1
|
Lal S, Paine P, Tack J, Aziz Q, Barazzoni R, Cuerda C, Jeppesen P, Joly F, Lamprecht G, Mundi M, Schneider S, Szczepanek K, Van Gossum A, Wanten G, Vanuytsel T, Pironi L. Avoiding the use of long-term parenteral support in patients without intestinal failure: A position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut-Brain Interaction. Neurogastroenterol Motil 2024:e14853. [PMID: 38973248 DOI: 10.1111/nmo.14853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 07/09/2024]
Abstract
The role of long-term parenteral support in patients with underlying benign conditions who do not have intestinal failure (IF) is contentious, not least since there are clear benefits in utilising the oral or enteral route for nutritional support. Furthermore, the risks of long-term home parenteral nutrition (HPN) are significant, with significant impacts on morbidity and mortality. There has, however, been a recent upsurge of the use of HPN in patients with conditions such as gastro-intestinal neuromuscular disorders, opioid bowel dysfunction, disorders of gut-brain interaction and possibly eating disorders, who do not have IF. As a result, the European Society of Clinical Nutrition and Metabolism (ESPEN), the European Society of Neuro-gastroenterology and Motility (ESNM) and the Rome Foundation for Disorders of Gut Brain Interaction felt that a position statement is required to clarify - and hopefully reduce the potential for harm associated with - the use of long-term parenteral support in patients without IF. Consensus opinion is that HPN should not be prescribed for patients without IF, where the oral and/or enteral route can be utilised. On the rare occasions that PN commencement is required to treat life-threatening malnutrition in conditions such as those listed above, it should only be prescribed for a time-limited period to achieve nutritional safety, while the wider multi-disciplinary team focus on more appropriate biopsychosocial holistic and rehabilitative approaches to manage the patient's primary underlying condition.
Collapse
Affiliation(s)
- S Lal
- National Intestinal Failure Reference Centre, Northern Care Alliance and University of Manchester, Salford, Manchester, UK
| | - P Paine
- Department of Gastroenterology, Northern Care Alliance and University of Manchester, Salford, Manchester, UK
| | - J Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
- Rome Foundation, Raleigh, North Carolina, USA
| | - Q Aziz
- Blizard Institute, Wingate Institute for Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Queen Mary University of London, London, UK
| | - R Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - C Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - P Jeppesen
- Department of Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - F Joly
- Department of Gastroenterology and Nutritional Support, Center for Intestinal Failure, Reference Centre of Rare Disease MarDI, AP-HP Beaujon Hospital, University of Paris Inserm UMR, Paris, France
| | - G Lamprecht
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - M Mundi
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - S Schneider
- Gastroenterology and Nutrition, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - K Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - A Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Brussels, Belgium
| | - G Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - T Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - L Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Centre for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy
| |
Collapse
|
2
|
Lal S, Paine P, Tack J, Aziz Q, Barazzoni R, Cuerda C, Jeppesen P, Joly F, Lamprecht G, Mundi M, Schneider S, Szczepanek K, Van Gossum A, Wanten G, Vanuytsel T, Pironi L. Avoiding the use of long-term parenteral support in patients without intestinal failure: A position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut-Brain Interaction. Clin Nutr 2024:S0261-5614(24)00173-0. [PMID: 38824102 DOI: 10.1016/j.clnu.2024.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/03/2024]
Abstract
The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.
Collapse
Affiliation(s)
- S Lal
- National Intestinal Failure Reference Centre, Northern Care Alliance and University of Manchester, Stott Lane, Salford, Manchester, M6 8HD, UK.
