Bowel Neuroanatomy and Physiology
GI Anatomy
Bowel Neuroanatomy 101
Neural controls
Extrinsic (3)
1) 2) 3)
Sympathetic Parasympathetic Somatic Myenteric plexus Submucosal plexus
Intrinsic (2)
1) 2)
SNS and PNS modulate the enteric nervous system as opposed to directly controlling smooth muscle of bowel
Neuroanatomy & Physiology 101
Autonomic neural pathways
Parasympathetic
Upper via Vagus nerve innervates
Upper segments of GI tract to splenic flexure
Lower via Pelvic splanchnic nerves (nervi erigentes)
S2-S4 to the descending colon and rectum
Function
Stimulates GI secretion, motor activity Relaxes sphincters and blood vessels
Neuroanatomy & Physiology 101
Autonomic neural pathways
Sympathetic
Hypogastric nerve
L1, L2, L3 to the lower colon, rectum, and sphincters
Function
Inhibition of GI secretion, motor activity Contraction of GI sphincters and blood vessels
Somatic
Pudendal nerve
S2-S4 External anal sphincter and pelvic floor
Bowel - Autonomic Nervous System
Parasympathetics
Increases colonic motility
Sympathetics
Promote storage
Enhance anal tone Inhibit colonic contractions Bilateral sympathectomy has little clinical effect
Parasympathetic Control
Neurotransmitter
Ach Near the neurons of myenteric and submucosal plexuses
Nerve(s)
Vagus
From esophagus to mid transverse colon
Pelvic nerve
Supplies mid-transverse colon to rectum
Lack of PNS innervation to .
Small intestine
Function(s)
Increase peristalsis, stimulate secretions, relax sphincter, increase gut motility
Bowel Autonomic Nervous System
Parasympathetic nervous system
PNS functions
Increase peristalsis Stimulates secretions Relaxes sphincters Increases gut motility
Sympathetic Control
Neurotransmitter
Norepinephrine
Location
Intermediolateral SC (T5-L2) Superior and inferior mesenteric nerves (T9-T12) Hypogastric (T12-L3)
Functions
Decrease peristalsis Inhibits secretions Contracts sphincters Decreases gut motility
Neuroanatomy & Physiology 101
Intrinsic nervous system
Submucosal (Meissner) plexus Myenteric (Auerbach) plexus Regulate segment-tosegment movement of the gastrointestinal (GI) tract May be considered a 3rd part of the ANS
Intrinsic Nervous System
Myenteric plexus (Auerbach)
Located between the longitudinal and circular layers of muscle in the tunica muscularis Controls tonic and rhythmic contractions Exerts control primarily over digestive tract motility
Submucosal plexus (Meissner)
Buried in the submucosa Senses the environment within the lumen Regulates GI blood flow Controls epithelial cell function (local intestinal secretion and absorption) May be sparse or missing in some parts of GI tract
Partially controlled by autonomic nervous system
Peristalsis
Distinctive pattern of smooth muscle contractions that propels foodstuffs distally through the esophagus and intestines Mediated by.
Local, intrinsic nervous system Ex: peristalsis is not affect to any significant degree by vagotomy or sympathectomy
Peristalsis
Bolus of food Mechanical distension and mucosal irritation stimulates afferent enteric neurons 2 effects
1. Excitatory motor neurons above the bolus activated contraction of smooth muscle above the bolus
Via Ach, substance P
2. Inhibitory motor neurons stimulate relaxation of smooth muscle below the bolus
Via nitric oxide, vasoactive
intestinal peptide and ATP
GI Reflexes
Gastrocolic
Increase in colonic activity after a meal Distention of the stomach stimulates evacuation of the colon Blunted, but still useful after SCI
Enterogastric
Distention and irritation of the small intestine results in suppression of secretion and motor activity in the stomach
Colocolonic
Propels stool caudally by proximal muscle constriction and distal dilatation Mediated by myenteric plexus
Rectocolic
Colonic peristalsis due to stimulation of rectum Mediated by pelvic nerve
Normal Defecation
Rectosigmoid distention stimulates rectorectal reflex
Bowel proximal to bolus
contracts
Bowel distal to bolus
relaxes
Reflex relaxation of internal anal sphincter
Rectoanal inhibitory reflex Correlates with the urge to go
Volitional contraction of levator ani
Normal Defecation
Volitional control of levator ani
Opens proximal anal canal Relaxes external sphincter and puborectalis Allows straighter anorectal passage
May increase with
Valsalva Increasing intraabdominal pressure (squat)
Normal Defecation
Defecation deferred by volitionally contracting (2)
Puborectalis External anal sphincter Then, internal anal sphincter relaxation reflex will fade (within approx 15 sec) and urge will resolve until triggered again
Normal Defecation
Protective mechanisms
EAS will tense in response to small colonic contractions
Via spinal cord reflex (conus) and modulated by higher centers
Neurogenic Bowel Dysfunction
Loss of volitional control of defecation due to neurologic dysfunction
Fecal incontinence Difficulty with evacuation
Impact of Bowel Dysfunction
Decreases return to home after stroke Increases nursing home costs Embarrassment and humiliation result in vocational and social handicap
Pathophysiology UMN Bowel
Bowel dysfunction =
Constipation, reflex defecation
Transit time ( or ) =
Increases
Colonic motility =
GMC reduced
Anocutaneous, bulbocavernosus reflex =
Present to increased
Pathophysiology LMN Bowel
Bowel dysfunction =
Chronic constipation, rectal fecal impaction
Transit time
Prolonged
Anal sphincter pressure
Reduced resting tone, dilated rectum
Anocutaneous, bulbocavernosus reflex
Absent
Diagnostic Testing
Colonoscopy Manometry
Measures pressure and volume
Radiography
Structural defects Colonic transit time via serial radiographs
Bowel SCI Pathophysiology
Upper motor neuron lesion
Increased or decreased gastric motility?
Decreased
Shorter or prolonged transit times?
Prolonged
Spastic or flaccid anal sphincter?
Spastic
Reflexes remain intact or lost?
Intact
Bowel SCI Pathophysiology
Lower motor neuron lesion
Flaccid or spastic anal sphincter?
Flaccid
Voluntary and reflex activity intact or lost?
Lost
Bowel Care Algorithm
Evaluate bowel history and perform physical exam
Assess knowledge, cognition, function, and performance
Design bowel care program
Reflexic?
Areflexic?
Adapted from: NEUROGENIC BOWEL: GUIDE FOR EFFECTIVE MANAGEMENT, Nelson et al
Bowel Care Algorithm
Reflexic Areflexic
Manual evacuation
Chemical/mechanical rectal stimulant
Establish consistent, individualized schedule Monitor elements of personalized bowel program and evaluate after consistent adherence for 3-5 cycles: [diet, fluids, activity, assistive techniques, oral meds, type of rectal stimulation, positioning, assistive devices]
Adapted from: NEUROGENIC BOWEL: GUIDE FOR EFFECTIVE MANAGEMENT, Nelson et al
Bowel Care Algorithm
Effective bowel care?
Yes
No
Continue effective bowel program, including recognize/manage complications, evaluate for improvements, establish educational program, perform followup exam
Reevaluate and modify one element at a time [diet, fluids, activity, frequency, position, type of rectal stimulant, oral medications]
Adapted from: NEUROGENIC BOWEL: GUIDE FOR EFFECTIVE MANAGEMENT, Nelson et al
