Convegno Nazionale CNOPUS
Ancona 18-19 nov. 2011
Il lavaggio colico nella gestione
dell’intestino neurologico
a cura di Mihaela Beznea, AOU Careggi Firenze
Agenzia Regionale per la cura del Medulloleso
con la collaborazione di Fabrizio Torsi
La disfunzione neurologica intestinale rappresenta
uno dei problemi fisici e psicologici principali della
persona che vive la lesione midollare.
Descrive la perdita del controllo volontario sulla
defecazione, la perdita della capacità di percepire le
sensazioni provenienti dal retto (stimolo alla
defecazione), la perdita della possibilità di rinviare
volontariamente l’atto contraendo lo sfintere anale e la
compromissione delle vie della sensibilità che trasportano
informazioni dalle superfici peritoneale.
La fase di shock spinale (fase acuta) è caratterizzata da:
- ileo paralitico determinato dalla disfunzione del sistema autonomo parasimpatico e
del sistema nervoso enterico, responsabili della motilità intestinale;
- sovradistensione gastrica (ristagno gastrico, accumulo di gas);
La fase post-acuta:
lesione sovrasacrale
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riflesso anale-inibitore conservata
(funzione di serbatoio), riflesso eccitatorio
retto-anale conservato;
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ipertonia dello sfintere esterno e della
muscolatura perineale;
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tendenza alla stipsi.
lesione sacrale
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ridotta conservazione del riflesso inibitorio
retto-anale (funzione di serbatoio);
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abolizione del riflesso eccitatorio retto-anale;
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tendenza all’incontinenza.
ipotono dello sfintere esterno e paralisi
flaccida della muscolatura perineale;
Nella persona con lesione midollare cronica
‘’Le alterazioni del sistema nervoso centrale e periferico comportano
rallentamento dello svuotamento gastrico, allungamento dei tempi di
transito intestinale e diminuzione della motilità del colon. Frequentemente
si manifestano con distensione addominale post-prandiale, coprostasi, stipsi
e incontinenza.’’
(Bazzocchi et al. Valutazione e trattamento delle disfunzioni intestinale e ano-rettali nel mieloleso)
Obiettivi della rieducazione intestinale
1) Prevenire la stipsi,
2) Prevenire l’incontinenza fecale,
3) Consentire evacuazioni efficaci ad orari prevedibili,
4) Limitare i tempi necessari per effettuare un’efficace evacuazione,
5) Raggiungere l’autonomia nella gestione delle problematiche intestinali,
6) Prevenire le complicanze gastro-intestinali,
7) Favorire una migliore qualità di vita.
E’ necessario inoltre tener conto di:
- funzione intestinale precedente alla lesione midollare,
- sintomatologia attuale (distensione addominale, senso di mancato od incompleto
svuotamento, mancanza di stimolo evacuativo, incontinenza, diarrea, sanguinamento,
dolore, crisi disreflessiche associate, ecc)
- frequenza e modi di defecazione,
- caratteristiche delle feci,
- terapie in atto,
- valutazione medica (esame obiettivo dell’addome, esplorazione rettale, esame
neurologico, ecc),
- indagini di laboratorio e strumentali (esame colturale delle feci, tempo di transito,
esami manometrici, Rx addominale, defecografia, clisma opaco, retto-colonscopia),
- grado di autonomia acquisito,
- tipo di assistenza necessaria, ausili, ecc,
- aspettativa del paziente,
- qualità di vita percepita.
Esperienze acquisite
Precoce riabilitazione intestinale
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dieta
fibre aggiuntive
assunzione corretta di liquidi
massagio addominale
stimolo esterno perineale
stimolo interno ano-rettale
pre- e probiotici
microclismi e supposte
lassativi
Esperienze acquisite
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Nonostante una corretta e precoce
riabilitazione intestinale si stima che il
20% delle persone con lesione midollare
sviluppano la stipsi neurogena cronica.
Perche parlarne ancora?
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‘’Il 19-23% dei mielolesi necessita di almeno un’ospedalizzazione nella vita per disturbi correlati al
tratto gastro-intestinale (GI), e la mortalità per patologie del tratto alimentare è di 10%’’.
