|Year : 2014 | Volume
| Issue : 1 | Page : 9-13
Gastrointestinal complications and their relationship with functional performance in stroke survivors
Lukman F. Owolabi1, Adamu A. Samaila2, Taofiki Sunmonu3
1 Department of Medicine, Neurology Unit, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Gastroenterology Unit, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
3 Neurology Unit, Federal Medical Centre, Owo, Ondo State, Nigeria
|Date of Web Publication||15-May-2014|
Dr. Lukman F. Owolabi
Department of Medicine, Neurology Unit, Aminu Kano Teaching Hospital, Bayero University, PMB 3452, Kano, Kano State
Source of Support: None, Conflict of Interest: None
Background: Gastrointestinal (GI) complications can retard or limit a patient's rehabilitation and functional recovery. Thus, if not recognized and prevented early, they can be a significant determinant of morbidity and mortality in patients with stroke.
Objective: The study was designed to determine the frequencies of GI symptoms in stroke survivors and to evaluate their relationships with functional performance.
Methodology: Consecutive patients with diagnosis of stroke in medical wards and neurology clinic at the Aminu Kano Teaching Hospital and apparently healthy age and sex matched volunteers were recruited. A structured, pre-tested, close-ended questionnaire inquiring about common GI symptoms and demographic and stroke characteristics such as type, number and hemispheric side of stroke was administered in each case and control. Functional performance was assessed using the Barthel index.
Results: A total of 150 patients and 150 control subjects were recruited for the study. The mean age of the patients was 58.1 ± 13 and that of the control subjects was 58.0 ± 12 and the difference was not statistically significant (P = 0.9846). There were 113 (80.7%) ischemic stroke and 27 (19.3%) hemorrhagic stroke. The most common GI symptoms were constipation (16.7%), dysphagia (12.1%) and masticatory difficulty (10.0%). There was no statistically significant difference in the occurrence of GI symptoms with respect to side of stroke. Constipation, dysphagia, masticatory difficulty, incomplete evacuation, abdominal pain, malnutrition, vomiting, bloating were found to be associated with low functional performance.
Conclusion: Constipation, dysphagia and masticatory difficulty were the most common GI complications. They appear to be independent of the side or type of stroke, but are associated with low functional performance of the stroke survivors.
Keywords: Complications, gastrointestinal, stroke, survivors
|How to cite this article:|
Owolabi LF, Samaila AA, Sunmonu T. Gastrointestinal complications and their relationship with functional performance in stroke survivors. J Med Trop 2014;16:9-13
|How to cite this URL:|
Owolabi LF, Samaila AA, Sunmonu T. Gastrointestinal complications and their relationship with functional performance in stroke survivors. J Med Trop [serial online] 2014 [cited 2020 Jun 6];16:9-13. Available from: http://www.jmedtropics.org/text.asp?2014/16/1/9/132568
| Introduction|| |
Stroke is one of the foremost causes of death and disability in both developed and developing countries. , Medical complications, including gastrointestinal (GI) complications, are believed to be an important problem following stroke that potentially constitute huge challenges to optimal recovery from stoke. , Medical complications can retard or limit a patient's rehabilitation and functional recovery. Therefore, if not recognized and prevented early, they can be a significant determinant of morbidity and mortality in patients with stroke. , In light of this, after the acute stage of stroke, optimal recovery requires a holistic as well as multidisciplinary approach to care given to stroke survivors. 
Although there has been some concern that GI complications is not uncommon and that these complications may have some relationships with the functional status of the patients, there is paucity of data, particularly from developing countries, on this emerging field in gastroenterology that focuses on the interrelation between neurology and gastroenterology as it relates to optimal functional recovery among survivors of stroke.
Previous report from a study conducted in southwestern Nigeria showed that constipation and masticatory difficulty were the most predominant GI symptoms among stroke survivors.  However, the relationship of these complications with functional status of the stroke survivors was not explored in the study.
In another study conducted on stroke survivors in a rehabilitation center, constipation was strongly related to functional status of patients with a lower rate of constipation among those with a higher Barthel index (BI).  In Northwestern Nigeria, like in other regions of Nigeria and Africa, stroke is one of the most common medical conditions warranting admission and also a major cause of morbidity and mortality. ,,, It is associated with myriads of medical complications including GI complications  which often mar clinical improvement. Knowledge of frequency of GI complications and their relationship with functional status of the patients will be of use in designing effective preventive strategies and prescribing appropriate treatment for the patients for optimal results.
