Table 14.
Management of gastrointestinal dysfunction in patients with transverse myelitis
| Problem | Management Strategies |
|---|---|
| Gastroparesis | Stop drugs that inhibit gastrointestinal motility (eg, narcotics, calcium channel blockers, anticholinergics). Consultation with a gastroenterologist for endoscopy, gastric emptying studies, and investigations to characterize the nature of dysmotility. Gastric decompression with a nasogastric tube, bowel rest, intravenous fluids, and proton-pump inhibitors or gastric H2-receptor blockers should be considered. Prokinetic agents (eg, metoclopramide, macrolide antibiotics, bethanecol or pyridostigmine) may be used. Tardive dyskinesia is a risk of metoclopramide use. Gastric electrical stimulation (Enterra therapy) and endoscopic injection of botulinum neurotoxin may be of potential benefit. In refractory cases, surgical interventions like pyloroplasty may be needed. |
| Constipation |
General measures: high-fiber diet, bulking agents, increased fluid intake (at least 2 L daily), physical exercise, and establishing a regular toileting routine (best accomplished after breakfast to take advantage of the gastrocolic response, which peaks about 30 minutes after eating). Stimulant or osmotic laxatives (senna and bisacodyl) can be titrated to produce a satisfactory response (without producing liquid stool). Osmotic laxatives, although effective, can produce liquid stool with subsequent incontinence. Rectal stimulants have a predictable time of response. Begin with a glycerine suppository, progressing to bisacodyl, sodium citrate micro-enema, and ultimately a phosphate enema. Biofeedback may help, particularly in pelvic floor incoordination. Neostigmine in combination with glycopyrrolate has been shown to be effective. 4-aminopyridine may improve constipation. Digital stimulation of the anal canal serves to manually disimpact the rectum. Abdominal massage may be helpful. For refractory cases: colostomy, neuromodulation, Malone Antegrade Continence Enema. Transanal irrigation (TAI). |
| Fecal incontinence | Mild and infrequent: loperamide, codeine phosphate. Antidiarrheal drugs should be used with caution if incontinence and constipation coexist, and periodic checks for impaction may be required. Fecal impaction is a common complication and patients experience anorexia, nausea, and spurious diarrhea (liquid stool passing around the blockage). Biofeedback is another useful tool. Anal plugs or pads may be needed. Severe cases: surgical intervention (eg, dynamic graciloplasty, artificial bowel sphincter, and sacral nerve stimulation). TAI |