(Bazzocchi et al Valutazione e trattamento delle disfunzioni intestinale e ano-rettali nel mieloleso)
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‘’Per quanto concerne gli effetti sulla qualità della vita, basti pensare alle restrizioni sulle attività svolte
fuori casa che il paziente incontinente si impone per paura di evacuazioni inaspettate, o alla frustazione
del paziente stitico che si trova costretto ad impiegare da 1 a 5 h/die nel tentativo di defecare e alle
conseguenze di tutto ciò sulle relazioni sociali e sull’attività lavorativa’’.
(D.Harari et al Costipation-related symtoms and bowel program cocerning individuals witha spinal cord injury. Paraplegia 1997;
35:394-401;
G.I.Corea et al Clinical evaluation and management of neurogenic bowel after spinal cord injury. Spinal cord 2000; 38: 301-308)
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‘’Evidenze di correlazione tra disturbi intestinali e depressione maggiore’’.
(Rosemarie B.King et al Neurogenic bowel management in adults with spinal cord injury. Clinical practice guidelines march 1998)
Perche parlarne ancora?
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La letteratura riporta anche un incremento delle infezioni urinarie associate dovute al
fenomeno di ‘’migrazione’’ dei germi dal livello intestinale a livello vescicale ( ‘’bacteryal
translocation from bowel to bladder, not only in SCI person’’
- relazione dr. Bazzocchi Gabriele, ‘’Colorectal dysfunction in spinal cord injury: Pathophysiological and clinical consideration’’,
Congresso ISCOS Firenze 2009)
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‘’Bowel problems are the second most common trigger for autonomic dysreflexia (.....).
Noxious stimulation of the sympathetic nervous system - due most commonly to
distension of abdominal organs such as the bladder or bowel- can result in sweating,
chills, bradycardia and rapidly rising blood pressure, which can result in stroke or death.
Other problems associated with bowel dysfunction include abdominal pain, abdominal
bloating and discomfort, haemorroids, anal fissures and rectal bleeding. Faecal
incontinence or the fear of incontinence are experienced by many patients with SCI and
are socially limiting. Bowel management can be very time consuming and may interfere
with an individual’s ability to work or socially integrate outside the home’’.
( Transanal irrigation after spinal cord , Maureen Coggrave, 2007, Nursing time; 103:47, 44-46)
Come comportarsi quando il
programma di rieducazione intestinale
non funziona?
L’irrigazione trans-anale
Patients
SCI (including mixed populations with a high proportion of SCI
patients)
SCI, n=87 (including spina bifida, n=2)
SCI, n=62 (including spina bifida, n=2; 42
from RCT)
SCI, n=33 (including spina bifida, n=12; MS,
N=2
Study design
RCT, 10 weeks, N0042 allocated to Peristeen
Prospective, before after study, 10 weeks,
Extension to RCT; patiens in conservative Prospective, before after study, 3 weeks
arm offered cross-over to Peristeen
System equipment
TAI versus conservative management
Peristeen
Main findings
- reduced symptoms of costipation (Cleveland Clinic
costipation scoring system)
- reduced symptoms of faecal incontinence (St. Mark’s faecal
incontinence grading system)
- reduced symptoms of NBD (NBD score)
- confirmed findings from RCT no predictors
- improved QoL (Modified America Society of colon and rectal of successul outcome identified; supports
Surgeon fecal incontinence score, numeric scale)
trial of TAI in all suitable patients
- reduced time spent on bowel management
- improved intestinal functionality (numeric box scale)
- reduced UTIs
- four adverse events in the TAI group
- reduced symptoms of NBD (NBD score)
- improved QoL
- increased degree of satisfaction
- reduced time spent on bowel management
- improved intestinal functional functionality
- no adverse events reported
Strengths (+) /
limitations (-)
+ prospective
+ RCT (CONSORT)
+ Multicentre
+ Standard scoring system / scales
+ prospective
- non-comparative
- short duration
Reference