Apart from highlighting the frequencies of GI problems among stroke survivors, the study was also designed to examine the relationship of these problems with functional performance.
| Methodology|| |
In this cross-sectional study conducted over a 2-year period, consecutive patients with diagnosis of stroke in medical wards as well those seen in neurology clinic at Aminu Kano Teaching Hospital were recruited. Diagnosis and classification of stroke was based on clinical, brain computed tomography/magnetic resonance imaging finding and WHO criteria.  Apparently healthy age and sex matched volunteers constituted the control group.
A structured, pre-tested, close-ended questionnaire inquiring about common GI symptoms as well as demographics, stroke characteristics such as type, number and hemispheric side of stroke was administered in each case and control. Among others, symptoms evaluated included dysphagia, constipation, vomiting, diarrhea, odynophagia and masticatory difficulty.  Functional performance was assessed using the BI which consists of 10 items that measure a person's daily functioning that borders on the activities of daily living and mobility. The items include feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on a level surface, going up and down stairs, dressing, continence of bowels and bladder.
All patients and control subjects were on typical Nigerian diet which is usually based around a starchy staple made from maize/corn, wheat, yams, cassava and rice.
Patients with dysphasia and those with impaired level of consciousness as well as those with complaints of GI symptoms, similar to those evaluated in this study before developing stroke, were excluded from the study.
Analysis of data was carried out using the "Statistical Package for Social Sciences" (SPSS) program for Windows version 16.0 (SPSS Inc., Chicago, IL). Functional performance on BI was categorized into low score (<50% score) and high score ≥50% score). Mean and standard deviation were used to describe quantitative variables. Bivariate analysis was carried out using Pearson Chi-square or Fisher exact test for categorical variables. Student's t-test was used to compare the means of continuous variables. P < 0.05 was considered to be statistically significant level.
| Result|| |
During the study period, a total of 150 patients and 150 control subjects were recruited. Their age ranged between 24 and 90 years. The mean age of the patients was 58.1 ± 13 years and that of the control subjects was 58.0 ± 12 years and the difference was not statistically significant (P = 0.9846). The patients and control subjects comprised 108 males and 42 females with a male to female ratio of 2.57. There were 113 (80.7%) patients with ischemic stroke and 27 (19.3%) patients with hemorrhagic stroke. Sixty two (41.3%) and 88 (58.7) patients had right and left hemispheric stroke respectively. One hundred and thirty four (89.3%) patients had stroke for the 1 st time while 16 (10.7%) patients presented with a repeat stroke.
The most common GI symptoms were constipation (16.7%), dysphagia (12.1%) and masticatory difficulty (10.0%) [Table 1]. There was no statistically significant difference in the occurrence of GI symptoms between patients that had left hemispheric and those with right hemispheric stroke [Table 2]. The type of stroke had no influence on the GI complications [Table 3].
|Table 1: Distribution of gastrointestinal symptoms in the stroke survivors and control|
Click here to view
|Table 2: Distribution of gastrointestinal symptoms in relation to side of stroke|
Click here to view
|Table 3: Distribution of gastrointestinal symptoms in relation to type of stroke|
Click here to view
Constipation, dysphagia, masticatory difficulty, incomplete evacuation, abdominal pain, malnutrition, vomiting, bloating and fecal incontinence were more frequent among patients when compared with those first stroke (P < 0.05). This statement should be modified.
Constipation, dysphagia, masticatory difficulty, incomplete evacuation, abdominal pain, malnutrition, vomiting, bloating were found to be associated with low functional performance [Table 4].
|Table 4: Distribution of gastrointestinal symptoms in relation to functional performance on BI|
Click here to view
| Discussion|| |
Our data showed that the most prevalent GI symptoms among the stroke survivors were constipation, dysphagia and masticatory difficulty. These findings are compatible with reports from previous studies. ,, However, the frequency of GI symptoms differed from those reported in some other studies , possibly because of differences in methodology employed. In the current study, unlike in these other studies, only patients with new onset (after stroke) GI symptoms were included.
The neurophysiology of the GI system is a complex one. There are three factors involved in regulation of GI system namely luminal, endocrine and neural factors.  Smooth modulation of the GI occurs due to the complex interplay of these factors. Thus, disruption of this mechanism may manifest as GI symptoms.
In the current study, constipation appeared to be the most common GI symptom in stroke survivors. This finding agrees with previous reports. , Previous studies have also shown a statistically significant association between constipation and stroke both in institutionalized subjects  and in independently-living elderly subjects. 
Constipation can have a great negative impact on a patient's quality-of-life and consequently contribute to a poorer outcome especially in patients with moderately severe stroke.  In a similar study, constipation was found to be associated with poor stroke outcome in rehabilitation unit. 
