel care and don’’t t

forget education/implementation strategiesforget education/implementation strategies

Nonsurgical adjunctive measuresNonsurgical adjunctive measures Transanal irrigationTransanal irrigation Colonic irrigationColonic irrigation Functional electrical and magnetic stimulation of skeletal musclFunctional electrical and magnetic stimulation of skeletal muscleses

Surgical measures (in order of suggested preference)Surgical measures (in order of suggested preference) MACEMACE SARSSARS ColostomyColostomy IleostomyIleostomy

23

24

Research opportunities Biologic issuesBiologic issues

Pathology and physiologic changesPathology and physiologic changes Effects of level, time since injury and autonomic Effects of level, time since injury and autonomic

dysfunction on NBDdysfunction on NBD

Outcome measurementOutcome measurement TestingTesting

Policy issuesPolicy issues Funding of supplies, attendant careFunding of supplies, attendant care Scope of practice for attendantsScope of practice for attendants Primary Care Primary Care

25

27