Dr. Karen M. Smith, Associate Professor at Queen’s University in the Faculty of Health Sciencesfrom l994 to the present. She is affiliated with Providence Care, St. Mary’s of the Lake Site,Kingston General, Hotel Dieu and Brockville Hospitals. She is the Clinical Director of the AcquiredBrain Injury and Spinal Cord Injury Rehabilitation Services from 1994 to present. She was AssociateProfessor at McMaster University until 1994.

Dr Smith completed her Physical Medicine and Rehabilitation residency training at McMasterUniversity. She is a Fellow of the Royal College of Physicians and Surgeons of Canada, Diplomatof the American Board of Electrodiagnostic Medicine and the American Board of Physical Medicineand Rehabilitation with subspecialty certification in Spinal Cord Injury Medicine attained in 2003.Her clinical interests and expertise are in ABI, SCI and pediatric rehabilitation. Her research interestsare in clinical trials with current trials in the areas of primary care for persons with disabilities,quality of life, exercise, and neurogenic bowel management.

CONTACT INFO:

Providence Care | St. Mary’s of the Lake HospitalDept. of Physical Medicine and Rehabilitation340 Union Street, Box 3600, Kingston, ON K7L 5A2Phone: 613-544-1894 karens@providencecare.ca

DR. KAREN SMITH

with THOMSON, ROGERS

and Canadian Paraplegic Association Ontario

 

Neurogenic Bowel UpdateDr. Karen M. Smith

Associate ProfessorQueen’s University

 

Disclosure

Have received an honorarium from Coloplast for speaking on one occasion

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

Provided with free supplies to trial TAI with first 10 patients

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Objectives

Present a treatment paradigm for neurogenic bowel dysfunction to include transanalirrigation

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

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

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

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

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

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Standard neurogenic bowel care

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

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

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Nonsurgical adjunctive measures

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

Colonic irrigation Level 4 removing stool

Electrical stimulation of the abdominal wall Level 1

Functional magnetic stimulation Level 4

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Transanal Irrigation

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Transanal irrigation

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

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

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

Christensen 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

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Scintigraphy – pre and post irrigation with Peristeen in SCI individual

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Colonic Irrigation

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Colonic Irrigation

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Colonic irrigation

Level 4 evidence shown in 31 patients with SCI that this was effective in removing stool

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

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

Puet et al Spinal Cord 1997;35:694-699 Gramlich et al Dig Dis Sci 1998;43:1831-1834 Kososka et al Dis Colon Rectum 1994;37:161-164 Gilger et al J Ped 1994;18:92-95 Chang et al Gastro Endosc 1991;37:444-448

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Surgical strategies

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

Primary outcome quality-adjusted life expectancy

Furlan et al Br J Surgery 2007;94:1139-115017

Ranking based on primary outcome

MACE

SARS implantation

Colostomy

Ileostomy

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MACE Malone Antegrade Continence Enema

picture

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Clinical Assessment Tools

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

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

Anorectal manometry

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Optimal conservative neurogenic bowel care

Targeted implementation strategies improve provider adherence to Clinical Practice Guidelines

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

Level 1 evidence preferring polyethylene glycol-based suppositories

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Neurogenic Bowel Care

Optimize conservative neurogenic bowel care and don’t forget education/implementation strategies

Nonsurgical adjunctive measures Transanal irrigation Colonic irrigation Functional electrical and magnetic stimulation of skeletal muscles

Surgical measures (in order of suggested preference) MACE SARS Colostomy Ileostomy

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Research opportunities Biologic issues

Pathology and physiologic changes

Effects of level, time since injury and autonomic dysfunction on NBD

Outcome measurement

Testing

Policy issues

Funding of supplies, attendant care

Scope of practice for attendants

Primary Care 25

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