Christensen P, Bazzocchi G, Coograve M,
Christensen P, Bazzocchi G, Coograve M, Abel R, Hultling C,
Abel R, Hultling C,Krogh K et al,’’Outcome of
Krogh K et al, ‘’Arandomized, controlled trial of Tai versus
TAI for bowel dysfunction in patients with
conservative bowel management in spinal cord injured
spinal cord injury, J Spinal Cord Med 2008,
patients’’, Gastroenterology 2006, 131:738-747
46:560-567
+ prospective
- non-comparative
Peristeen
Del Popolo G, Mosiello G, PilatiC , Lamartina
M, Battaglino F, Buffa P et al, ‘’Treatment of
neurogenic bowel dysfunction using TAI: a
multicenter Italian study, Spinal Cord 2008,
46: 517-522
Author,
Country
Score,
Research
design,
Total sample
size
Christensen et al. USA Downs Christensen et al; Denmark; Downs and
Christensen et al. Denmark; PEDro
Del Popolo G et al, Italy; Downs and
and black score= 20; pre-post black scores=17; retrospective interviews
score=7; RCT; N=87
black score=14; pre-post, N= 32
N=55
and case series; N=29, 19 SCI patients
Methods
Population:
Tai group: mean age: 47,5 years; level of
injury: T10-S1, 23 complete and 12
incomplete. Conservative management
group: mean age: 50,6 years; T10-S1, 23
complete, 22 incomplete
Treatment:
TAI (Peristeen anal irrigation system) or
conservative management (PVA clinical
guidelines) for 10 weeks OM: CCCSS,
FIGS; Faecal incontinence score
Outcome
1. TAI group scored better on symptomrelated quality-of-life tool, CCCSS, FIGS,
and NBD
2. Improvement found in the TAI group
was non confined to the more physically
able patients
3. The frequency of urinary tract
infection was lower in the TAI group
Population:
Mean age 47,5 +/- 15,5 years;
level of injury: 61 supraconal, 37
completed, 25 incomplete.
Treatment:
TAI (Peristeen anal irrigation) for
10 weeks OM: CCCSS, FIGS; and
NBD
Population:
ECC group: mean age: 39,9 years, range: 7-72
years; level of injury: T2-T11, canal or cauda
equina injuries (N=15).
MACE group: mean age: 32,8 years, range:
15-66 years; level of injury: C5-T2 (n=4)
Treatment:
ECC versus MACE
OM: Colorectal function, practical procedure,
impact on daily living and QoL, general
satisfaction
1. CCCSS, FIGS and NBD scores
improved
2. TAI significantly reduced
constipation, improved anal
continence, and improved
symptom-related QoL
1. Significant increase in QoL
1. The ECC was successful in 53% of scores and improvment of
participants (8 subjects)
constipation
2. The MACE procedure was successful in 2. Significant decrease in
75% participants (3 subjects)
abdominal pain and incidence of
3. Successful treatment with the ECC or the incontinence
MACE led to significant improvment of QoL 3. Nine patients reduced or
eliminated pharmaceutical use
Population:
Mean age: 31,6 years, 13 complete
and 14 incomplete,
Treatment:
TAI (Peristeen anal irrigation) for 3
weeks.
OM: QoL, use of pharmaceuticals,
incidente of incontinence and
constipation, abdominal pain or
disconfort
Review of the efficacy and safety of transanal irrigation for neurogenic
bowel disfunction
A Emmanuel, Department of Gastroenterology and Nutrition, University College Hospital, London, UK
Spinal Cord (2010), 1-10
Study design: Neurogenic bowel dysfunction(NBD) is a common occurrence after spinal cord injury (SCI) and in patients
with a spina bifida or multiple sclerosis. The impact of NBD on well-being is considerable, affecting both physical and
psycological aspects of quality of life. Transanal irrigation (TAI) of the colon promotes the evacuation of the faeces by
introducing water into the colon and rectum through a catheter inserted into the anus. Regular and controlled evacuation in
this manner aims at preventing both constipation and faecal soiling.
Objectives: The aim of this study was to review current evidence for the efficacy and safety of TAI in patients with NBD.
Materials and methods: A literature search was conduced in PubMed. All identified papers were assessed for relevance
based on the title and abstract; this yielded 23 studies that were considered to be of direct relevance to the topic of the
rewiew.
