10
Digestive Tract Health
I Still Remember Clearly how thrilled I was to be able to eat solid food after my injury. For six weeks, I had been receiving nourishment and calories from a feeding tube, and I dearly missed the pleasure of tasting, savoring, chewing, and swallowing food. My injury had made it impossible for me to swallow; I was told I would have to relearn how to do that—it wouldn’t be automatic. The process would take time, but I was determined to enjoy meals with family and friends again. My first solid food? Chocolate pudding. I can still taste it!
Food is one of life’s simple pleasures, a significant element of our quality of life, and the best way to nourish our bodies with the nutrients we need. Sure, there are supplements we can take, but none are as beneficial as real food itself. But after your injury swallowing can be difficult or even impossible, not only changing your entire relationship with food, but also affecting your digestive health.
Although many assume the digestive tract begins in the stomach, or even the small intestine, it actually begins in your mouth. After your injury, every part of the digestive tract—from your mouth to your rectum—may be dysfunctional. Chewing and swallowing, for example, might be difficult. While trouble swallowing limits what you can eat, it also poses a safety issue; not only can you choke on food, but it can also go into your lungs (aspiration), which can cause pneumonia (see Figure 14).
The anatomy of the gastrointestinal (GI) tract (Figure 21) is a series of connected tubes including the stomach, small intestine, colon, and rectum. The GI tract plays a key role in your absorption of nutrients and proper function of your immune system. The most common problem is constipation, which can be caused by a multitude of reasons: not moving or standing enough (and thus not allowing gravity to help move stool); weak core muscles; opiates and other drugs that slow stool movement; and dysfunction of the autonomic nervous system, which controls the muscle movement of the intestine and colon. Some people experience fecal incontinence, which is usually caused by loss of control of your anus, specifically the external sphincter muscle, which is controlled by the autonomic nervous system. Fecal incontinence and constipation are not inconveniences; they are potential health threats. You’ll need to develop a “bowel program” so that you have regular bowel movements and avoid constipation or fecal incontinence.
Figure 21. GI tract
Swallowing and Dysphagia
The psychological benefits of being able to eat and drink normally cannot be overstated. Even when you’re in the hospital, the pleasure of eating is important. Eating is also a social opportunity that allows you to enjoy time with your friends and family. So, your health care team will be working to help you take food by mouth as soon as possible. Dysphagia, or difficulty in swallowing, is a common problem, and it can be described in three phases. In the first phase, food is placed in the mouth and kept there by the tongue and palate (oral cavity). This phase is voluntary and under our control. The second phase begins when food is transferred from the mouth into the throat (pharynx). The third phase occurs when the esophagus, a muscular tube that produces waves of coordinated contractions, pushes the food down. As the esophagus contracts, a muscular valve at the end opens and allows the food to enter the stomach.
Oropharyngeal dysphagia is characterized by difficulty initiating a swallow, which is the most common problem. Swallowing may be accompanied by coughing, choking, aspiration, and a sensation of food remaining in the throat. Many people, myself included, have these problems, especially with liquids, chewy foods like white bread and apple skin, and large pills. Chewable pills were developed to help people with dysphagia.
Esophageal dysphagia, characterized by difficulty swallowing, causes the feeling that food is stuck in your throat several seconds after you start to swallow. This is a painful problem that most people deal with by trying to cough up and spit out the pill or food.
Aspiration: Dysphagia isn’t only unpleasant; it can actually be harmful when it leads to aspiration, which is when something enters your airway or lungs by accident. During the process of swallowing, the epiglottis (a valve over the windpipe, or trachea) must come down and direct the food into the esophagus and stomach. If this doesn’t occur, due to dysphagia, the food will go into your lungs instead. It’s also possible that the contents of your stomach can be regurgitated into your esophagus and then down into your lungs. These scenarios can lead to a serious medical complication: aspiration pneumonia. This is particularly harmful, since the lungs become stiffer (harder to inflate) after pneumonia. If you have underlying respiratory problems—either control of breathing by the brain or diaphragm dysfunction due to nerve injury—this makes the lifetime risk of pneumonia much greater (more on this on page 167).