Constipation in patients with stroke has been attributed to disruption of the neuronal modulation of colonic motility causing prolonged colonic transit time.  The other factors contributing to the development of constipation among stroke patients includes the inability to relax the pelvic floor and inability to reduce the anorectal angle  decreased mobility, reduced fluid and fiber intake, environmental factors, cognitive impairment and drugs. 
In this study, dysphagia appeared one of the most common GI symptoms. Though the proportion of patients with dysphagia recorded in this study is lower than that reported in some other studies in which the figure could be as high as 50% in patients with stroke,  our finding is comparable with that obtained in a similar study in Ibadan, Southwestern Nigeria. In general, dysphagia is considered one of the most common sequelae following acute stroke.  It may resolve within 2 weeks of stroke or persist for a longer time.
Occurrence of dysphagia in stroke survivors has been attributed with increased mortality and with morbidities such as malnutrition, dehydration and pulmonary compromise. , However, previous studies had revealed that early detection of dysphagia in acute stroke survivors improves outcomes such as pneumonia, mortality, length of hospital stay and overall health care expenditures.  If undetected, dysphagia potentially cause serious medical complications, including aspiration pneumonitis, dehydration and malnutrition. , Thus, prompt screening and detection of dysphagia with the view to instituting appropriate treatment strategies is expected to impact positively on the affected patients. 
Like in reports from previous studies, ,,, the other GI symptoms that were found to be commoner in stroke patients in comparison with normal control subjects in our study included bloating, fecal incontinence, odynophagia, rectal prolapse and regurgitation.
GI symptoms were found not to be related to the hemispheric side of stroke and type of stroke in our study. This finding is in agreement with previous studies that showed that the hemispheric side of stroke did not appear to influence the presentation of stroke in the post-stroke period. ,
In the current study constipation, dysphagia, masticatory difficulty, aspiration/choking, incomplete evacuation, abdominal pain, malnutrition, nausea, vomiting and bloating were individually related to functional status of patients assessed by BI. This finding agrees with a previous report on constipation after a recent stroke.  BI is a standard measurement of disability. Patients with a low BI score are more dependent and physically less active and as such may be more susceptible to constipation.  This finding suggests that prompt detection of GI symptoms and institution of appropriate management strategies may help to improve the functional status of stroke survivors.
Therefore, knowing the types and frequency of GI complications in stroke patients, as seen in this study, during in-patient and out-patient care, will be extremely helpful for providing the best possible treatment strategies aimed at improving their physical and functional status, thereby breaking potential barriers to an optimal recovery in stroke survivors.
Needless to reiterate that in an attempt to increase the general awareness of physicians caring for stroke survivors, we focused on the GI symptoms most commonly experienced by stroke survivors, this list is, however, not exhaustive.
| Conclusion|| |
The most common GI symptoms in stroke survivors were constipation, dysphagia and masticatory difficulty. They appear to be independent of the side or type of stroke, but are associated with low functional performance of the stroke survivors.
| References|| |
|1.||Murray CJ, Lopez AD. Global Comparative Assessments in the Health Sector: Disease Burden, Expenditures, and Intervention Packages. Geneva: World Health Organization; 1994. |
|2.||Mathers CD, Lopez AD, Stein C, Ma Fat D, Rao C, Inoue M, et al. Deaths and disease burden by cause: Global burden of disease estimates for 2001 by World Bank country groups. Washington, The World Health Organization (WHO), the World Bank, and the Fogarty International Center, US National Institutes of Health (NIH), 2003. DCPP Working Papers Series No. 18, Second Project on Disease Control Priorities in Developing Countries (DCPP). |
