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Spinal Cord Injury and Bowel Dysfunction

Presented by Angela Stancil January 10 , 2014. Spinal Cord Injury and Bowel Dysfunction. Epidemiology of SCI. 200,000 - 273,000 people in U.S. have SCI Estimated 12,000 – 20,000 new cases in U.S. annually Average age at time of injury 42.6 y/o 80.7% males 76.8% Caucasian

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Spinal Cord Injury and Bowel Dysfunction

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  1. Presented by Angela Stancil January 10 , 2014 Spinal Cord Injury and Bowel Dysfunction

  2. Epidemiology of SCI • 200,000 - 273,000 people in U.S. have SCI • Estimated 12,000 – 20,000 new cases in U.S. annually • Average age at time of injury 42.6 y/o • 80.7% males • 76.8% Caucasian • Alcohol implicated in 25% of cases

  3. A&P of the Spinal Column

  4. SCI Classifications • Complete or Incomplete • Quadraplegia • Tetraplegia • Paraplegia • Monoplegia

  5. Altered muscle tone Spacisity Flaccidity Muscle atrophy Weight loss (new injury) Loss of Mobility Sexual Dysfunction Depression Pain Complications of SCI • Lack of bladder control • Bowel Dysfunction • Altered or missing skin sensation • Problems with circulatory control • Orthostatic hypotension • Autonomic Hyperreflexia • Edema • Respiratory problems

  6. Autonomic Hyperreflexia

  7. Neurogenic Bowel Problems with storing, removing, or moving stool from the intestines resulting from nerve damage • Classifications • Reflexic Bowel • Areflexic Bowel

  8. Symptoms of Neurogenic Bowel • Trouble having a bowel movement • Repeated bowel accidents • Swollen abdomen • Feeling full (not hungry) quickly • Loose stools or very hard stools • Bleeding from the rectum • Abdominal pain

  9. Treatment/Bowel Training • Dietary changes • Exercise/PA program • Specific times, assistance, and positions for BMs • Medications (stool softeners, laxatives, colonic stimulants, bulking agents) • Digital Stimulation (mechanical, enemas, suppositories) • Surgery (Colostomy or Ileostomy)

  10. Rationale and Study Objectives • Moisture content of stool remains 70-75% • Low fiber intake does not = constipation • Symptoms may increase with increased fiber intake • Other treatments (i.e. lactulose) may be more beneficial than fiber • Patients with constipation already have high fiber intake Objective: to study the effect of decreasing fiber in patients with constipation Hypothesis: Reducing dietary fiber reduces fecal bulk making defecation easier

  11. Study Design • Prospective longitudinal case study • Inclusion criteria: • Straining to expel bulky stools • Bowel frequency <1 per 3 days over 3 months • Exclusion criteria: • Colorectal cancer, previous colonic surgery, melanosis coli, thyroid disorders, anal problems • 63 subjects enrolled in the study

  12. Methods • Each patient acted as their own control • No dietary intake of fiber for 2 weeks • Normal CHOs and protein • No laxatives • Sieved juices and clear vegetables soups • Low fiber diet • F/U at 1 month and 6 months

  13. Methods Data Collection: • Age & sex • Fiber intake • Frequency of BMs • Straining difficulty • Evacuation difficulty • Abdominal pain and bloating • Anal Bleeding Statistical analysis • Paired t tests using SPSS software

  14. Results • 16 males, 47 females • Median age 47 years • High fiber diet + fiber supplement • At 6 months: • 41 no fiber, 16 reduced fiber, 6 high fiber

  15. Results - Demographics No significant difference in age or sex between groups

  16. Results – BM Frequency Net Effect: Increase in frequency in No Fiber and Low Fiber groups, no change in High Fiber group

  17. Results – Associated Symptoms Net Effect: Reduction in associated symptoms in Reduced and No Fiber groups

  18. Conclusions Authors' Conclusions: Removing dietary fiber improves constipation and associated symptoms Study Limitations • Small sample size • No baseline symptoms by group • P values • Results not generalizable

  19. Rationale • IBS is a functional bowel disorder characterized by abdominal pain and discomfort related to bowel disturbances • Probiotics are a safe candidate for controlling IBS symptoms • Dietary fiber is commonly used in the treatment of IBS Objective: Evaluate the effect of probiotics on patients with IBS and determine if dietary fiber has an additive effect

  20. Study Design • Single center, randomized, control trial • Recruited volunteers ages 18 – 70 y/o • Exclusion criteria: • Severe liver, lung, renal, hematological, or major psychiatric disorder • Adults > 50 y/o who had not had colonoscopy or sigmoidoscopy in past 5 years • Abnormal thyroid function, blood counts, serum chemistry • Antipsychotics or anticholergenics in past month • Pregnant or lactating • Receiving medications for IBS

  21. Methods • 142 participants • Each participant received a fermented milk product taken 2x/day for 4 weeks • Control group: 150 ml milk + Probiotics • Test group: same + 3.15 g dietary fiber • Questionnaire • Primary endpoint: difference in defecation frequency, duration, and VAS score

