Bowel Dysfunction in Neurological Disease Best Practice in an Evolving Disorder

Transcription

1 Bowel Dysfunction in Neurological Disease Best Practice in an Evolving Disorder Anton Emmanuel October 2016 National Hospital for Neurology & Neurosurgery

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3 Regulation of colonic function Brain gut axis Two-way interaction between ENS and CNS via sympathetic and parasympathetic nervous system So, a number of factors can influence colonic function: Conscious: Behavioural factors 1 Sympathetic nervous system Parasympathetic nervous system e.g. toilet avoidance Unconscious: Emotional distress 2 Hormonal: Increased expression of progesterone receptors Kamm MA. Gastroenterology 2006;131: ; 2. Chan AOO et al. World J Gastroenterol. 2005;11(34): Cong P et al. Gastroenterology 2007;133: ; Image developed for programme

4 Motility: Healthy vs. constipated motor activity 1 1. Dinning et al. World J. Gastroenterol 2010;16(41): Copyright permission pending

5 Scintigraphic study showing defaecation produces a complete emptying of the left colon in healthy subjects, but not in SCI Before defaecation After defaecation Healthy subject (Score = 81 (53-140) Spinal injury (Score = 27 (0-44) Rasmussen MM et al. Spinal Cord 2013; 51: 683-7

6 Importance of synchronising defaecatory effort with colonic mass movements Narducci et al Gut 1987;28(1):17-25 Dinning et al Gastroenterology 2004;127(1):49-56

7 Pathophysiology Reflex bowel: Loss of sensation of fullness Rectal pressure high Anal sphincter high pressure opens as a reflex when the rectum is full Predisposes to inappropriate emptying Flaccid bowel: Loss of sensation of fullness Rectal pressure low Anal sphincter at low pressure Predisposes to bowel soiling

8 Prevalence of neurogenic bowel symptoms % patients with dysfunction SCI Gen Popn Constipation Faecal Incont Megacolon Rectal prolapse

9 Bowel Dysfunction in MS 60-70% of MS patients 25% regular incontinence Neurological: Cortical involvement (frontal lobe) Hypothalamic autonomic dysfunction Spinal Cord Conus Medullaris Non-Neurological: Polypharmacy Reduced mobility Coeliac Others (cancer, IBD, IBS, preexisting condition)

10 Constipation in Parkinson s Disease Pathophysiology 1. Slow transit due to disturbed parasympathetic tone - Commonest cause - Constipation predates treatment 2. Rectal outlet dysfunction: rare - Dyssynergic anal sph. contraction on attempted voiding - Probably related to loss of rectal sensation 3. Medication related: probably not dominant factor - No dose-relationship with gut transit rate - At best, drugs may potentiate pre-existing constipation

11 Insufficient treatment is reflected in the current disease burden on neurogenic patients 4 out of 10 have symptoms of constipation 1,2 5 out of 10 patients spend more than 30 minutes emptying their bowels 7 out of 10 suffer from faecal incontinence 2 39% report that colorectal dysfunction causes some or major restrictions on social activities / QoL 2 1. Coggrave M, Norton C, Cody JD. Management of fecal incontinence and constipation in adults with central neurological disease (review) The Cochrane Collaboration. 2. Krogh K et al. Colorectal function in patients with spinal cord lesions. Dis Colon Rectum 1997;40:

12 Bowel dysfunction ruins quality of life Spinal Cord Injury Multiple Sclerosis Limitation Impact (0-6) Mobility 4.8 Bowel 4.3 Sexual 3.5 Bladder 3.4 Sensation 2.7 Limitation Impact (0-6) Multiple Sclerosis Bowel 4.4 Bladder 3.9 Sexual 3.5 Mobility 3.1 Sensation 3.1 Glickman & Kamm, Lancet 1998 Preziosi et al, DDW 2011 Hospitalisations twice as frequent in SCI patients with bowel symptoms Sonnenberg et al, Am J Gastro 2004