| | - P Paine
- Department of Gastroenterology, Northern Care Alliance and University of Manchester, Stott Lane, Salford, Manchester, M6 8HD, UK
| | - J Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Herestraat 49, 3000, Leuven, Belgium; Rome Foundation, Raleigh, North Caroline, USA
| | - Q Aziz
- Blizard Institute, Wingate Institute for Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Queen Mary University of London, London, UK
| | - R Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Italy
| | - C Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - P Jeppesen
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - F Joly
- Department of Gastroenterology and Nutritional Support, Center for Intestinal Failure, Reference Centre of Rare Disease MarDI, AP-HP Beaujon Hospital, University of Paris Inserm UMR, 1149, Paris, France
| | - G Lamprecht
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - M Mundi
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - S Schneider
- Gastroenterology and Nutrition, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - K Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - A Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - G Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - T Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - L Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Centre for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy
| |
Collapse
|
3
|
Alcalá González LG, Malagelada C. Current insights on chronic intestinal dysmotility: pseudo-obstruction and enteric dysmotility. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:63-67. [PMID: 37929992 DOI: 10.17235/reed.2023.10038/2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Chronic intestinal dysmotility is a rare and debilitating digestive disorder characterized by symptoms of mechanical obstruction without an organic lesion. It has diverse causes and involves various pathological mechanisms. Small bowel manometry is the preferred diagnostic method, particularly for patients with severe and progressive symptoms. The condition can be categorized as intestinal pseudo-obstruction and enteric dysmotility, both entities share abnormal small bowel motility, but with important differences in prognosis and management.
Collapse
|
4
|
Basilisco G, Marchi M, Coletta M. Chronic intestinal pseudo-obstruction in adults: A practical guide to identify patient subgroups that are suitable for more specific treatments. Neurogastroenterol Motil 2024; 36:e14715. [PMID: 37994282 DOI: 10.1111/nmo.14715] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/24/2023]
Abstract
Chronic intestinal pseudo-obstruction is a rare and heterogeneous syndrome characterized by recurrent symptoms of intestinal obstruction with radiological features of dilated small or large intestine with air/fluid levels in the absence of any mechanical occlusive lesion. Several diseases may be associated with chronic intestinal pseudo-obstruction and in these cases, the prognosis and treatment are related to the underlying disease. Also, in its "primary or idiopathic" form, two subgroups of patients should be determined as they require a more specific therapeutic approach: patients whose chronic intestinal pseudo-obstruction is due to sporadic autoimmune/inflammatory mechanisms and patients whose neuromuscular changes are genetically determined. In a context of a widely heterogeneous adult population presenting chronic intestinal pseudo-obstruction, this review aims to summarize a practical diagnostic workup for identifying definite subgroups of patients who might benefit from more specific treatments, based on the etiology of their underlying condition.
Collapse
Affiliation(s)
- Guido Basilisco
- Gastroenterology and Endoscopic Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Margherita Marchi
- Neuroalgology Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Marina Coletta
- Gastroenterology and Endoscopic Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
5
|
Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
Collapse
Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
| |
Collapse
|
6
|
Alcalá-González LG, Malagelada C, Monrroy H, Mego M, Accarino A, Malagelada JR, Azpiroz F. Clinical significance of small bowel manometry patterns suggestive of intestinal obstruction. Neurogastroenterol Motil 2023; 35:e14462. [PMID: 36102622 PMCID: PMC10078417 DOI: 10.1111/nmo.14462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/20/2022] [Accepted: 08/23/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Minute rhythm and prolonged simultaneous contractions are patterns of postprandial small bowel contractile activity that historically have been considered as suggestive of mechanical intestinal obstruction; however, these patterns have been also encountered in patients with motility-like symptoms in the absence of bowel obstruction. The objective of this study was to determine the current diagnostic outcome of patients with these intestinal manometry patterns. METHODS Retrospective study of patients with chronic digestive symptoms evaluated by intestinal manometry at our center between 2010 and 2018. RESULTS The minute rhythm (MRP) or prolonged simultaneous contractions (PSC) postprandial patterns were detected in 61 of 488 patients (55 MRP and 6 PSC). Clinical work-up detected a previously non-diagnosed partial mechanical obstruction of the distal intestine in 10 (16%) and a systemic disorder causing intestinal neuropathy in 32 (53%). In the remaining 19 patients (31%, all with MRP), the origin of the contractile pattern was undetermined, but in 16, substantial fecal retention was detected within 7 days of the manometric procedure by abdominal imaging, and in 6 of them colonic cleansing completely normalized intestinal motility on a second manometry performed within 39 ± 30 days. CONCLUSION AND INFERENCE Currently, the most frequent origin of MRP and PSC encountered on small bowel manometry is intestinal neuropathy, while a previously undetected mechanical obstruction is rare. Still, in a substantial proportion of patients, no underlying disease can be identified, and in them, colonic fecal retention might play a role, because in a subgroup of these patients, manometry normalized after colonic cleansing. Hence, colonic preparation may be considered prior to intestinal manometry.