  22. Statistical Analysis • Shapiro-Wilk test • Student t tests • Paired t tests • P < 0.05

  23. Results

  24. Results

  25. Results

  26. Results

  27. Authors' Conclusions: Plain probiotic milk and probiotic milk containing fiber are safe and effective. Probiotic milk containing fiber was more effective for the constipation dominant subtype of IBS Study Limitations: • No placebo group

  28. Mr. W • 57 y/o AAM w/ C4 quadreplegia • PMH: neurogenic bowel and bladder w/ chronic indwelling catheter, ventilator dependent respiratory failure s/p trach (capped), osteomyelitis, migraines, anemia, keratoderma, and VRE • BT: Digital Stimulation, Mini enema • Skin: Braden 10, Severe risk of HAPU • Stage 4 PU to clavicle and R. ischeal • Stage 3 PU to Sacrum • Unstageable PU to R. heel

  29. Mr. W • Laboratory Data: No new lab data • Previously, low pre – albumin (17.39) • Anthropometrics • HT: 74 in. • WT: 130.1 lbs (12/8/13) 130.2 lbs (11/21/13) 126 lbs. (11/15/13) • DBW: 162 – 171 lbs. (adjusted 5-10% for tetraplegia) • %DBW: 80% • Pertinent Medications: • Omeprazole, Acidophilus, Docusate, Tizanidine, Baclofen

  30. Nutrition Assessment • Estimated Nutrition Needs • Calories: 1776 – 2072 kcals/day (30-35 kcals/kg) • Protein: 74 – 89 g (1.25 – 1.5 g/kg) • Fluid: 1 ml/kcal + 500 ml or per PCP • Diet Hx: • PO: Liberal diet • EN: TwoCal @ 60 ml/hr x 12 hrs • Free water @ 250 ml/hr q4h • Prostat supplement • 10 am: orange/mango applesauce (meds only) • 8pm snack: PB &J, 1 choc milk, 1 cookie

  31. Nutrition Assessment • Nutrition Assessment • Appetite: “so so” • No V/C/D • Tolerating TF w/o problems • Physical Assessment • Moderate deficits in temples and OFP • 24 hour calorie count: 381 kcals, 16.1 g protein • Nitrogen Balance: + 2.57 (PO + EN+ Prostat)

  32. Mr. W • Nutrition Dx: • Increased protein/energy needs related to malnutrition and wound healing as evidenced by presence of multiple PUs and Braden of 9. • Inadequate oral intake related to poor appetite as evidenced by ongoing need for nutrition support and results of 24 hour calorie count. • Nutrition Prescription: Increase intake by 10% by next visit utilizing supplements, snacks, and select menus thereby decreasing dependence on EN

  33. Mr. W Nutrition Interventions • Continue Liberal diet • Continue Prostat and evening snack • Continue EN : TwoCal @ 60 ml/hr from 7p - 7a Nutrition Monitors • Wound healing • Tolerating TF • Prevent Unintentional Weight loss • Lab values WNL • Consume >80% nutrition needs

  34. Mr. W Nutrition Evaluation Patient's PO intake remains suboptimal. With EN, patient's nitrogen balance is positive. Recommend continuing Liberal diet and EN. Encourage PO intake to decrease dependence on nutrition support. Will continue to follow while admitted. Prognosis: ??

  35. References • The University of Alabama at Birmingham NSCISC National Spinal Cord Injury Statistical Center. Spinal Cord Injuries Facts and Figures at a Glance. Updated February 2013.Accessed January 5, 2014. Available at https://www.nscisc.uab.edu/. • The Centers for Disease Control and Prevention. Spinal Cord Injury (SCI): Fact Sheet. CDC's Injury Center webpage. Updated November 4, 2010. Accessed January 5, 2014. Available at http://www.cdc.gov/traumaticbraininjury/scifacts.html. • The Mayo Clinic. Spinal Cord Injury. Diseases and conditions webpage. Updated Oct. 22, 2011 . Accessed January 5,2014. Available athttp://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/basics/definition/con-20023837. • National Institutes of Health Clinical Center. Managing Bowel Dysfunction patient education handout. Accessed January 5, 2014. Available at http://www.cc.nih.gov/ccc/patient_education/pepubs/bowel.pdf. • NYU Langone Medical Center. Neurogenic Bowel. Diseases and conditions webpage. Updated March 2013. Accessed January 5, 2014. Available at http://medicine.med.nyu.edu/conditions-we-treat/conditions/neurogenic-bowel. http://medicine.med.nyu.edu/conditions-we-treat/conditions/neurogenic-bowel. • Ho, K, Tan, CY, Daud MA, Seow-Choen, F. Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms. World J Gastroenterology. 2012;18(33):4593-4596. • Choi,SC, Kim BJ,Rhee P, et al. Probiotic fermented milk containing dietary fiber has additive effects in IBS with constipation compared to plain probiotic fermented milk. Gut and Liver; 2011.(5):22 – 28.

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