Troubleshooting guides

Issues

Enteral feeding can result in:

• loose stools (Bristol stool scale type 5-7)
• frequent unplanned bowel motions (which can compromise skin integrity)

Management

• Start with a formula that contains fibre to help maintain a healthy microbiome and improve the transit of waste.
• If needed, trial a fibre-free formula—some individuals may achieve a better bowel routine with a fibre-free formula.
• Switch to 3-6 bolus feeds per day to mimic a normal eating pattern (and stimulate the gastro colic reflex in people with UMN injuries).
• Release trapped gas by regularly ‘degassing’ the tube to improve comfort and the transit of waste through the digestive tract.

Medication

• Stimulant medication such as Senokot and Bisacodyl can take 10-16 hours to take effect. These can be crushed and used as noted in the ‘The right trigger’ information’.
• Softening agents such as Coloxyl or Docusate may not be required and should be ceased if bowel motions continue to be loose.
• If softening agents are needed, use small volume liquid agents such as lactulose, sorbitol or liquid paraffin (instead of macrogol) to reduce bloating.
• In case of constipation, consider small volume liquid medication such as sodium picosulfate drops.
• Rectal medications and triggers should be attended to as per ‘The right trigger’ information with a preference for the person to sit over the toilet to manage the bowel routine.

Issues

Changes post SCI can:

• Lead to changes in the body that impact the gut microbiome (which can cause bloating/wind).
• Cause a ‘slowing down’ in the digestive tract which can lead to bacterial growth in regions where there shouldn’t be a large bacterial load. This can lead to small intestinal bowel overgrowth and consequent malabsorption, pain, bloating, weight loss and/or diarrhoea.

Potential issues include:

• reflux
• gastroparesis
• irritable bowel syndrome
• gastroenteritis and
• constipation.

Increased gas intake or production can be caused by:

• External sources such as eating too quickly, drinking through a straw without a good lip seal and types of non-invasive ventilation such as continuous positive airway pressure (CPAP) machines
• Introduction through enteral feed tubes when inserting fluids or medications
• Pre-existing bowel issues such as reflux, gastroparesis or irritable bowel syndrome
• Certain softening medications can create increased gas production

Management

• Eat slowly, ensure a good lip seal while using a straw, and if fed through a feeding tube – degas the tube regularly.
• Avoid or limit the following foods to reduce external sources of gas:
  • Fizzy or carbonated drinks
  • Sweets, lollies & chewing gum labelled as ‘sugar free’
  • Vegetables such as cabbage, brussel sprouts, cauliflower, broccoli stalks, mushrooms, onion and garlic
  • Legumes such as baked beans and lentils
  • Eating a high fibre diet without drinking enough fluid
• Stimulate gastric motility by eating small frequent meals, reviewing fibre intake, reviewing medication (stimulants and medications that can contribute to constipation) and keeping active.
• Improve gut health and microbiota.
  • Eat a well-balanced diet high in variety and include plenty of fibre-rich foods
  • Maintain general health – reduce inflammation by keeping chronic diseases such as diabetes in check, looking after the skin and preventing infections (chest, urinary tract)
  • Manage life stress by getting enough sleep, spending time outside and staying connected to friends and family
  • Consider other lifestyle changes such as moderating alcohol intake or quitting smoking
• Consider herbal remedies such as Iberogast, peppermint and chamomile teas.
• Consider referring to a Dietitian who can help to explore strategies to improve bloating.
• Consider a referral to a doctor/GP if the above measures aren’t helpful in resolving the bloating.

Medication

• To decrease gas production in the system, consider changing softening medications (eg. Coloxyl, lactulose or sorbitol) to alternatives that produce less gas in the intestinal tract. Everyone is different and respond differently to medications.

Issues

Constipation is defined as the passing of hard, dry bowel movements (faeces/stools).

The stool may be hard to pass or there is reduced frequency compared to usual routine.

It can cause:

• Flatulence, bloating and discomfort
• Tiredness
• Poor appetite and nausea
• Overflow diarrhoea where only liquid bypasses the hard stool
• Increased spasms
• Autonomic Dysreflexia
• Increased pain including neuropathic pain
• Bowel obstruction or blockage which can lead to bowel perforation in extreme circumstances.
• Abdominal distension impacting respiratory function. Bowel pressure can apply pressure on the diaphragm increasing inspiratory effort. This is especially problematic with people who have higher level spinal cord injuries.
• Abdominal distension impacting bladder function. Urinary bypassing is caused by increased pressure on the bladder from a full bowel.
• Long term issues with damage to the colorectal structures including haemorrhoids, anal fissure, rectal prolapse and/or development of megacolon.