Collapse
Affiliation(s)
- Luis G Alcalá-González
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Carolina Malagelada
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Hugo Monrroy
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Marianela Mego
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Anna Accarino
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Juan-Ramon Malagelada
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Fernando Azpiroz
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| |
Collapse
|
7
|
Chronic intestinal pseudo-obstruction: a case report with review of the literature and practical guidance for the clinician. Acta Gastroenterol Belg 2022; 85:85-93. [PMID: 35304998 DOI: 10.51821/85.1.9704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic Intestinal Pseudo-obstruction (CIPO) is a rare but debilitating and severe form of gastrointestinal dysmotility. The diagnosis is often made very late in the disease course due to its rarity and complexity. Treatment is mainly supportive, as there is no definitive cure. Pharmacologic therapy comprises prokinetics, antibiotics for bacterial overgrowth and pain management. Pain can also be alleviated with intestinal decompression in selected cases. Beside the pharmacologic therapy, nutrition and fluid replacement play a key role. Rarely, intestinal transplantation is necessary in patients with CIPO and intestinal failure. In this review, we describe an advanced CIPO case and provide an update of the clinical and diagnostic features and current management strategies. The goal of our review is to raise awareness around CIPO and to give practical guidance for the clinician.
Collapse
|
8
|
Chronic Intestinal Pseudo-Obstruction: Is There a Connection with Gut Microbiota? Microorganisms 2021; 9:microorganisms9122549. [PMID: 34946150 PMCID: PMC8703706 DOI: 10.3390/microorganisms9122549] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 12/23/2022] Open
Abstract
Chronic intestinal pseudo-obstruction (CIPO) is a rare clinical syndrome characterized by severe impairment of gastrointestinal (GI) motility, and its symptoms are suggestive of partial or complete intestinal obstruction in the absence of any lesion restricting the intestinal lumen. Diagnosis and therapy of CIPO patients still represent a significant challenge for clinicians, despite their efforts to improve diagnostic workup and treatment strategies for this disease. The purpose of this review is to better understand what is currently known about the relationship between CIPO patients and intestinal microbiota, with a focus on the role of the enteric nervous system (ENS) and the intestinal endocrine system (IES) in intestinal motility, underling the importance of further studies to deeply understand the causes of gut motility dysfunction in these patients.
Collapse
|
9
|
Conley TE, Lal S. Nutritional considerations in severe primary chronic small intestinal dysmotility. Curr Opin Clin Nutr Metab Care 2021; 24:433-439. [PMID: 34175871 DOI: 10.1097/mco.0000000000000775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To provide an update on the recent evidence underpinning the approach to nutritional care in patients with severe primary chronic small bowel dysmotility. RECENT FINDINGS Patients with severe chronic small intestinal dysmotility suffer nutritional and nonnutritional morbidity, both as a result of their underlying polysymptomatic, poorly understood condition and the interventions required. A proportion require artificial nutrition support; however, this is associated with impaired quality of life and associated complications. The approach to nutritional support must therefore engage a multidisciplinary team (MDT) to ensure that decisions to escalate beyond oral nutrition reflect individualised risk-benefit discussions while adopting a holistic approach to symptom management. Since nutritional outcomes are worse in those with the chronic intestinal pseudo-obstruction (CIPO) phenotype, differentiation into CIPO and non-CIPO subgroups, using a pragmatic diagnostic approach rather than invasive/poorly tolerated investigations, can be an important step in achieving nutritional care tailored to the individual. SUMMARY Malnutrition in patients with severe chronic small intestinal dysmotility is multifactorial. Early engagement of a broad team that includes dietitians, psychologists and pain management experts is crucial to achieving the most beneficial and least harmful patient-centred nutritional care outcomes.
