Bowel Training

Definition
Bowel training helps to reestablish normal bowel movements in persons who suffer from
constipation, diarrhea, incontinence, or irregularity. Healthy bowel activity is considered one or
two movements of moderate size every day.

Purpose
Many people for many reasons have irregular bowel function. In some cases, the
irregularity lasts beyond the condition that caused it. The bowels by themselves develop bad
habits that can be retrained with suitable exercises and education. Normal bowel habits not only
improve the quality of life, they help prevent several common diseases—for example, diverticulitis
and fecal impaction. Gall stones, appendicitis, colon cancer, hiatal hernia, diabetes, and heart
disease have also been related to the quality of bowel movements and the foods that affect them.

* One of the most common causes of constipation is the laxative habit. Repeated artificial
stimulation of the bowels destroys their natural emptying reflex, so that they will no longer move
without artificial stimulants. The laxative habit begins innocently enough with the correct belief
that bowels should move every day, however, laxatives will cause the evacuation of several days
worth of stool in a single movement. Impatient for stool to reaccumulate for the necessary few
days, the patient takes another laxative, and the cycle begins.
* The other major cause of constipation is a diet with insufficient bulk or roughage. The bowel
works more smoothly the more contents it has. Western diets of highly refined foods have
eliminated most of the residue from food. The result is that most food is absorbed, leaving little to
pass through and be excreted as feces.
* Constipation occurs acutely with impaction—the presence in the rectum of a mass of feces
too large to pass. Fecal impaction is usually the result of poor bowel habits, a diet with too little
liquid and roughage, and inadequate physical activity.
* Diarrhea, whether acute or chronic, can disrupt the bowel's normal rhythm and lead to
irregularity.
* Several diseases of the nervous system affect bowel reflexes.

Description
Bowel training reestablishes the bowel's normal reflexes by repeating a routine until it
becomes a habit. Naturally the patient must be able and willing to cooperate. Some patients are
so convinced they need daily laxatives that they are afraid to do without them. It takes time for a
changed diet to effect the bowels and for the bowel to regain its normal rhythm. Trust and
patience are necessary.
After gaining the patient's cooperation, the next step is to optimize the diet. Healthy bowel
movements require ingestion of a large amount of liquids and bulk foods. The patient should drink
two to three quarts of liquids every day, with liberal inclusion of prune juice and perhaps coffee for
their natural laxative effect. Bulk comes from unrefined foods. Oat bran, wheat bran, brown rice,
green vegetables, apples, and pears are a few examples of high residue foods. Many patients will
benefit from adding bulk preparations of psyllium. Constipating foods like bananas and cheese
should be avoided until a natural rhythm is well established.
To assure that stools are soft enough to pass easily, it is a good idea to add a pure stool
softener like DOSS (dioctyl sodium sulfosuccinate), two to four per day as needed. DOSS also
helps prevent impaction.
There is usually a time of day when bowel movements are more likely to occur. In
anticipation of this time, the patient should participate in activities that stimulate a normal bowel
movement. Walking, eating unrefined foods, and drinking prune juice or coffee, encourage natural
evacuation. It is acceptable to use lubricants such as glycerine suppositories or oil enemas at this
time. For severe constipation, water enemas may be needed to initiate a movement.
It is also important for the patient to recognize the urge to defecate and to respond right
away to that urge. The longer stool sits in the rectum, the more water the rectum will absorb from
it, making it harder and more difficult to pass.
Normal results
With patience and diligence, normal bowel habits and the health that comes with them will return
in most patients.

Enema
An enema (plural enemata or enemas) is the procedure of introducing liquids into the
rectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the
lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful
peristalsis, a feeling of extreme urgency and complete evacuation of the lower intestinal tract.
Enemas can be carried out as treatment for medical conditions, such as constipation and
encopresis, and as part of some alternative health therapies. They are also used to administer
certain medical or recreational drugs. Enemas have been used for rehydration therapy
(proctoclysis) in patients for whom IV therapy is not applicable.

