ANATOMY

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• ANATOMY PHYSIOLOGY
• OF THE BOWEL
• Gill Nottidge
• Continence Nurse Specialist

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CC01 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 this
• b) normal defaecation
• c) the nervous system including autonomic
  dysreflexia
• d) the bowel
• e) the pelvic floor/complex and anal sphincter
  muscles
• f) the endocrine system
• g) reflexes

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Digestion period

• Stomach
• 3hours converted to chyme
• Small intestine
• 4 6 hours
• Large intestine
• 12 72 hours

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5 Main functions of the bowel

• Absorption Minerals, water, fats, medicines
• Secretion Enzymes secreted by the small
  intestine
• Mucus secreted by the colon to help lubricate
  the faeces

• Synthesis Synthesises some vitamins
• Storage unabsorbed food residue
• Elimination Propulsion of faecal matter and
  absorption of fluid

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Small 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.

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Small intestine

• Absorptive surface in adults 7600cm
• Lined with villi to increase surface area
• 90 of our daily fluid intake is absorbed in the
  small intestine

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Large intestine

• 5-6 feet in length
• Caecum with appendix
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon

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Structure of intestine

• Small large intestine has 4 layers
• Peritoneal
• Muscular
• Submucosal
• Mucosal

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Peristalsis

• 2-3 mass peristaltic movements per day
• Stimulated by consumption of food and warm drinks

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Excretion

• How does it work?
• Muscles work together to propel waste matter
• (Peristalsis)
• During process substances not absorbed by the
  body becomes faeces
• Faeces arrives in rectum to be expelled

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Pelvic floor muscles

• Supports the pelvic organs
• Contraction causes urethral compression helps
  maintain continence during abdominal pressure
• Collectively called Levator Ani
• Striated muscle slow and fast
• muscle fibres
• (under Voluntary control)

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Normal Defaecation

• Full rectum
• Adopt correct posture
• Raise intra-abdominal pressure
• Internal and external anal sphincters relax
• Rectum contracts to expel stool

• Should pass soft formed stool with minimal effort
• Sphincter snaps shut after completion
• Normal 3 times / day to 3 times / week

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Correct position
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Bristol Stool Chart
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What affects the bowel?

• Poor diet
• Lack of fluid
• Mobility
• Medications
• Surgery

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Continence is Complex

• Anal sphincters (structural integrity, residual
  function if damaged)
• Internal anal sphincter - passive stool retention
• External anal sphincter- control of urge to stool
• Pelvic floor and mucosal seal
• Sensory function and co-ordination
• Stool consistency (e.g. diet)
• Gut motility
• Emotional factors
• Lifestyle and toilet access

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Effect of endocrine system

• Pancreas Diabetes
• Adrenal glands fight/flight
• Corticotrophin-releasing factor (CRF) (Stress
  hormone) eg. IBS

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Nervous system

• Vagus nerves stimulate acid secretion
• Intestine sympathetic and parasympathetic nerve
  supply - sub mucosa
• Internal sphincter autonomic (smooth muscle)
• External sphincter under voluntary control
  (striated muscle)

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Reflexes

• Anal wink
• Anal reflex
• Perineal reflex
• Reflexive contraction of external anal sphincter
  on touching/stimulation

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WHAT ISAUTONOMIC DYSREFLEXIA?

• It develops after spinal cord injury/ lesion at
  or above T6
• Exaggerated response of nervous system to
  localised trigger below level of spinal cord
  injury
• This causes an sudden extreme rise in blood
  pressure
• It can occur without warning and is a medical
  emergency

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Autonomic 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
  removed
• Autonomic nervous system attempts to lower BP
  above lesion this causes the symptoms that aid
  the diagnosis of AD

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Signs and symptoms

• Stuffy nose / nasal obstruction
• Severe pounding headache, usually frontal
• Raised BP (by 20mm/hg) / bradycardia
• Cutis anserina (goose bumps) above and possibly
  below level of SCI and shivering
• Flushing above level of lesion due to
  vasodilatation
• Reduced urine output
• Blurring vision spots before eyes
• Increased spasms

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What Goes Wrong?

• Anal sphincter (childbirth, injury, iatrogenic
  damage, degeneration)
• Internal - passive soiling External - urge
  incontinence
• Gut motility (infection, inflammation, radiation,
  hypermotility, emotions)
• Stool consistency (diet, motility, anxiety)

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What Goes Wrong?

• Local pathology (prolapse, piles, fistula)
• Neurological damage (motor or sensory)
• Lifestyle, toilets, drugs, immobility, frailty
• Impaction with overflow diarrhoea most
• common in frail dependent individuals

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Facts

• Annual 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 year
• One in three people consulting GPs have a bowel
  problem
• Bowel disorders such as irritable bowel syndrome,
  colitis, crohns disease and diverticulitus affect
  1250 people in the UK (National association for
  colitis and crohns disease 2010)

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Constipation!
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• Thank you for your attention.
• Any questions?
• Gill Nottidge
• Tel [phone]
• Gillian.nottidge_at_bradford.nhs.uk

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