Collapse
|
10
|
Vasant DH, Lal S. Recent Advances in the Management of Severe Gastrointestinal Dysmotility. Clin Exp Gastroenterol 2021; 14:163-172. [PMID: 34007199 PMCID: PMC8121621 DOI: 10.2147/ceg.s249877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022] Open
Abstract
Severe gastrointestinal motility disorders with small bowel involvement continue to pose a major clinical challenge to clinicians, particularly because of the limitations of diagnostic tests and the lack of efficacious treatment options. In this article, we review current understanding and the utility of diagnostic modalities and therapeutic approaches, and describe how their limitations may potentially exacerbate prolonged suffering with debilitating symptoms, diagnostic delays, the risk of iatrogenic harm and increased healthcare utilisation in this group of patients. Moreover, observations from intestinal failure units worldwide suggest that this problem could be set to increase in the future, with reported trends of increasing numbers of patients presenting with nutritional consequences. Unfortunately, until recently, there has been a lack of consensus recommendations and guidance to support clinicians with their management approach. The aim of this narrative review is to summarise recent developments in this field following publication of an international census of experts, and subsequent clinical guidelines, which have emphasized the importance of holistic, multidisciplinary care. This is particularly important in achieving good clinical outcomes and ensuring the appropriate use of artificial nutritional support, in order to prevent iatrogenic harm. We discuss how these recent developments may impact clinical practice by supporting the development of specialised clinical services to deliver optimal care, and highlight areas where further research is needed.
Collapse
Affiliation(s)
- Dipesh H Vasant
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Simon Lal
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| |
Collapse
|
11
|
Twenty Years of Gut Transplantation for Chronic Intestinal Pseudo-obstruction: Technical Innovation, Long-term Outcome, Quality of Life, and Disease Recurrence. Ann Surg 2021; 273:325-333. [PMID: 31274659 DOI: 10.1097/sla.0000000000003265] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To define long-term outcome, predictors of survival, and risk of disease recurrence after gut transplantation (GT) in patients with chronic intestinal pseudo-obstruction (CIPO). BACKGROUND GT has been increasingly used to rescue patients with CIPO with end-stage disease and home parenteral nutrition (HPN)-associated complications. However, long-term outcome including quality of life and risk of disease recurrence has yet to be fully defined. METHODS Fifty-five patients with CIPO, 23 (42%) children and 32 (58%) adults, underwent GT and were prospectively studied. All patients suffered gut failure, received HPN, and experienced life-threatening complications. The 55 patients received 62 allografts; 43 (67%) liver-free and 19 (33%) liver-contained with 7 (13%) retransplants. Hindgut reconstruction was adopted in 1993 and preservation of native spleen was introduced in 1999. Immunosuppression was tacrolimus-based with antilymphocyte recipient pretreatment in 41 (75%). RESULTS Patient survival was 89% at 1 year and 69% at 5 years with respective graft survival of 87% and 56%. Retransplantation was successful in 86%. Adults experienced better patient (P = 0.23) and graft (P = 0.08) survival with lower incidence of post-transplant lymphoproliferative disorder (P = 0.09) and graft versus host disease (P = 0.002). Antilymphocyte pretreatment improved overall patient (P = 0.005) and graft (P = 0.069) survival. The initially restored nutritional autonomy was sustainable in 23 (70%) of 33 long-term survivors with improved quality of life. The remaining 10 recipients required reinstitution of HPN due to allograft enterectomy (n = 3) or gut dysfunction (n = 7). Disease recurrence was highly suspected in 4 (7%) recipients. CONCLUSIONS GT is life-saving for patients with end-stage CIPO and HPN-associated complications. Long-term survival is achievable with better quality of life and low risk of disease recurrence.
Collapse
|
12
|
Zhu CZ, Zhao HW, Lin HW, Wang F, Li YX. Latest developments in chronic intestinal pseudo-obstruction. World J Clin Cases 2020. [DOI: 10.12998/wjcc.v8.i23.5850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
|
13
|
Zhu CZ, Zhao HW, Lin HW, Wang F, Li YX. Latest developments in chronic intestinal pseudo-obstruction. World J Clin Cases 2020; 8:5852-5865. [PMID: 33344584 PMCID: PMC7723695 DOI: 10.12998/wjcc.v8.i23.5852] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 10/02/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic intestinal pseudo-obstruction (CIPO) is a type of intestinal dysfunction presenting as symptoms of intestinal obstruction but without actual mechanical obstruction. An extremely low incidence, non-specific clinical symptoms, strong heterogeneity, and no definitive cause in some patients make CIPO very difficult to diagnose correctly. Imaging and gastrointestinal manometry are commonly used. Most patients have progressive worsening of their symptoms and require intervention, and nutritional assessment and treatment are very important to determine the prognosis. With improvements in surgical techniques, small bowel transplantation is a feasible treatment option for patients with advanced CIPO; however, the long-term prognosis for CIPO patients remains unsatisfactory. Generally, the disease is rare and difficult to diagnose, which leads to clinicians’ lack of understanding of the disease and results in a high rate of misdiagnosis. This review describes the characteristics of CIPO and the latest developments in diagnosis and treatment, in detail. The goal of our review is to improve clinicians' understanding of CIPO so that the disease is identified quickly and accurately, and treated as early as possible to improve patients’ quality of life.