Reference: “Constipation: managing different causes” Dietitian/ Nutritionists from the Nutrition Education Materials Online, "NEMO" team Constipation: managing different causes (health.qld.gov.au)

Management

For Firm Stool

• Intervene early: make changes to diet and/or medications after the first 1-2 days of a small firm stool or no bowel movement at all.
• Increase fluids, primarily water, up to 2-3 litres (unless on fluid restrictions).
• Increase activity as able.
• Stimulate gastric-colic reflex prior to the provision of enemas/suppositories/digital stimulation using a small meal or a hot drink.
• Have an abdominal x-ray to review the extent of the constipation if indicated by the treating medical officer.

For Urinary bypassing

• Rule out a bladder infection if there are problems with bypassing or leaking in between catheters.
• If the person does intermittent catheters, increase the frequency of catheters until constipation has resolved.

Please seek advice from a health professional if the person is:

• experiencing Autonomic Dysreflexia
• eating less than usual
• vomiting or struggling with breathing
• not passing adequate stool for the last three days or
• concerned about how to manage constipation at home.

Medication

• Increase stimulant medications such as Senokot to the maximum dose until there is a large bowel motion. It is best to space the Senokot as two separate doses to get more coordinated contractions through the gut. For example, the maximum dose is 30mg of Senokot and these could be taken as two tablets at 6pm and two tablets at 8pm.
• Increase softeners – The dose of medication to ‘clear out’ the bowel will depend on the extent of the constipation. Taking 2 sachets of magrogol twice a day for 3 days is a relatively ‘mild’ treatment for constipation. There may be a delay of 2-3 days for this to take full effect. Please contact QSCIS for advice regarding dosing, if required.
• Continue usual medications after the bowels start moving, even when there are soft stools. Stopping and starting medications can lead to cycling of ‘clearing out’ then ‘filling up’.
• Reduce firming agents (dietary and/or medication) until the bowels have cleared and slowly introduce as needed. Early intervention usually requires less medication and leads to quicker resolution.

Issues

Some people experience ongoing problems with soft stools.

Soft stools can be problematic as they can be:

• Difficult to empty, even when performing rectal stimulation
• Responsible for unplanned bowel movements, especially with lower motor neurone or Cauda Equina Syndrome injuries during physical activity or when straining occurs
• Less likely to move through the gastrointestinal tract effectively
• Hard to problem solve as any contributing factors may have been consumed or taken in the diet or medications at least 2-3 days previously

Management

• Inspect the stool to rule out overflow diarrhoea caused by constipation in cases where:
  • bowel motions are smaller than usual for the days leading up to onset of loose motions
  • abdomen is distended or
  • the person reports other symptoms of constipation such as poor appetite and abdominal discomfort.

  The presence of undigested food in the stool makes overflow diarrhoea unlikely indicating rapid transit time of the faeces.

• Review possible causes of soft stools, such as:
  • Food:
    • large serves of fruit (especially stone fruit, pears, apples, watermelon), fruit juice or dried fruit
    • Low fibre intake
    • Alcohol
    • Spicy foods
    • Fatty or fried foods
    • Large serves of gums, mints, lollies or drinks labelled 'sugar free'
  • Gastroenteritis - viral or contaminated food/water
  • Lifestyle factors such as stress, anxiety and smoking
  • Other potential health conditions (including pre-existing) including irritable bowel syndrome, Crohn's disease or ulcerative colitis
• Rule out any food intolerances such lactose intolerance or coeliac disease
• Exclude infection with Clostridium difficile, which is associated with recent antibiotic use
• Increase fluid intake to counteract fluid losses - consider over the counter electrolyte supplementation if diarrhoea is frequent and/or persists
• Rest and avoid strenuous activity if there is a suspected illness
• Review food safe practices and hand hygiene in the household
• Consult the GP if a person is unwell or the problem persists including
  • Stool samples to check for blood and viral, bacterial or parasitic infections
  • Blood tests to check for a range of potential issues such as electrolyte imbalance, hyperthyroidism and/or screening for other health issues including coeliac disease
• Recommence usual aperients after the bowel motions start returning to 'normal', to avoid a cycle of 'clearing out' then 'filling up'
• If stools continue to be loose despite working through all the above points – a fibre supplement such as Metamucil or Benefibre can be commenced to help 'mop up' the excess water and firm up bowel motions

Medication

Review medications with a Pharmacist that can cause soft stools such as:

• Softening aperients - see Right Consistency for more information
• Antibiotics such as amoxicillin including amoxicillin/clavulanic acid, cephalexin and clindamycin
• Antidepressant medications such as sertraline, fluoxetine and escitalopram
• Metformin
• Non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen or meloxicam
• Magnesium supplements which work by drawing water into the bowel

Issues

Having a bowel motion prior to a planned evacuation or urgency in needing to get to the toilet can be the result of a combination of issues including incorrect:

• Timing of medication and/or routine.
• Stool consistency - A softer stool is likely to empty prior to the routine as it can be difficult to contain. This is especially an issue for people with LMN/CES injuries. Softer stools also naturally transition more quickly through the digestive tract which can result in an unplanned bowel motion.
• Use of triggers - Some people try to empty the bowels by relying on feedback alone (when the bowel feels full) and this can result in episodes of constipation and unplanned bowel movements. Inconsistent use of bowel triggers can create problems with training the bowel to empty at a set time, including:
  • Changing the time and frequency of rectal stimulation - for example doing twice daily routines (if not indicated) or changing from daily to second daily routines at any time.
  • Sometimes not using a trigger at all can create problems with bowel urgency and an unplanned bowel movement occurring prior to making it to the toilet.

Management

For Consistency

• See more information on the trouble shooting guide for soft stools.

For Triggers

• Allowing time over the toilet. Do not rush having a bowel motion. If there is not enough time for a morning routine, consider switching to an evening routine (pending availability of care supports).
• Keeping a consistent routine, regardless of whether there is an urge to go or not.
• Using a suitable trigger such as an enema or digital removal of faeces as this avoids unplanned bowel motions.
• Appropriate use of aperients to help establish a routine, see information on the right trigger.

Medication

For Timing Issues

• Understanding how long a stimulant medication takes to work can help with planning the emptying of the bowel.
• The average time span is about 10-16 hours but can differ between people. If the stool is emptying too early, it may assist to adjust the timing of the evening medication to a later time to accommodate this.
• If there are unplanned bowel movement prior to getting over the toilet, try taking the stimulant medication a bit later, 1-2 hours later than the usual time.

Issues

Delayed bowel movements (passing a motion that takes longer than the recommended period or occurs after the bowel routine) can negatively impact the quality of life.

It can

• Create anxiety regarding potential for unplanned bowel movements.
• Increase time spent on the commode/toilet which can compromise skin integrity.
• Create challenges with care/support worker timetables.

Delayed bowel motions can be caused by a combination of factors, including:

• stool not in the right place
• inadequate time for the trigger to work
• stool not being the right consistency (often too hard) or
• not having the right trigger.

Management

For consistency

• Stool consistency is important – aim for type 2-4 for UMN bowels and type 2-3 for LMN/CES as a start point to help achieve efficient emptying.
• If the stool is too hard, see trouble shooting for constipation.

For trigger

• Stimulate the gastric colic reflex when it is the strongest (in the morning) with a warm drink and/or something to eat - this can help push stool into the rectum. The food or drink should be consumed 20-30 minutes prior to initiating the bowel routine.
• The preference for using an enema instead of suppositories can be an individual choice. It can be dependent on:
  • Ability to insert either option.
  • Time allocated to the bowel routine - suppositories take longer to work as they are given in bed and take time to ‘melt’, whereas an enema is more efficient and is given over the toilet.
  • Inserting an enema has the advantage of providing additional rectal stimulation through a gentle stimulation and stretch when removing the enema.
• Enema or suppository insertion alone may not be enough stimulation to relax the internal and external anal sphincters. Enema or suppository insertion can trigger spasm and contract the anal sphincters in people with an UMN bowel, impeding a bowel motion being passed. This can be addressed through additional rectal stimulation as outlined in the right trigger.
• Someone may be able to feel when the bowel needs to be emptied but may not have appropriate control over the emptying process. Delaying a bowel evacuation when the person has the urge to defaecate requires the activation of the Valsalva manoeuvre or needing to strain. Straining can be an issue with impaired functioning of the pelvic floor and can lead to damage such as haemorrhoids or prolapse. Using a suitable rectal trigger can manage this issue.
• Please note that attending any rectal stimulation will not impact any recovery or potentially damage the anal sphincters if done correctly. Establishing a reliable routine assists people in gaining control over their bowels and sometimes the need for rectal stimulation may reduce with time.

Medication

For right place and right time

• Delayed emptying or faecal incontinence following the bowel routine suggests the stool isn’t in the right place. It may be moving through the gastrointestinal tract too slowly and taking stimulant medication an hour earlier than the usual time, can help.
• Allowing enough time for the bowel motion to occur. It may take between 5-45 min depending on the individual.