|3.||Roth EJ. Medical complications encountered in stroke rehabilitation. Phys Med Rehabil Clin N Am 1991;2:563-77. |
|4.||Johnston KC, Li JY, Lyden PD, Hanson SK, Feasby TE, Adams RJ, et al. Medical and neurological complications of ischemic stroke: Experience from the RANTTAS trial. RANTTAS Investigators. Stroke 1998;29:447-53. |
|5.||Tan WS, Chong WF, Chua KS, Heng BH, Chan KF. Factors associated with delayed discharges after inpatient stroke rehabilitation in Singapore. Ann Acad Med Singapore 2010;39:435-41. |
|6.||Saxena SK, Ng TP, Yong D, Fong NP, Gerald K. Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients. Acta Neurol Scand 2006;114:307-14. |
|7.||Brandstater ME, Shutter LA. Rehabilitation interventions during acute care of stroke patients. Top Stroke Rehabil 2002;9:48-56. |
|8.||Otegbayo JA, Talabi OA, Akere A, Owolabi MO, Owolabi LF, Oguntoye OO. Gastrointestinal complications in stroke survivors. Trop Gastroenterol 2006;27:127-30. |
|9.||Robain G, Chennevelle JM, Petit F, Piera JB. Incidence of constipation after recent vascular hemiplegia: A prospective cohort of 152 patients. Rev Neurol (Paris) 2002;158:589-92. |
|10.||Owolabi LF, Shehu MY, Shehu MN, Fadare J. Pattern of neurological admissions in the tropics: Experience at Kano, Northwestern Nigeria. Ann Indian Acad Neurol 2010;13:167-70. |
|11.||Owolabi LF, Nagoda M. Stroke in developing countries: Experience at Kano, Northwestern Nigeria. Sudan J Med Sci 2012;7:9-14. |
|12.||Owolabi LF, Ibrahim A. Stroke in young adults: A prospective study from northwestern Nigeria. ISRN Neurol 2012;2012:468706. |
|13.||Femi OL, Mansur N. Factors associated with death and predictors of one-month mortality from stroke in Kano, Northwestern Nigeria. J Neurosci Rural Pract 2013;4:S56-61. |
|14.||Watila MM, Nyandaiti YW, Balarabe SA, Ibrahim A, Alkali NH, Gezawa ID, et al. Medical complications among stroke patients at the University of Maiduguri Teaching Hospital, Northeastern Nigeria. J Med Med Sci 2012;3:189-94. |
|15.||Stroke - 1989. Recommendations on stroke prevention, diagnosis, and therapy. Report of the WHO Task Force on Stroke and other Cerebrovascular Disorders. Stroke 1989;20:1407-31. |
|16.||Ojini FI, Danesi MA. The pattern of neurological admissions at the Lagos University College Hospital, Nigeria. J Clin Pract 2003;5:38-41. |
|17.||Odusote KA. Management of stroke. Niger Med Pract 1996;32:54-62. |
|18.||Sonnenberg A, Tsou VT, Müller AD. The "institutional colon": A frequent colonic dysmotility in psychiatric and neurologic disease. Am J Gastroenterol 1994;89:62-6. |
|19.||Wong ML, Wee S, Pin CH, Gan GL, Ye HC. Sociodemographic and lifestyle factors associated with constipation in an elderly Asian community. Am J Gastroenterol 1999;94:1283-91. |
|20.||Su Y, Zhang X, Zeng J, Pei Z, Cheung RT, Zhou QP, et al. New-onset constipation at acute stage after first stroke: Incidence, risk factors, and impact on the stroke outcome. Stroke 2009;40:1304-9. |
|21.||Harari D, Norton C, Lockwood L, Swift C. Treatment of constipation and fecal incontinence in stroke patients: Randomized controlled trial. Stroke 2004;35:2549-55. |
|22.||Duraski SA, Denby FA, Clemens JQ. Bladder and bowel management after stroke. In: Stein J, Zorowitz R, Harvey R, Macko R, Winstein C, editors. Stroke Recovery and Rehabilitation. New York, NY: Demos Medical Publishing; 2009. p. 495-511. |
|23.||Winge K, Rasmussen D, Werdelin LM. Constipation in neurological diseases. J Neurol Neurosurg Psychiatry 2003;74:13-9. |
|24.||Nazarko L. Stroke: Bowel care. Nurs Resid Care 2007;9:251-4. |
|25.||Smithard DG, O'Neill PA, Parks C, Morris J. Complications and outcome after acute stroke. Does dysphagia matter? Stroke 1996;27:1200-4. |
|26.||Barer DH. The natural history and functional consequences of dysphagia after hemispheric stroke. J Neurol Neurosurg Psychiatry 1989;52:236-41. |
|27.||Martino R, Pron G, Diamant N. Screening for oropharyngeal dysphagia in stroke: Insufficient evidence for guidelines. Dysphagia 2000;15:19-30. |
|28.||McLean DE. Medical complications experienced by a cohort of stroke survivors during inpatient, tertiary-level stroke rehabilitation. Arch Phys Med Rehabil 2004;85:466-9. |
|29.||Hung JW, Tsay TH, Chang HW, Leong CP, Lau YC. Incidence and risk factors of medical complications during inpatient stroke rehabilitation. Chang Gung Med J 2005;28:31-8. |
[Table 1], [Table 2], [Table 3], [Table 4]