Prevalence: If you’re experiencing dysphagia, you face potentially life-threatening complications. There are two significant predictors of risk for dysphagia: age and tracheostomy with mechanical ventilation. Additional risk factors include spinal surgery via an anterior cervical approach for SCI (likely in tetraplegics with injuries to the neck), and low scores on cognitive ability and level of consciousness (Glasgow coma scale) for TBI and stroke. Many stroke and TBI patients also have difficulties with swallowing because the action is complex; damage in many parts of the brain (brain stem, thalamus, basal ganglia, limbic system, cerebellum, and motor and sensory cortices) can cause problems in different phases of swallowing. In particular, patients who have a tracheostomy and low cognitive function are at the highest risk.
If you have depressed coughing reflexes, the aspiration of food and stomach acid may occur silently, which is why you should have a swallowing study performed in the hospital prior to starting to eat food again. The best test is a video fluoroscopic swallowing study, a relatively simple test in which a thick mixture containing barium is swallowed and the motion of the barium down the throat and esophagus is followed by using a video X-ray. The time to initiate a swallow, transfer into the stomach, and the size of the bolus (the amount of mixture) are key measures of difficulty swallowing.
Management and treatment: Because of the severity of my injury, my team waited about two weeks to begin my swallowing exercises. The good news is that these exercises, usually taught by a speech pathologist, can both strengthen normal swallowing and teach you compensatory ways to swallow. The exact exercises and maneuvers that work are specific to each individual, and they progress from strengthening the muscles all the way to learning new ways of swallowing that prevent aspiration. Traditional dysphagia rehab therapies include chin tuck, effortful swallow, head tilt, head turn, supraglottic swallow, and the Mendelsohn and Masako (tongue hold) maneuvers. In my situation, the Masako maneuver—in which I held my tongue between my teeth while swallowing—was hugely helpful. I also learned effortful swallow, in which I had to squeeze my throat muscles as hard as I could while swallowing, because food would get stuck in the back of my throat. All these years later, I’m still careful to chew my food well, swallow carefully, and not talk while eating. Certain foods are particularly high-risk for me, including soft bread and spaghetti, both of which can get stuck in my throat.
The Neurogenic Bowel
Restoring bowel function has an enormous impact on your quality of life. Normal bowel function requires the brain and peripheral nervous system (together called the autonomic nervous system; Figure 6) to work properly, so those who have experienced an ANI are at risk for impaired bowel function. Most people suffer from constipation, though some will experience fecal incontinence. The two represent the ends of the normal spectrum, but fecal incontinence can be particularly challenging in terms of a normal social life. It’s important to note that constipation is common in the general population and increases with age, as you get older, constipation may become more of a problem. But it can almost always be treated with nonpharmacologic interventions (see page 148). In contrast, fecal incontinence is more complex and requires greater adherence to strict therapeutic interventions (see page 152).
Assessing the neurogenic bowel: Assessment of your bowel function should be done by your primary care physician annually or when a significant change in your function occurs. While you may consider examinations of your anus and questions regarding your bowel movements embarrassing, it’s critical that you have a thorough examination every year. As we grow older, gastrointestinal problems increase steadily; such that by age sixty-five, half of the general population has a history of gastrointestinal problems and nearly a third are actively being treated for a problem.
At least three examinations of bowel function should be performed yearly: a rectal exam including anal sphincter tone; a stool test for blood beginning at age fifty; and a colonoscopy every five years beginning at age fifty (or earlier, if you have a family history of colon cancer or severe constipation). The need for colonoscopy should be weighed with the difficulties associated with this test, because the bowel preparation and anesthesia may be too exhausting and risky; your doctor will discuss the pros and cons with you.
Developing and evaluating an effective bowel program: For effective management of your bowel function, you’ll need a bowel program. A successful bowel program should provide predictable and reliable results, take less than thirty minutes per day, have minimal side effects, and require the fewest number of medications and surgeries. To design an effective bowel program, consider your functional abilities, including your ability to sit (your balance and endurance), your arm and hand strength and dexterity, your ability to transfer if you’re in a wheelchair, and the condition of your skin. You should also consider your diet, frequency of bowel movements, consistency of stool, ability to exercise and stand, and any medications you may be taking. Because bowel function is so heavily influenced by these factors, changes in bowel function can occur frequently, and when that happens, you’ll need to revisit your plan.
