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