Stroke: Bowel Dysfunction in Patients Admitted for Rehabilitation§

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Cerebrovascular accident (CVA) or stroke is considered to be the second leading cause of death in the world [1]. In Brazil, according to a survey conducted by the Ministry of Health in which data collected over a period of 16 years (between 1990 and 2006) were analyzed, stroke is the leading cause of death amongst cerebrovascular diseases and the seventh cause of hospitalizations [2]. The gastrointestinal tract can be affected after a stroke, with dysphagia and alterations in the intestinal rhythm being the most common manifestations [3]. Motor, cognitive, and communication alterations may ensue and thus impair the dynamics for defecation to occur at a socially acceptable place and time [4]. Nevertheless, the specific changes that take place in the gastrointestinal tract after a stroke, which is responsible for causing such alterations, still need further investigation [5].

The main alterations in intestinal rhythm are intestinal constipation and fecal incontinence, whose prevalence varies depending on the definitions used in the studies, staging of the lesion and type of study. The prevalence of intestinal constipation varies between 22.9 and 60% [3, 6-11], whereas that of fecal incontinence oscillates between 31 and 40% in the two weeks following stroke [12], and between 9 and 15% in its chronic phase [5].

The definition of intestinal constipation is not a simple one. It can be influenced by cultural factors, therefore one needs to take into consideration both subjective and objective aspects when diagnosing it [13]. Intestinal constipation may thus be defined as the elimination of hard and dry stools with a frequency lower than three bowel movements a week; unsatisfactory or unsuccessful evacuation; or as the general assessment of any difficulty completing the act of defecation, such as need for straining, manual handlings, or excessive time spent on the toilet [13, 14]. According to the most common definition, anyone showing two or more of those symptoms can be considered constipated [13].

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Fecal incontinence is a condition that restricts one’s social interactions and can be characterized as the incapacity for keeping one’s physiological control at an appropriate time and place. It is estimated that between 0.5% and 5% of the general population have fecal incontinence [15, 16].

Under the neurological rehabilitation program kept by Hospital SARAH-Brasília, which integrates the SARAH Network of Rehabilitation Hospitals and provides free care to the Brazilian population, we observed reports provided both by patients and their caregivers describing difficulties related to evacuation and expectations of improved bowel function. When facing such problems, an interdisciplinary team must also advise patients and caregivers on measures that can alleviate symptoms and promote bowel retraining. Still, the literature on programs able to provide for better care of this specific population is scarce. A better understanding of these symptoms, as self-reported by patients and their caregivers, will allow for establishing bowel retraining strategies that have a positive impact on the patient’s expectations.

The current study thus aimed to assess the prevalence of diminished frequency of bowel movements, lumpy or hard stools, intestinal constipation, straining, incomplete evacuation, incontinence (bowel dysfunctions) before and after stroke as self-reported by patients (or reported by their caregivers) with brain injury resulting from it; to describe the type and frequency of such disorders, and the prevalence of laxatives use both before and after stroke.

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About the Author: Tung Chi