Constipation: Many factors cause constipation, with age at the top of the list. If you have any two of the following—straining, hard stools, sensation of incomplete evacuation, sensation of a blockage in the rectum, and fewer than three bowel movements per week—you are experiencing constipation. Without even thinking about it, healthy people use several maneuvers to help achieve normal bowel movements: They sit up and lean forward on the toilet seat, squeeze their stomach muscles, and take a deep breath before squeezing (a Valsalva maneuver). But after your injury, you may not have the strength or coordination to do these things. If this is the case, part of your PT program should be to regain these functions or develop compensatory approaches. For example, digital stimulation of the anus and rectum (inserting a finger into the anus and gently pushing against the rectum several times), abdominal pressure, and caffeinated coffee or tea can help initiate a bowel movement. Suppositories and enemas may be useful to start a bowel movement and soften the stool (see page 151).
Diet and nutrition: What you eat plays a major role in the composition of stool as well as its movement through your intestines. But the same diet can result in differences in bowel movement among any two individuals, so any diet will likely need to be modified for you. Work with a registered dietitian to develop a diet that helps your bowel program. Let’s start with fiber. Most dietary fiber isn’t digested or absorbed; it’s combined with other products of digested food and bacteria to form stool and regulate its consistency. For nondisabled people, fiber intake of 20 to 25 grams per day is recommended. There are two types of fiber: soluble, which is found in fruits, oats, barley, peas, and beans; and insoluble, which is found in many whole grains, such as wheat, rye, rice, and oats, as well as flaxseeds. Soluble fiber dissolves in water to make a gel that may reduce blood cholesterol and sugar, thereby maintaining lower blood glucose and preventing diabetes. Insoluble fiber attracts water into your colon, making your stool softer and preventing constipation.
In general, fruits and vegetables are very useful in preventing constipation. To determine the correct amount of fiber in your diet, keep a weekly food diary. Generally, recommendations include starting with at least 15 grams of fiber per day, then increasing it by 5 grams every two weeks (and consuming at least 25 grams daily as a goal); keep a journal to monitor stool consistency and side effects on a daily basis. Be aware that increased fiber intake can lead to side effects, like bloating and flatulence. Cramping pain can occur with certain types of fiber, such as flax. But these should disappear as your body adapts and your bowel health improves.
Two other important considerations in your diet are your consumption of animal products and your fluid intake. In general, meat (beef, pork, lamb, chicken) is more constipating than seafood. Meat also alters the composition of the bacteria in your intestine, which affects the formation and consistency of stool. (Refer back to chapters 6 and 8 for more on healthy diets, like the Mediterranean, DASH, and Chinese diets.) To keep your stools soft, which makes moving your bowels easier, it’s essential that you consume enough fluids (eight 8-ounce servings of water) each day. This may be a problem if you’re restricting fluids to decrease urine output when performing self-catheterization. The amount of fluid you need depends on your health, how active you are, and your local climate. This is a subject to discuss with your health care team.
Developing a bowel program for constipation: While your injury may have altered your normal daily routine, it is important to establish a regular schedule for your bowel program, and it should allow for a minimum of three bowel movements each week. (My program allows for bowel movements on Tuesday, Thursday, and Saturday, so that during the work week I have only two “long” mornings in the bathroom.)
It’s essential that you do your bowel movement program at the same time, whether it’s every day or every other day. The optimal time for your bowel movements is within the first two hours after you wake up (and after you’ve eaten breakfast) because the colon is most active first thing in the morning and after a meal. During the work week, I’m usually in a rush to get to my office, so on Tuesdays and Thursdays I speed things up by using a Magic Bullet suppository and drinking a cup of coffee as soon as I wake up.
Exercise and standing: You can greatly improve your intestinal motility with exercise and standing, which can be incorporated into your bowel program. There are many kinds of exercise that stimulate the bowels; the best ones are those that increase your heart rate and cause you to use your breathing muscles, and even better, your abdominal muscles. These exercises activate receptors that cause the muscles that line your intestine to contract, and they strengthen the muscles necessary to help squeeze your abdomen and your lower diaphragm, which creates pressure that helps propel the stools down and out.