The main medical usages of enemas are:

* As a bowel stimulant, not unlike a laxative – the main difference being that laxatives are
commonly thought of as orally administered while enemas are administered directly into the
rectum, and thereafter, into the colon. When the enema injection into the rectum is complete, and
after a set "holding time", the patient expels feces along with the enema in the bedpan or toilet.
* Enemas may also be used to relieve constipation and fecal impaction, although in the U.S.A.
and some other parts of the world, their use has been replaced in most professional health-care
settings by oral laxatives and laxative suppositories. In-home use of enemas for constipation and
alternative health purposes is somewhat harder to measure.
* Bowel stimulating enemas usually consist of water, which works primarily as a mechanical
stimulant, or they may be made up of water with baking soda (sodium bicarbonate) or water with
a mild hand soap dissolved in it; buffered sodium phosphate solution, which draws additional
water from the bloodstream into the colon and increases the effectiveness of the enema – which
often can be rather irritating to the colon, causing intense cramping or "griping" – or mineral oil,
which functions as a lubricant and stool softener, but which often has the side effect of sporadic
seepage from the patient's anus which can soil the patient's undergarments for up to 24 hours.
Other types of enema solutions are also used, including equal parts of milk and molasses heated
together to slightly above normal body temperature. In the past, castile soap was a common
additive in an enema, but it has largely fallen out of use because of its irritating action in the
rectum and because of the risk of chemical colitis as well as the ready availability of other enema
preparations that are perhaps more effective than soap in stimulating a bowel movement. At the
opposite end of the spectrum, an isotonic saline solution is least irritating to the rectum and colon,
having a neutral concentration gradient. This neither draws electrolytes from the body – as can
happen with plain water – nor draws water into the colon, as will occur with phosphates. Thus, a
salt water solution can be used when a longer period of retention is desired, such as to soften an
impaction.
* Cleansing the lower bowel prior to a surgical procedure such as sigmoidoscopy or
colonoscopy. Because of speed and supposed convenience, enemas used for this purpose are
commonly the more costly, sodium phosphate variety – often called a disposable enema. A more
pleasant experience preparing for testing procedures can usually be obtained with gently-
administered baking soda enemas; cleansing the lower bowel for colonoscopy and other bowel
studies can be effectively achieved with water-based, or water with baking soda, enema
administration.
* The administration of substances into the bloodstream. This may be done in situations where
it is undesirable or impossible to deliver a medication by mouth, such as antiemetics given to
reduce nausea (though not many antiemetics are delivered by enema). Additionally, several anti-
angiogenic agents, which work better without digestion, can be safely administered via a gentle
enema. Medicines for cancer, for arthritis, and for age-related macular degeneration are often
given via enema in order to avoid the normally-functioning digestive tract. Interestingly, some
water-based enemas are also used as a relieving agent for Irritable Bowel Syndrome, using
cayenne pepper to squelch irritation in the colon and rectal area. Finally, an enema may also be
used for hydration purposes. See also route of administration.
 * The topical administration of medications into the rectum, such as corticosteroids and
mesalazine used in the treatment of inflammatory bowel disease. Administration by enema avoids
having the medication pass through the entire gastrointestinal tract, therefore simplifying the
delivery of the medication to the affected area and limiting the amount that is absorbed into the
bloodstream.
* General anesthetic agents for surgical purposes are sometimes administered by way of an
enema. Occasionally, anesthetic agents are used rectally to reduce medically-induced vomiting
during and after surgical procedures, in an attempt to avoid aspiration of stomach contents.
* A barium enema is used as a contrast substance in the radiological imaging of the bowel. The
enema may contain barium sulfate powder, or a water-soluble contrast agent. Barium enemas
are sometimes the only practical way to "view" the colon in a relatively safe manner. Following
barium enema administration, patients often find that flushing the remaining barium with
additional water, baking soda, or saline enemas helps restore normal colon activity without
complications of constipation from the administration of the barium sulfate.

In certain countries such as the United States, customary enema usage went well into the
20th century; it was thought a good idea to cleanse the bowel in case of fever; also, pregnant
women were given enemas prior to labor, supposedly to reduce the risk of feces being passed
during contractions. Under some controversial discussion, pre-delivery enemas were also given
to women to speed delivery by inducing contractions. This latter usage has since been largely
abandoned, because obstetricians now commonly give pitocin to induce labor and because
women generally found the procedure unpleasant.

Now obsolete, the tobacco smoke enema was the principal medical method for
resuscitating victims of drowning during the 18th century.

