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CHAPTER 27
In patients with paralysed peristalsis, the bowel sounds are either absent or scanty
on auscultation. Meteorism may develop fairly rapidly, but its degree varies, being
usually absent altogether in lesions below Tio. However, when present in upper thoracic
and, in particular, cervical lesions, it always represents a serious complication, as it inter
feres with the function of the diaphragm and thus greatly increases the respiratory
distress of the tetraplegic, which develops as a result of the paralysis of the intercostal
muscles.
Such a patient needs constant supervision by both medical and nursing staff, and
the early intramuscular injection of 0-3-0-5 mg of prostigmine at regular intervals
(3 to 5 hr), combined with the introduction of a rectal tube, has proved a beneficial and
even life saving measure.
In cervical and upper thoracic lesions, the paralysis of peristalsis may also involve
the stomach, resulting in acute dilatation, which in turn increases the respiratory
distress considerably. Gastric suction should be introduced as soon as this complication
arises.
A further complication of the gastric involvement are mucosal haemorrhages and the
development of acute gastric or duodenal ulcers called 'stress ulcers'. These stress ulcers
have been observed in acute lesions anywhere in the course of the descending autonomic
fibres, from the level of the anterior hypothalamus to the level of the cervical cord. The
interruption of the vasoconstrictors in the spinal cord results in paralytic vasodilatation,
leading to mucosal haemorrhage forming necrotic areas, eventually causing ulceration.
How far stimulation of the vagus also plays a part in the development of stress ulcers is
still a matter of conjecture, and it is possible that both mechanisms, paralysis of the
vasoconstrictors on the one hand and hyperactivity of the vagus on the other, are respon
sible. If vomiting of the gastric juice or suction of the dilated stomach reveals more or less
digested blood, blood transfusions may become an urgent indication. Patients who had
previously gastric or duodenal ulcers may be particularly endangered.
The paralytic vasodilatation as a result of the paralysis of the vasoconstrictors also
leads to the formation of oedema in all tissues, in particular the lungs. Therefore, intra
venous transfusions of saline or glucose have to be restricted to prevent increase of the
oedema, which could result in drowning the patient by excess fluid in the lungs.
The depression of the gastrointestinal function in the stage of spinal shock is, like the
depression of the reflex function of skeletal muscles, the result of the sudden withdrawal
of the central control. Consequently, the reflexes controlling defaecation are abolished
and, as pointed out, there is complete faecal retention. Evacuation of the bowels in this
stage should be achieved only by careful digital evacuation or by enema. However, the
latter is not indicated in the first 2-3 days after an acute transverse lesion, as the intake
of solid and even semi-solid food, as a rule, is greatly reduced, especially in high thoracic
and cervical lesions. An enema of saline or soap solution in the acute stage is only indicated
if digital examination reveals heavy accumulation of bowel content in the rectum, and
it should be given carefully by an experienced nurse. Such an enema will at least remove
the contents of a full rectum, and may also serve as stimulation to the sigmoid colon.
Sedatives and analgesics should, if possible, be avoided in the initial stage, as these
drugs delay the development of the automatic function of the intestinal tract.