Standing is perhaps the simplest way to improve bowel function. Without any other effort on your part, gravity helps your stool move through your intestines. Even if you’re unable to move your legs, you may be able to use a standing frame, with assistance (ask your physical therapist). I use a standing frame to stand for one hour each day (Figure 22). The top serves as a desk so that I can work while standing. It only takes two minutes to get on and off, using a transfer board.
Figure 22. Standing frame
In addition to improving bowel function, standing prevents bone loss (osteoporosis), because it’s a weight-bearing exercise; it improves heart and lung function; and it just feels good. But be aware that your blood pressure must be carefully monitored while you’re standing to avoid fainting. Time of day is important too—standing after a big meal is not a good idea. Avoid standing during hot weather, after taking medications that lower your blood pressure, or when you’re dehydrated.
Medications: In most cases, medications should be a last resort for improving bowel function. That said, there are several that can be useful for a practical and effective bowel program. They are listed here in the order that they should be tried, based on their efficacy and safety.
A typical American diet (low in fiber, high in meat) produces harder stools, which makes them more difficult to move and increases your risk of hemorrhoids. The two most common drugs to help soften stool are docusate sodium (Colace) and docusate calcium (Surfak); they work by decreasing reabsorption of water in the colon, thereby softening the stool. Increasing the absorption of water increases the stool volume, causing the walls of the intestine to expand and stimulating movement of the stool. The most common over-the-counter products to help in this regard are psyllium (Metamucil; Perdiem) and methylcellulose (Citrucel). Be sure to drink extra fluids when using these supplements.
You can also use laxatives to stimulate bowel motility. Personally, I prefer laxatives that contain polyethylene glycol (MiraLax, Glycolax), which do not cause gas or bloating. Faster-acting are the saline laxatives, which include magnesium hydroxide (Milk of Magnesia) and magnesium citrate. Magnesium citrate can cause a bowel movement in as quickly as one hour after drinking it. Stimulant laxatives promote stool movement by irritating the bowel; these include senna—Ex-Lax, Fletcher’s Laxative (formerly Castoria), Senokot—and bisacodyl (Correctol, Dulcolax). It’s important to use these the day before your bowel program only, because excessive use can decrease bowel motility and dilate the bowel.
Some people use suppositories or enemas for bowel movements. (Personally, I find enemas messy and not as effective as pills or suppositories.) The best known enema is saline solution (Fleet). The most common suppository is bisacodyl, which comes with either a vegetable oil base (Dulcolax) or a polyethylene glycol base (Magic Bullet). I like the Magic Bullet due to its rapid onset of action, which is usually less than thirty minutes. I don’t recommend using mineral oil to soften stools, as it’s less reliable and can be potentially harmful.
Fecal Incontinence
Diagnosis: Fecal incontinence is the loss of voluntary control over bowel movements. The most common cause of fecal incontinence is a loss of control of your anal sphincter. This is most prevalent in people with complete SCI. However, it may also be due to diseases of the intestines, such as gluten and lactose intolerance. Finally, it may be due to other foods in your diet that stimulate contractions of your intestine, such as coffee and tea. To determine the cause, your doctor will examine your colon. This is usually performed using colonoscopy, which not only shows your doctor the entire colon, but also allows for biopsy, if needed, to determine if there’s an underlying illness. Other imaging techniques include ultrasound, CT scan, and magnetic resonance imaging (MRI). Anorectal manometry measures the pressure in different parts of the colon to identify the anatomic site of the problem. It’s especially useful to assess the tone of the anal sphincters, which can also be used to determine if rectal sensation and rectal reflexes are impaired.
Make it easy to find the toilet: One of the easiest solutions for fecal incontinence is to use a bedside commode, especially if you have limited mobility. Many people will experience a delayed sense of when they need to go; by the time they feel the urge to defecate, stool may already be in the rectum. If you’re in bed, the time it takes to get out of bed, find a walker or your wheelchair, and get to the bathroom may be so long that you aren’t able to maintain enough anal sphincter control to prevent an accident.
Diet: The foods you eat play a critical role in fecal incontinence, but just like constipation, your diet must be individualized working with a registered dietitian. Start by determining whether you’re lactose or gluten intolerant, as these intolerances can cause abdominal cramping and diarrhea in many people. Spicy foods, fatty foods, caffeine, and alcohol can also increase stool frequency. Large meals stimulate the bowel, so eating several smaller meals throughout the day can be helpful.