Results: A multicentre, randomized, controlled trial has supported observational reports in demostrating that TAI offers
significant benefits over conservative bowel management in patients with SCI, in terms of managing constipation and faecal
incontinence, reducing NBD symptoms and improvingquality of life. Among other population with NBD, TAI shows the
greatest promise in children with spina bifida; however, further investigation is required. The overall safety profile of TAI is
good, with few, and rare, adverse effects.
Conclusions: Building on the positive data reported for patients with SCI, continued evaluation in the clinical trial setting
is required to further define the utility of TAI in other populations with NBD.
Keywords: transanal irrigation; neurogenic bowel; spinal cord injury; bowel management; faecal incontinence; constipation
Neurogenic bowel management after spinal cord injury: a systematic
review of the evidence
A Krassioukov 1,2,3, JJ Eng 1,3,4,5, G Claxton3, BM Sakakibara3,5, S Shum3, and the SCIRE Research Team
Spinal Cord (2010), 1-10
Study design: Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports
that assessed pharmacological and non-pharmalogical intervention for the management of the neurogenic bowel after spinal
cord injury (SCI) were included.
Objectives: To systematically review the evidence for the management of neurogenic bowel in individuals with SCI.
Setting: Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic
databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature.
Methods: Two independent reviewers evaluated each study’s quality, using Physiotherapy Evidence Database scale for RCTs
and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned.
Results: A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57
studies mat the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and arev supported by
lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a
promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective,
pharmacological interventions (for example prokinetic agents) arev supported by strong evidence for the treatment of
chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be
considered and arev supported by lower levels levels of evidence in reducing complications.
Conclusions: Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for nonpharmacological approaches and high for pharmacological interventions.
Keywords: spinal cord injury; autonomic control; neurogenic bowel; management; evidence based; SCIRE
Scale di valutazione
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NBDS -Neurogenic Bowel Dysfunction
Score (10 item che indagano la frequenza delle evacuazioni, il
tempo necessario per evacuare, la presenza del malessere/mal
di testa/sudoorazione durante l’evacuazione, il regolare uso di
lassativi, la frequenza dell’esplorazione rettale, la frequenza degli
episodi di incontinenza fecale, l’utilizzo di medicinali contro
l’incontinenza fecale, incontinenza per gas, i problemi della cute
perineale- punteggio NBDS da 0 a 47, cut off per NBD severa
14)
FIQoL -Fecal Incontinence Quality of Life
Questionnaire (si propone di esplorare 4 domini: lifestyle
-10 domande, coping/behaviour - 9 domande, depression/self
perception - 7 domande, embarassement - 3 domande, utile per
studi prospettici, RTC)
Wexner Continence Score (valutazione della
continenza mediante item che riguardano la frequenza di feci
liquide o solide, la presenza di gas, l’uso di PAD, l’alterazione
delle attività quotidiane)
.............per un linguaggio comune
Clinical concomitant benefits on pelvic floor
dysfunctions after sacral neuromodulation in
patients with incomplete spinal cord injury
Lombardi G, Nelli F, Mencarini M, Del Popolo G. Spinal Cord 2011 May; 49(5):629-36. Epub 2011 Feb 1.
Objectives: To assess the concomitant clinical improvement in incomplete spinal cord injury patients (SCIPs) suffering
from neurogenic bowel symptoms (NBSs), neurogenic lower urinary tract symptoms (NLUTSs) and neurogenic erectile
dysfunction (NED) using sacral neuromodulation (SNM) for NBSs and NLUTSs.
Methods: Seventy-five SCIPs were selected. Before and during the follow-ups post-SNM, NLUTSs and NBSs were detected
mainly through specific diaries. Erectile function was assessed using the international Index of Erectile Function composed of
5 question (IIEF5). Quality of life (QoL) was measured with the Short Form 36 Health Survey questionnaire (SF-36). During
the first stage, in which a permanent electrode was inserted percutaneously into the third sacral foramina and stimulated
using an external generator, patients with NBSs or NLUTSs were required to improve their symptoms by at least 50%
compared with baseline before proceeding to the second stage in which the generator was placed in the patient’s buttock.
NED patients needed to increase their IIEF5 score by at least 25% compared with baseline (evaluated initially 3 months after
the second stage) in order to continue follow-up.
