2CC01 Assess bladder and bowel dysfunction an in-depth understanding of the anatomy and physiology of the male and female lower gastro intestinal tract in relation to lower bowel function and continence status including:a) stool production and what influences thisb) normal defaecationc) the nervous system including autonomic dysreflexiad) the bowele) the pelvic floor/complex and anal sphincter musclesf) the endocrine systemg) reflexes
3Digestion period Stomach: 3hours – converted to chyme Small intestine: Large intestine:12 – 72 hoursfood goes through varying stages of digestion and takes varying lengths of time. Can you tell me how long it takes for the:StomachSmall intestineLarge intestineThe bowel consist of two sections:The small intestine and large intestineColonic movement can be stimulated by anger, physical exercise, medications such as laxatives and the old Deli Belly, better known as gastroenteritisFactors that alter colonic movement are sleep, anxiety, fear and in some cases change of environment
45 Main functions of the bowel Absorption – Minerals, water, fats, medicinesSecretion – Enzymes secreted by the small intestineMucus secreted by the colon to help lubricate the faecesSynthesis – Synthesises some vitaminsStorage – unabsorbed food residueElimination – Propulsion of faecal matter and absorption of fluidThe bowel has 5 functions can you think what they are??STORAGE: The colon stores unabsorbed food residue but within 72 hours 70% of this will have been excreted.The other 30% can stay in the colon for a further week or moreABSORPTION: The bowel is responsible for absorbing minerals, water and fats. Sodium, chlorideDrugs are also absorbed or metabolised through the coloneg: aspirin, steroids. Some antimuscarinic drugsDiazepam can also be given rectallySECRETIONS: Mucus is secreted by the colon.This helps to lubricate the faeces during the passing of the stool.
5Small intestine Duodenum 12 ins Jejunum 5-8 feet Ileum 16-20 feet Goblet cells in the mucosa produce mucus.The duodenum is the major portion of the small intestine where enzyme secretion takes place.The small intestine in adults is approximately 22 feet in length.In newborn infants the small intestine is only 25% of its adult length and 13% of its diameter.The absorptive surface in infants is 950cm whereas the average adult has about 7600cm.So you can see the enormous growth that we have throughout our lives
6Small intestine Absorptive surface in adults 7600cm Lined with villi to increase surface area90% of our daily fluid intake is absorbed in the small intestine
7Large intestine 5-6 feet in length Caecum with appendix Ascending colonTransverse colonDescending colonSigmoid colonIn adults the large intestine is between 5 to 6 feet in length and varies in width from 1 to 2 1/2 inches.There are 5 regions to the large intestine they are (what are they called):Caecum with appendixAscending colonTransverse colonDescending colonSigmoid colonCan any one tell me what the main functions of the large intestine are?The function of the colon includes collection, absorption transportation and elimination of intestinal waste matter.It is estimated that 2 litres of fluid is passed through the small intestine into the caecum every day.After water, electrolytes, glucose and urea have been absorbed, there is between 100 – 150mls of fluid left to be excreted.
8Structure of intestine Small & large intestine has 4 layersPeritonealMuscularSubmucosalMucosalBoth the small and large intestine have four layers. These are:Peritoneal or serousMuscular – which consists of longitudinal and circular fibres onlySub mucosal and mucosal – In the small intestine the submucosal and mucosal layers are arranged in folds. This helps to significantly increase the absorptive surface
9Peristalsis 2-3 mass peristaltic movements per day Stimulated by consumption of food and warm drinks
10Excretion How does it work? Muscles work together to propel waste matter(Peristalsis)During process substances not absorbed by the body becomes faecesFaeces arrives in rectum to be expelledSO HOW IS THE FAECES EXCRETED:The muscles in the colon work together to propel the waste matter through the colon. This is called peristalsisDuring this process substances which cannot be utilised by the body are transformed into faeces.Eventually the faeces arrives in the rectum to be expelled. So what happens then?
11Sampling of bowel contents at dentate line Internal sphincter contributes 85% of resting anal tone. Weakness of this sphincter may result in passive incontinenceExternal sphincter is striated muscle – contributes 15% towards resting anal toneResponsible for voluntary contraction of sphincter. Weakness of EAS may result in urge incontinenceRectal sampling with IAS
12+The rectum is S Shaped and leads outwards through the anus. The rectum has the ability to distend in order to accommodate the faeces.The anal canal is slightly shorter in women than in men and is surrounded by the two cylinders of muscle called the internal and external sphinctersas you can see the muscle surrounding the rectum (which is part of the pelvic floor) helps to maintain a right angle between the anus and rectum.This acts as a barrier and stops faeces from escapingBoth the internal and external sphincters are contracted.With the rectum and anus in this position the person can remain continent
13This picture shows what happens when we are ready to pass the stool. The rectum begins to expand with the pressure of the faeces.stretch receptors send signals to the brain.In normal circumstances we can differentiate between flatus and stool.When we have decided it is faeces the internal sphincter begins to open.If it is appropriate to carry on the external sphincter and muscular sling will also relax.The rectum contracts and abdominal pressure increases and with a bit of luck you will be able to pass it.
14Pelvic floor muscles Supports the pelvic organs Contraction causes urethral compression – helps maintain continence during abdominal pressureCollectively called “Levator Ani”Striated muscle slow and fastmuscle fibres(under Voluntary control)
15Normal Defaecation Full rectum Adopt correct posture Raise intra-abdominal pressureInternal and external anal sphincters relaxRectum contracts to expel stoolShould pass soft formed stool with minimal effortSphincter “snaps shut” after completion“Normal” 3 times / day to 3 times / weekNormal stool output is about 200g a day.Production affected by gender, diet and healthMovement of faeces into rectum initiates call to stool.