13 Assessment: diary 2 week diary at initial assessment

14 Assessment: Neurogenic Bowel Dysfunction Score Krogh et al Spinal Cord 2002

15 NBD Score and Quality of Life

16 Care algorithm in neurogenic bowel dysfunction More invasive Minimally invasive Conservative options Stoma Sacral anterior root stimulation Antegrade colonic irrigation Sacral nerve stimulation Transanal irrigation Digital stimulation / suppositories / biofeedback Diet and fluid / lifestyle alteration / laxatives or constipating drugs

17 Management of neurogenic bowel dysfunction 2007 Stoma 9% SARS 1% Antegrade irrigation 2% Sacral nerve stimulation 1% Transanal irrigation 0 Digital stimulation & suppositories 68% Diet &drugs 19%

18 Management of neurogenic bowel dysfunction 2015 Stoma 3% SARS 1% Antegrade irrigation 1% Sacral nerve stimulation 0 44% Transanal irrigation 33% Digital stimulation & suppositories Diet &drugs 18%

19 Bowel management after SCI in community settings Interventions used for bowel care (multiple responses possible) Coggrave M. et al. Spinal Cord 2009; 47:

20 Management of Faecal Soiling The Anal Plug 14 patients with spinal injury All 14 incontinent weekly at least 13/14 stopped liquid leak 11/14 controlled gas incontinence Well tolerated in 11 All had attenuated anal sensation Norton et al GI Nursing (2004)

21 Are current laxative options effective for chronic constipation? 16 40% of those with constipation use laxatives Symptoms persist despite laxative use Patients with ongoing constipation symptoms (%) Use laxative Do not use laxative US UK FR GE IT BR SK Country Approximately 2000 adults each from: United States, US; United Kingdom, UK; France, FR; Germany, GE; Italy, IT; Brazil, BR; South Korea, SK Wald et al. Aliment Pharmacol Ther 2008;28:917

22 Summary: Tailoring laxatives to the patient, based on their symptoms and diagnosis Episodic hard stool Bulk fibre 1 Episodic reduced frequency Slow transit constipation Difficulty evacuating Megarectum or megacolon Stimulant 1 Osmotic 1 Glycerine or stimulant suppository 1 Osmotic 2 If no improvement: Increase dose 1 Rational combination e.g. Stool softener and stimulant laxative 3,4 or bulking agent Emmauel Ther Adv Gastroenterol 2011;4(1): Szarka & Pemberton Curr Treat Options Gastroenterol. 2006;9(4): Larkin et al. Palliat Med. 2008;22(7): Sykes. Cancer Surv. 1994;21:137-46

23 Emerging treatments Gut flora in colon lumen 5-HT 4 receptor Basolateral membrane Tight junction Apical membrane Lumen Epithelial cell layer Chloride channel Mucosa Cl Enteric nervous system Muscularis mucosa Submucosa Circular muscle layer Myenteric nerve plexus Guanylate cyclase receptor Longitudinal muscle layer + Cl Prucalopride Alvimopan Lubiprostone Methylnaltrexone Linaclotide μ-opioid receptor

24 PRESSURE CONSTANT PRESSURE VARIABLE

25 Which patient? Neurogenic bowel dysfunction (NBD) Spinal cord injury 1 supraconal cauda equina Functional disorders Faecal incontinence 2 4 idiopathic post-traumatic Post-surgical situations Low anterior rectal resection syndrome 5 7 Spina bifida 8 Constipation 3,4 slow transit rectal evacuation difficulties Ileo-anal pouch dysfunction 9 Multiple sclerosis 10 congenital Anorectal Malformations (ARM) 1 Christensen P, et al. Gastroenterology 2006;131:738 47; 2 Briel JW, et al. Dis Colon Rectum 1997;40:802 5; 3 Christensen P, et al. Dis Colon Rectum 2009;52:286 92; 4 Gosselink MP, et al. Colorectal Dis 2005;7:65 9; 5 Iwama T, et al. Jpn J Surg 1989;19:251 3; 6 Koch SM, et al. Int J Colorectal Dis 2009;24: ; 7 Rosen H, et al. Colorectal Dis 2011;13:335 8; 8 Shandling B, Gilmour RF. J Pediatr Surg 1987;22:271 3; 9 Gosselink MP, et al. Colorectal Dis 2005;7:65 9; 10 Preziosi G, et al. Gut 2011;60:A29