Results: Fourteen out of 37 subjects who manifested two functional pelvic dysfunctions at baseline maintained notable
clinical improvement in two pelvic functions (median follow-up>3 years). Six had non-obstructive retention (NOR) and
NED, six double incontinence, and two constipation with NOR. In the general and mental health domains of the SF-36, all
patients improved their scores by at least 20% compared with baseline.
Conclusions: SNM may be beneficial to selected incomplete SCIP with concomitant pelvic functional disturbances.
Clinical outcome of sacral neuromodulation
in incomplete spinal cord-injured patients
suffering from neurogenic bowel dysfunctions
Lombardi G, Del Popolo G, Cecconi F, Surrenti E, Macciarella A. Spinal Cord 2010 Feb; 48(2): 154-9. Epub 2009 Aug 11.
Study Design: Retrospective study.
Objectives: Efficacy and safety of sacral neuromodulation (SNM) in incomplete spinal cord-injured patients (SCIPs)
affected by chronic neurogenic bowel symptoms (NBSs).
Setting: Neurourology Department. Primary to tertiary care.
Methods: Retrospective non-blinded study without controls. Thirty-nine SCIPSs were submitted to temporary stimulation
for NBS. Permanent implantation was carried out if both their NBSs improved and the Wexner questionnaire scores were
reduced by at least 50% during the first stage compared with that at baseline. Outcome measures included episodes of fecal
incontinence and number of evacuations per week, as well as the Wexner score and the Short Form 36 (SF-36) Health
Survey questionnaire.
Results: Twenty-three SCIPs were submitted to definitive SNM, maintaining their clinical benefits after permanent
implantation with a median follow-up of 38 months. The length of time since neurological diagnosis to SNM therapy
represents the only factor related to the success of the implantation, P<0.05. In subjects with constipation (12), the median
number of evacuations shifted from 1.65 to 4.98 per week, whereas the Wexner score changed from 19.91 to 6.82 in the
final checkup with P<0.005. In subjects with fecal incontinence (11), the median number of episodes per week in the final
follow-up was 1.32 compared with 4.55 pre-SNM. The general and mental health of both groups was measured with the
SF-36 questionnaire and consistently showed statistical improvement (P<0.05). Anorectal manometry showed no important
variation compared with baseline. There were no major complications.
Conclusions: SNM therapy should be considered for the treatment of NBS for select patients with incomplete spinal cord
injury when conservative treatments fail.
Scenario futuro
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NMS
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Posterior
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-
Neuro
Modulazione
Sacrale
(‘’If conservative management fails, sacral nerve stimulation
is one treatment option which is a minimally invasive
technique allowing modulation of nerves and muscles in
the pelvic floor’’ - Sacral nerve stimulation for the
management of faecal incontinence, Sharpe A, Read A BrJ
Nurs.2010 Apr 8-21; 19(7):415-9)
tibial
nerve
stimulation
(‘’Outcome measured varied, but short term primary
endpoint success ranged from 30.0% to 83.3%. The
limitations to this early evidence, whilst encouraging, are
significant, and it remians to be seen whether this novel
treatment modality represents the minimally invasive, welltolerated, cost-effective and flexible panacea hoped for this
common and debilitating disease. Three upcoming
multicenter placebo-controlled trials will better be able to
delianeate its role’’ - ‘’Posterior tibial nerve stimulation and
faecal incontinence: a review’’, Findlay JM, Maxwell-Armstrong
C, Int J Colorectal Dis 2011 Mar; 26(3):265-73, Epub 2010
Nov 11
Irrigazione trasanale
velocità controllate
a
pressione
e
Conclusioni:
Conclusioni
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Maggiore attenzione alla riabilitazione intestinale
Intestino neurologico- Disfunzione intestinale neurogena
Approccio multidisciplinare, programmi ‘’multifaceted’’
Empowerment del paziente e caregiver
Linee guida di riferimento
Protocolli di riabilitazione condivisi
Evoluzione della professione infermieristica
Take home message
Bowel
management
CARE
Convegno Nazionale CNOPUS
Ancona 18-19 nov. 2011
GRAZIE
[email protected]
[email protected]