17Bristol Stool ChartBristol Stool chart useful tool when assessing bowels for both patient and nurse
18What affects the bowel? Poor diet Lack of fluid Mobility Medications SurgeryDiet plays a key role in the healthy bowel. It important to get a good balance of both fruit and fibreHowever it is equally important to have an adequate fluid supply. If you have too much fibre without sufficient fluid that can cause constipationLack of mobility or exercise can cause the body to become sluggish causing the transit times to be decreased which in turn can cause increased bulking in the bowel. If the rectum becomes impacted it loses the S shape therefore making it more difficult for the rectum to contractCertain medications can cause constipation can you tell me what these areSurgery can also cause the body to become sluggish which is due to a number of factors such as the general anaesthetic, lack of mobility and poor diet and fluid
19Continence is ComplexAnal sphincters (structural integrity, residual function if damaged)Internal anal sphincter - passive stool retentionExternal anal sphincter- control of urge to stoolPelvic floor and mucosal sealSensory function and co-ordinationStool consistency (e.g. diet)Gut motilityEmotional factorsLifestyle and toilet access
20Effect of endocrine system Pancreas – DiabetesAdrenal glands – fight/flightCorticotrophin-releasing factor (CRF) – (Stress hormone) eg. IBSThe adrenal medulla produces adrenaline and noradrenaline, substances that increase the heart rate and blood pressure during times of stress. Their action is referred to as the "fight-or-flight" response.Hydrocortisone reduces the amount of glucose absorbed by muscles and adipose tissue. Another function of cortisol is to protect the body from the adverse affects of stress, including emotional and physical trauma.GH), has a central role in controlling the growth and development of the body and its components, including organs, tissue, and muscle. It also affects the metabolism of carbohydrates,protein, and fat. For example, GH increases glucose levels in the blood by reducing the amount of glucose used by muscle cells and adipose tissue and by promoting glucose production from certain liver molecules.CRF is the brain’s “stress hormone.” When stimulated, itinteracts with many systems within the body.These interactions include those between the brain and thedigestive tract. They effect whether or not we feel discomfort orpain, and the way our bowels move.In some people, the stress response is overactive. When thestress response is out of balance, unwanted symptoms canresult.
21Nervous system Vagus nerves – stimulate acid secretion Intestine – sympathetic and parasympathetic nerve supply - sub mucosaInternal sphincter – autonomic (smooth muscle)External sphincter – under voluntary control (striated muscle)Between the two muscle layers the blood vessels, lymphvessels and the major nerve supply to the GI tract can befound. The nerve supply is called the mesenteric or Auerbach’splexus, and it consists of both sympathetic and parasympatheticnerves. It is mostly responsible for GI motility, which isthe ability of the GI tract to move spontaneously (Tucker 2002;Martini 2004).SubmucosaThe submucous layer is highly vascular as it houses plexusesof blood vessels, nerves and lymph vessels, and tissue. It consistsof connective tissue and elastic fibres. It also contains thesubmucosal or Meissner’s plexus, which is important in controllingthe secretions in the GI tract (Martini 2004).Mucosa
22Reflexes Anal wink Anal reflex Perineal reflex Reflexive contraction of external anal sphincter on touching/stimulationA noxious or tactile stimulus will cause a wink contraction of the anal sphincter muscles and also flexion. The stimulus is detected by the nociceptors in the perineal skin to the pudendal nerve, where a response is integrated by the spinal cord sacral segments S1-S3.The absence of this reflex indicates that there is an interruption of the reflex arc, which may be in the sensory afferent limb or the motor efferent limb. The synapse between the afferent and efferent limbs occurs in the lowest sacral segments of the spinal cord.
23WHAT IS AUTONOMIC DYSREFLEXIA? It develops after spinal cord injury/ lesion at or above T6Exaggerated response of nervous system to localised trigger below level of spinal cord injuryThis causes an sudden extreme rise in blood pressureIt can occur without warning and is a medical emergency
24Autonomic Dysreflexia Normally a harmful stimulus causes the autonomic nervous system to respond resulting in a rise in blood pressure.If T6 lesion or above present, stimulus below the injury causes BP to rise, but autonomic nervous system does not act to lower it below the lesion.Therefore BP continues to rise until stimulus is removedAutonomic nervous system attempts to lower BP above lesion: this causes the symptoms that aid the diagnosis of AD
25Signs and symptoms Stuffy nose / nasal obstruction Severe pounding headache, usually frontalRaised BP (by 20mm/hg) / bradycardiaCutis anserina (goose bumps) above and possibly below level of SCI and shiveringFlushing above level of lesion due to vasodilatationReduced urine outputBlurring vision – spots before eyesIncreased spasms
27What Goes Wrong? Local pathology (prolapse, piles, fistula) Neurological damage (motor or sensory)Lifestyle, toilets, drugs, immobility, frailtyImpaction with “overflow diarrhoea” mostcommon in frail dependent individuals
28FactsAnnual spend on laxatives in the UK is £50 million per year. (DH 2001)The UK has the highest incidence of bowel cancer in the world with 20,000 new cases per yearOne in three people consulting GPs have a bowel problemBowel disorders such as irritable bowel syndrome, colitis, crohns disease and diverticulitus affect 1:250 people in the UK (National association for colitis and crohn’s disease 2010)Just a few factsThe UK is the most constipated nation in the world. Why do you think that is?The UK has the highest incidence of bowel cancer in the world. Not a nice statistic to have.Can anyone tell me the causes of bowel cancer.DietLong term conditionsInactive lifestylesFamily historyOld age1 in 3 need to see the GP with a bowel problem, that’s a lot of peopleBowel disorder are now widespread do you think this is due to the same reason as with bowel cancer