Neurogenic Bowel Management, Spina Bifida — Troubleshooting the ACE/MACE — Clinical Pathway: Outpatient Specialty Care

Neurogenic Bowel Management, Spina Bifida Clinical Pathway — Outpatient Specialty Care

Troubleshooting the ACE/MACE

The Malone Antegrade Continence Enema (MACE) is a surgical procedure that creates a catheterizable channel that is used for delivering antegrade irrigations to the colon to evacuate the colon of stool. Consistency in timing is key to a good bowel-management program. Consider possible impaction when there is poor response to therapy. If the patient or caregiver is unable to pass the catheter into the channel, this requires a surgical evaluation.

Troubleshooting the ACE/MACE
Problem Intervention
Difficulty passing the catheter at skin level
  • If catheter is passed, secure catheter by tying off or using ACE stopper, leave catheter in channel and contact provider (tied off catheter or ACE stopper).
Inability to pass the catheter
  • Contact surgeon immediately.
Leakage immediately after irrigation
  • Clear leakage: Increase sit time, decrease volume of irrigant.
  • Feculent leakage: Increase sit time, increase additives.
  • Consider non-latex catheter (22-24 Fr.) per rectum to allow for drainage.
Hard daytime accidents
  • Assess diet: fiber, water intake, trigger foods.
  • Consider increasing volume of irrigant.
  • Consider additives: glycerin, PEG, Castile soap.
Loose daytime accidents
  • Assess diet: fiber, water intake, trigger foods.
  • Decrease oral laxative.
  • Adjust additives: glycerin, PEG, castile Soap.
Monthly accidents coinciding with menstruation.
  • Decrease oral laxatives prior to menstruation
  • Consider irrigation every 12 hours (morning and evening) at time of menstruation
Abdominal pain/vomiting
  • Prime tubing prior to administration to eliminate air.
  • Ensure proper temperature of irrigant (warm, not cold or hot).
  • Adjust volume of irrigant.
  • Adjust rate of administration (slow down or stop, rest and try again).
  • Ensure proper timing of last oral intake (> 30 minutes after meals is best).
Slow flow or stoppage of flow
  • Advance catheter.
  • Check for clogging of tube due to additive (flush tubing with hot water when NOT connected to the patient).
  • May have increased stool burden at the site; push 60 mls of warm water via catheter-tip syringe through catheter rather than relying on gravity to clear.
Poor clean out
  • Repeat irrigation.
  • Consider abdominal X-ray.
Severe abdominal or back pain, rectal bleeding
  • Refer to emergency department for immediate evaluation.