MEDICAL PROBLEMS IN TBI: BOWEL PROGRAM IN TRAUMATIC BRAIN INJURY: BOWEL MOVEMENTS/BOWEL PROGRAM IN TBI

     After brain injury, messages from the rectum to the brain that signal the need to have a bowel movement may be interrupted or blocked. As a result, you may not feel the urge to defecate and/or you may not have control of the sphincter muscle that makes your bowel move. Not being able to control the sphincter can result in an inability to have a bowel movement. Changes in diet and activity routine, level of arousal, and cognitive (thinking) skills, such as attention, self-awareness, and memory, can also interfere with bowel regulation. Lack of bowel regulation can result in problems such as diarrhea, constipation, or impaction. Impaction is severe constipation with an inability to pass stool and can be serious if it occurs high up in the bowel.

     Your nurse will help you work out the best possible bowel program for you.

     The goals of the bowel program are:

  • to have a bowel movement at a predictable time and avoid accidents
  • to make the stool soft
  • to make a sluggish bowel work better.

The parts of the bowel program are:

  • Suppository every night: In the beginning, your program will probably be as simple as a suppository or Theravac every night, which will cause the rectum to empty of stool. As time goes on, a pattern should start to develop and you should have bowel movements fairly regularly.
  • Suppository every 2nd or 3rd day: Your program will then be changed to a suppository every other day, or, for some patients, every third day.
  • Choose foods high in fiber (roughage), such as fresh fruits, vegetables, and whole grain foods.
  • Drink enough liquids to keep the stool soft and/or use a stool softener. Prune juice is a great natural laxative. Fluid requirements are managed through a feeding tube when an individual is unable to take liquids by mouth.
  • Avoid foods which cause constipation, or very hard stools, such as meats and dairy products which are low in fiber or roughage.
  • Avoid foods which cause diarrhea, or very loose stools, such as spicy, greasy foods, onions, etc.
  • Be as active as you can. The lack of activity can cause constipation.
  • If your program involves promoting bowel movements at a predictable time, stick to the program developed for you to avoid constipation, impaction, and bowel accidents
  • If necessary, medication will be prescribed to soften the stool and make the sluggish bowel work better.

     Learn, by experimenting, the foods and lifestyles that let you have bowel movements at a predictable time. Once you are having regular bowel movements, stick to the bowel program you developed. Skipping your program can cause constipation, impaction, and bowel accidents. If something is wrong with your program, it is usually related to diet and/or activity. Remember to think about what you eat, drink, and do if a difficulty occurs.

     When you are discharged from the hospital, you may decide to change your program to fit your lifestyle. If you have learned the things that work, and do not work for you, you will be able to make changes with a minimum amount of discomfort.

     The medications and stimulants used in managing your bowel program are:

PRODUCT/
EXAMPLE
WHAT IT DOES INFORMATION
Suppositories

Glycerine when effective; it is cheaper for long-term use.

Dulcolax

To set off reflexes that start movement of lower colon and rectum.
Glycerine irritates rectum mechanically and causes bowel movement.
Dulcolax takes effect when it comes into contact with the intestinal wall and stimulates nerve endings there.
Some patients are able to stop using suppositories and then digital stimulation (with gloved, lubricated finger) may be all that's needed

Many people need to use Dulcolax at first, but then are able to switch to Glycerine.

Stool Softeners

Colace
Surfal
Dialose

To soften stool (to avoid impaction or constipation)

You may not need them if your diet and fluids are adequate.

If stool softeners are going to work, you must drink plenty of fluids. If stool becomes too soft, you may have unscheduled bowel movement. What to do: stop stool softener or decrease dosage for a short period. Start again when stool is firm enough again.
Peristaltic Stimulators and Stool Softeners

Pericolace
Doxidan
Dialose-plus

To stimulate the normal wave-like movement of the bowel which propels stool through the bowel. If you're having loose or unscheduled bowel movements, medicine will need to be decreased or stopped.
Bulk Formers

Metamucil

To increase amount of material in intestine.

Amount prescribed is taken in a glass of water once or twice daily. Drink plenty of liquids when taking Metamucil.

Theravac Mini Enema To set off reflexes that start movement of bowel, colon, and rectum To administer: pinprick neck of enema bulb only. (Never cut, may tear rectal lining); with gloved, lubricated finger, gently squeeze contents into rectal vault-allow 20 to 30 min. for complete evacuation.
Nupercainal ointment To prevent acute symptoms if hyperreflexia is a problem. It may delay bowel movement; insert into rectum 5-10 minutes prior to inserting suppository, using digital stimulation or manual removal.
Enema

Fleets enema or oil retention enema in 4 ½ oz tube.

Use only if you are very constipated. 1. If you make your own enema, never use more than two cups (500cc); one cup should be enough
2. Do not use routinely; can decrease bowel tone.
Laxatives

Milk of Magnesia

Use only for severe constipation or if your doctor orders. They upset a bowel program as they can cause much of bowel to empty; can cause unscheduled bowel movement.

Based on Brain Injury Patient Care and Education Manual, by Pinecrest Rehabilitation Hospital; Neuro section of the Trauma Manual, Jackson Memorial Hospital; and Recovering from Head Injury; a Guide for Patients, by Nova University Neuropsychology Service, and edited for PoinTIS by the Louis Calder Memorial Library of the University of Miami School of Medicine and the PoinTIS Advisory Committee, and on Rehabilitation of Persons with Traumatic Brain Injury, NIH Consensus Statement 1998 Oct. 26-28.