Precautions
Improper administration of an enema may cause electrolyte imbalance (with repeated
enemas) or ruptures to the bowel or rectal tissues resulting in internal bleeding. However, these
occurrences are rare in healthy, sober adults. Internal bleeding or rupture may leave the
individual exposed to infections from intestinal bacteria. Blood resulting from tears in the colon
may not always be visible, but can be distinguished if the feces are unusually dark or have a red
hue. If intestinal rupture is suspected, medical assistance should be obtained immediately.
The enema tube and solution may stimulate the vagus nerve, which triggers an
arrhythmia such as bradycardia. Enemas should not be used if there is an undiagnosed
abdominal pain since the peristalsis of the bowel can cause an inflamed appendix to rupture.
Colonic irrigation should not be used in people with diverticulitis, ulcerative colitis, Crohn's
disease, severe or internal hemorrhoids or tumors in the rectum or colon. It also should not be
used soon after bowel surgery (unless directed by one's health care provider). Regular treatments
should be avoided by people with heart disease or renal failure. Colonics are inappropriate for
people with bowel, rectal or anal pathologies where the pathology contributes to the risk of bowel
perforation
Recent research has shown that ozone water, which is sometimes used in enemas, can
immediately cause microscopic colitis.

Fecal Impaction Removal

Definition
Fecal impaction removal is the digital (using the finger) means of breaking up and
removing a fecal impaction, or mass of hardened, clay-like stool lodged in the rectum.

Purpose
Fecal impaction is the result of extreme constipation. As the patient is unable to expel the
stool, it further accumulates into a larger, harder mass that is impossible to pass by normal
defecation. This accumulated stool can extend up into the sigmoid colon, the loop of large bowel
above the rectum. Impaction is most common in inactive elderly people, but there are other
causes beside inactivity. Among the other causes are:

* medications, including antacids that have aluminum as an ingredient; calcium and iron
supplements; a category of anti-hypertensive drugs known as calcium channel blockers; allergy
medicines (antihistamines); such psychotropic medications as antidepressants and tranquilizers;
such hormones as estrogen and progestin; and medications to reduce spasms such as those
used in treating Parkinson's disease
* poor bowel habits; not having a regular schedule for evacuating the bowel
* inadequate fluid intake
* a diet that is lacking in such fibers as bran, fruit, and vegetables
* such rectal disorders as rectocele

In addition to the discomfort this condition creates, untreated fecal impaction can also
become a serious health problem, producing a chronically over-dilated bowel, or megacolon, that
can require surgical correction. It is possible for rectal tissue to become damaged, ulcerated, or
even necrotic (lose its blood supply due to the pressure of the stool). The most serious potential
complication is that the lower bowel can become completely obstructed. Such intestinal
obstruction is potentially fatal.

The possibility that the patient has a fecal impaction should be considered if he or she
shows any or all of the following symptoms:

* complaints of inability to have a bowel movement despite frequently feeling the urge to
defecate
* upon defecation, the stool appears to be either diarrheic or thin and pencil-like
* abdominal pain
* bloating and a swollen or hard abdomen
* anorexia, or lack of appetite; nausea; and vomiting
* complaints of general malaise, or not feeling well
* the presence of hard stool in the rectum
* increased restlessness in patients suffering from Alzheimer's disease or other forms of
dementia

Precautions
This digital breaking up and removal of impacted stool can potentially damage the
mucous membrane linings in the bowel, and the stimulation to the vagus nerve that has endings
in the rectum can cause heart irregularities. It is therefore a procedure that is undertaken only
with extreme caution. Most often, nurses remove fecal impactions upon receiving a physician's
order, or under a physician's supervision.

Description
As gently as possible, the nurse inserts a gloved, lubricated index finger and massages
around the edges of the impaction, gradually working the gloved finger into the mass to break it
up. The broken-up pieces of stool are dislodged by carefully working them downward toward the
end of the rectum. During this procedure, the patient should be checked regularly to assure that
there are no untoward effects such as weakness, diaphoresis or clamminess, or changes in pulse
rate.

Preparation
The nurse positions the patient on his or her side, with knees flexed and back toward the
nurse. A waterproof pad is placed under the patient's buttocks, and a bedpan to hold any
removed stool is kept nearby. Occasionally, a patient will request to stand in the bathroom near
the toilet during this procedure, but that is not advisable due to possible adverse reactions and
the fact that this can be an exhausting process. The nurse then puts on rubber gloves and applies
lubricant to the index finger that will be inserted to break up the impaction. Explanation of what is
to be done, and reassurance that if the procedure is causing discomfort it will be stopped
immediately, should be given before beginning.

Aftercare
After the disimpaction is completed, it may be necessary to administer an enema or give
a suppository to complete the stool removal. The most important aspect of care is the prevention
of the reoccurrence of problems with elimination.

Complications
Vagus nerve stimulation, causing cardiac irregularities with possible fainting or weakness,
is the most serious potential complication. However, rectal bleeding, the result of trauma to the
bowel mucosa, can also occur.

Results
Expected results will be the removal of the hardened stool from the patient's rectum,
making the patient much more comfortable.