10. Diet and Fluid Management in Neurogenic Bowel

Actionable Nuggets for SCI (3rd ed., 2016)

Refer spinal cord injured patients with persistent constipation to a specialist with experience with spinal cord injury or neurogenic bowel.

The Problem:

Evidence-based Best Practice:

Bowel management in SCI is aimed at maximizing independence, maintaining social continence, and increasing efficiency and satisfactory results (see Nugget #8). This is accomplished by balancing stool consistency, minimizing transit time and maintaining overall nutrition.

• 15-18 gms. of fibre per day is recommended, along with 35 ml of fluid (preferably plain water) per kg. of body weight. This results in a daily intake about 500 ml higher than the general population.
• Fluid intake must be modulated as it will have consequences for bladder emptying. An ideal level produces urine the colour of champagne!
• Since neurogenic bowel and bladder often occur coincidentally, a daily diary of intake (diet and fluid) and output (urine and stool) provides useful information for monitoring in primary care.

For those with an Upper Motor Neuron lesion (UMN; above T12), diet and fluid management is usually aimed at producing softer stools, whereas for those with a Lower Motor Neuron lesion (LMN; T12 or lower), slightly firmer stool is preferred to avoid incontinence. Rehabilitation specialists use the Bristol Stool Scale to describe seven types of stool.  Types 3 and 4 are ideal, as they are easy to defecate without containing any excess liquid.

• Type 1: Separate hard lumps, like nuts (hard to pass)
• Type 2: Sausage-shaped, but lumpy
• Type 3: Like a sausage but with cracks on its surface
• Type 4: Like a sausage or snake, smooth and soft
• Type 5: Soft blobs with clear cut edges (passed easily)
• Type 6: Fluffy pieces with ragged edges, a mushy stool
• Type 7: Watery, no solid pieces. Entirely liquid

 Key Reference:

    Coggrave, M., Ash, D., & Adcock, C.  (2012). Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions. Initiated by the Multidisciplinary Association of Spinal Cord, 1–60. Retrived from http://www.mascip.co.uk/wp-content/uploads/2015/02/CV653N-Neurogenic-Guidelines-Sept-2012.pdf

Additional References (chronological order):

    Abramson, C. (2014). Neurogenic Bowel after Spinal Cord Injury, 1–52. Retrieved from papers2://publication/uuid/F712958B-91F7-41BE-B8F2-C2860E2A2E26
    Canadian Agency for Drugs and Technologies in Health. (2014). Treatments for Constipation: A Review of Systematic Reviews. Canadian Agency for Drugs and Technologies in Health.
    Fisher, M., Middleton, J., & Pryor, J. (2014). Management of the Neurogenic Bladder for Adults with Spinal Cord Injuries. Agency for Clinical Innovation. Chatswood NSW.
  Lim, Y.H., Kim, D.H., Lee, M.Y., & Joo, M.C. (2012). Bowel dysfunction and colon transit time in brain-injured patients. Annals of Rehabilitation Medicine, 36(3), 371-8.
    Coggrave, M. J., & Norton, C. (2010). The need for manual evacuation and oral laxatives in the management of neurogenic bowel dysfunction after spinal cord injury: A randomized controlled trial of a stepwise protocol. Spinal Cord, 48(46), 504-510.
    Krassioukov, A., Eng, J. J., Claxton, G., Sakakibara, B. M., & Shum, S. (2010). Neurogenic bowel management after spinal cord injury: A systematic review of the evidence. Spinal Cord, 48(10), 718-733.
    Lombardi, G., Del Popolo, G., Cecconi, F., Surrenti, E., & Macchiarella, A. (2010). Clinical outcome of sacral neuromodulation in incomplete spinal cord-injured patients suffering from neurogenic bowel dysfunctions. Spinal Cord, 48(2), 154-159.
    Coggrave, M., Norton, C., & Wilson-Barnett, J. (2009). Management of neurogenic bowel dysfunction in the community after spinal cord injury: A postal survey in the United Kingdom. Spinal Cord, 47(4), 323-30.
    Krogh, K., & Christensen, P. (2009). Neurogenic colorectal and pelvic floor dysfunction. Best Practice and Research. Clinical Gastroenterology (of Publication: August 2009), 23(24): 531-543.
    Spinal Cord Injury Centres of the United Kingdom and Ireland (2009). Guidelines for management of neurogenic bowel dysfunction in the community after spinal cord injury. United Kingdom: Coloplast.
    Walters, J.L., Buchholz, A.C., Martin Ginis, K.A., & SHAPE Research Group. (2009). Evidence of dietary inadequacy in adults with chronic spinal cord injury. Spinal Cord, 47(4): 318-22.
    Christensen, P., et al. (2006). A Randomized, Controlled Trial of Transanal Irrigation Versus Conservative Bowel Management in Spinal Cord-Injured Patients. Gastroenterology, 131(3): 738-747. http://dx.doi.org/10.1053/j.gastro.2006.06.004
    Ng, C., Prott, G., Rutkowski, S., Li, Y., Hansen, R., Kellow, J., & Malcolm, A. (2005). Gastrointestinal symptoms in spinal cord injury: relationships with level of injury and psychologic factors. Diseases of the Colon & Rectum, 48(8), 1562-8.
    Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury (1998). Spinal Cord Medicine Consortium. Journal of Spinal Cord Medicine, 21(3), 248-93. http://www.pva.org/site/News2?page=NewsArticle&id=7651
    Consortium for Spinal Cord Medicine (1998). Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury. Journal of Spinal Cord Medicine, 21(3), 248-93.
    De Looze, D., et al. (1998). Constipation and other gastrointestinal problems in spinal cord injury patients. Spinal Cord, 36(1), 63-6.
    Cameron, K.J., et al. (1996). Assessment of the effect of increased dietary fibre intake on bowel function in patients with spinal cord injury. Spinal Cord, 34(5), 277-83.
    Menardo, G., et al. (1987). Large-bowel transit in paraplegic patients. Diseases of the Colon & Rectum, 30(12), 924-8.