Medical therapy: The three medical approaches to fecal incontinence are to increase stool volume, decrease frequency, and slow down bowel motility. The most common substances to increase stool volume are psyllium (Metamucil, Perdiem) and methylcellulose (Citrucel). Drugs for diarrhea, such as loperamide (Imodium) and diphenoxylate-atropine (Lomotil), can also decrease stool frequency, although they can also cause drowsiness. You can take an anticholinergic drug like hyoscyamine, which slows motility, prior to eating a meal.
Biofeedback: Biofeedback is a safe and noninvasive way that can help you identify and contract the anal sphincter muscles, which helps maintain continence. During biofeedback training, a pressure sensor is placed in the anus, where it can detect changes in pressure as you try to squeeze your anal sphincter muscles. You measure your progress using a pressure recording chart as you squeeze for thirty to sixty seconds to strengthen the muscles.
Surgery: The most invasive and helpful surgery is the colostomy, which requires general anesthesia. During the procedure, a part of the distal colon is attached to the abdominal wall, where stool collects in an external bag that is tightly attached to the skin. A good friend of mine had this done because he had a pressure ulcer that wouldn’t heal due to fecal incontinence. Most people would have had the colostomy reversed once the pressure ulcer healed, but he found that it was so beneficial for his mental health that he kept it! The drawbacks, however, include the need to change the bag three to four times daily, a frequent odor, and, perhaps, unpleasant body image as a result. Each person’s bowel program will differ; for him and many others, the convenience of the bag and lack of fecal incontinence outweigh the problems.
Bowel Management Outside the Home
The simplest approach to bowel management when you’re away from home is to have established an effective bowel program. I know approximately how much stool I should eliminate each time I perform my bowel program. If I don’t have adequate elimination, I remain on the toilet for up to fifteen minutes longer than my usual thirty minutes. If I still haven’t gone, I wear disposable absorbent briefs (Depend, for example), just in case I have some leakage.
When I travel, I have a bowel movement on the morning I depart, so that I don’t have to have another one until two or even three mornings later. If I’ll be away for longer than that, I have a lightweight travel chair that fits in a rolling suitcase and fits over most toilets (it also serves as a shower chair). It’s common to become dehydrated while traveling, especially on long plane flights, so I try to drink extra fluids (at least 16 ounces more than usual). You can also increase the amount of bowel stimulants (senna) and stool bulk formers (Miralax) if you’re unable to maintain a good bowel program while traveling.
It’s a Journey
After six weeks in the hospital, when I finally began to eat, I had a bowel movement every night after dinner and had to sleep wearing a diaper. Remarkably, within a few weeks of eating solid foods, I began to have regular bowel movements (every morning after breakfast), thanks to a regimen of stool softeners and bowel stimulants and a high-fiber diet. At first, I used a bedpan, then a bedside commode when I regained the ability to sit up. I eventually transitioned to using a shower chair as a seat over a regular toilet. Although I learned to surrender my modesty and my initial despair over what I felt was a loss of personal dignity, I continue to work on a plan for an independent bowel program. I’m almost there but can’t yet achieve complete elimination by myself. I think I still need stronger abdominal muscles.
For many years now, a routine bowel program that I manage myself has been part of my routine; sleeping in a diaper seems like something from a lifetime ago. Remember: Recovery is all about accepting the formerly unacceptable as you navigate this journey.
Everything You Need to Know
Good digestive-tract health is essential to your overall health. What you eat affects every aspect of your recovery.
• After your injury, your swallowing may be impaired (dysphagia). There is effective treatment, but first the underlying physiologic deficits must be identified during a formal swallowing evaluation.
• Traditional therapies focus on prevention of secondary complications such as aspiration and pneumonia, with the long-term aim of improved swallowing and control.
• Constipation is a common condition and poses real health threats if not addressed. An episodic approach won’t help you in the long term; develop and follow a bowel program that works for your lifestyle. Your health care team can help you create a plan that allows you to have regular, predictable bowel movements. This achievement will not only support better overall health but also improve your quality of life.
• Fecal incontinence can occur after your injury. There are a number of approaches to address it. Discuss your options with your health care team to find out which options appeal to you.