26 Reasons for starting TAI n % Insufficient relief with current regime % Adverse effects with current regime 77 34% Faecal incontinence 70 31% Excess time taken 64 28% Rectal bleeding/pain 30 13% Dependence on carers 68 30% Unpredictability / complexity 36 16% Heard/read about TAI 16 7% Passanati, et al. PLOS, 2016

27 Transanal irrigation Before irrigation After irrigation Anterior view of the 111In-labeled bowel content before washout (A) and after (B): the colon is empty up to the left colic flexure Christensen P et al. Dis Colon Rectum 2003: 46:68-76

28 Christensen et al Gastroenterol 2006 Randomised controlled trial: transanal irrigation vs standard therapy TAI Standard 14 p= p= p= Cleveland Clinic Constipation Scoring System St. Mark's Fecal Incontinence Grading System Neurogenic Bowel Dysfunction Score

29 Randomised controlled trial: transanal irrigation vs standard therapy Time (minutes) p=0.04 TAI Standard 60 p= p= Time in toilet Defaecation time uti % of contacts

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33 Tailoring treatment Set realistic expectations: may take 4 12 weeks to achieve a reliable and effective routine process of trial-and-error to optimise individualised parameters 25% of patients have a poor initial response to TAI Continue laxatives until TAI established, may need chronic use if very slow transit features Adjunctive interventions may be needed relaxation techniques / abdominal massage / digital rectal stimulation Many factors to manipulate to tailor treatment

34 TAI at UCH London Training Hospital nurse specialist (n=169) Community nurse (n=58) Follow up phone call at 4 weeks Hospital nurse specialist (n=227) 2-weekly adjustments of treatment as needed (median 3) Hospital nurse specialist (n=155) or clinic follow up annually (n=223) Median 4.5 years Passanati, et al. PLOS, 2016

35 NBD Scores 80 Particular improvement in those with severe NBD at TAI initiation Baseline All patients (ITT) Responders 0 to 6 7 to 9 10 to 13 >14 The % of patients with severe NBD score (NBD 14) decreased by 55% after one year of introducing TAI Passanati, et al. PLOS, 2016

36 Carer dependence % users 50 * p<0.01 vs baseline * * * * * * * Baseline months after start

37 Medical interventions related to NBD At year 1 (with TAI) versus baseline (pre-tai) * Comparing before and after 2007, when TAI was introduced -88% Hospital admissions -66% G.P/Specialist visits -57% Treated UTIs -61% Need for stoma surgeries* Passanati, et al. PLOS, 2016

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39 ACCESS THE PAPER Free open online access to paper Spinal Cord 2013: 51:

40 Tailoring the treatment Time with adjunctive measures (eg abdominal massage) Laxatives and/or adjunctive interventions Frequency of irrigation (daily, reduced to alternate days after ~10 14 days) Other irrigants (saline 1, phosphate 2 and other laxatives 2,3 not formally investigated) Parameters that can be individualised Timing (undertake minutes after a meal) Volume of rectal balloon ( ml [one to five pumps]; use only as much as necessary) Volume of irrigant (500 ml gradually increased to maximum of 1000 ml) Time of day (to fit with lifestyle of patient) 1 Shandling B, Gilmour RF. J Pediatr Surg 1987;22: ; 2 Bani-Hani AH, et al. J Urol 2008; 180(4 Suppl): ; 3 O'Bichere A, et al. Br J Surg 2000;87:902 8

41 12 Perforations per million irrigations (by weeks) Early cases: avoidable Overall risk 2 per million Late cases: NOT cumulative 2 0 Christensen & Emmanuel, Tech Coloproctol 2016

42 Adherence with transanal irrigation 1 Christensen et al. Dis Colon Rectum 2009;52:286 92;

43 Malone Antegrade Colonic Enema Water: ml Mean 45 min. (30-60) Every- every 3rd day Insert catheter every day

44 Antegrade colon irrigation Before irrigation After irrigation Christensen P, Br J Surg 2002; 89(10):

45 Left Colectomy Colostomy Right Colectomy Norton et al (2005) 30/32 would have it again 29/32 would recommend to friend Ileostomy BUT 1 in 3 patients complications Safadi et al Am J Surg 2003:!86;

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48 Work done by Physiology Unit team