Collapse
Affiliation(s)
- Chang-Zhen Zhu
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Hong-Wei Zhao
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Hong-Wei Lin
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Feng Wang
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Yuan-Xin Li
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| |
Collapse
|
14
|
Vasant DH, Pironi L, Barbara G, Bozzetti F, Cuerda C, Joly F, Mundi M, Paine P, Staun M, Szczepanek K, Van Gossum A, Wanten G, Lal S. An international survey on clinicians' perspectives on the diagnosis and management of chronic intestinal pseudo-obstruction and enteric dysmotility. Neurogastroenterol Motil 2020; 32:e13937. [PMID: 32696607 DOI: 10.1111/nmo.13937] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) and enteric dysmotility (ED) are small intestinal motility disorders defined by radiological and manometric criteria. In the absence of consensus guidelines, we surveyed opinions on the diagnosis and management of CIPO and ED among experts from different countries. METHODS A survey questionnaire was circulated electronically to members of the European society for Clinical Nutrition and Metabolism, European Society of Neurogastroenterology and Motility, and United European Gastroenterology. Only responses from participants completing all required components were included. KEY RESULTS Of 154 participants, 93% agreed that CIPO and ED should be classified separately. Overall, 73% reported an increasing incidence of CIPO and ED, with hypermobile Ehlers-Danlos Syndrome the group with the largest increase in referrals (37%), particularly in the UK (P < .0001). The majority (95%) find diagnosing CIPO and ED difficult. Notably, antroduodenal manometry, a test mandated to diagnose ED, is infrequently used (only 21% respondents use in >50% cases) and full thickness biopsies were reported to seldom influence medical treatment, nutritional management, and prognosis. Respondents reported that very few treatments are useful for most patients, with bacterial overgrowth treatment, prucalopride, and psychological therapies felt to be the most useful. While only 23% of clinicians felt that parenteral nutrition (PN) improves gastrointestinal symptoms in >50% of cases, 68% reported PN dependency at 5 years in the majority of cases. CONCLUSIONS AND INFERENCES These data highlight the difficulties with diagnosing and managing CIPO and ED and underscore the urgent need for international, multidisciplinary, clinical practice guidelines.
Collapse
Affiliation(s)
- Dipesh H Vasant
- Manchester University NHS Foundation Trust, Manchester, UK.,University of Manchester, Manchester, UK
| | | | | | | | | | | | | | - Peter Paine
- University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | | | - Geert Wanten
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simon Lal
- University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
| |
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW Chronic intestinal pseudo-obstruction (CIPO) is the most severe and disabling form of gastrointestinal dysmotility characterized by an impairment of coordinated propulsive activity in the gastrointestinal tract mimicking mechanical intestinal obstruction. Over the last few years, major advances have been made in the diagnostic and therapeutic management of this rare disorder. RECENT FINDINGS The present narrative review aims to summarize the current literature about the management of CIPO focusing on significant novelties about definition, epidemiology, diagnosis, and therapeutic options. The most significant advancement is a consensus on classification and dedicated diagnostic criteria for CIPO in children highlighting the distinctive features between adult and pediatric forms of CIPO (hence pediatric intestinal pseudo-obstruction). Despite no single diagnostic test is pathognomonic of CIPO and no recommended drug treatment is advised to improve gastrointestinal motility, recent reports suggest promising results in both diagnostic testing and therapy that might assist the diagnosis and help the management of patients with CIPO. SUMMARY The articles referenced in this review will help in optimizing the clinical management of this rare and severe disease in adult population.
Collapse
|
16
|
Gonzalez Z, McCallum R. Small Bowel Dysmotility, Pseudoobstruction, and Functional Correlation with Histopathology: Lessons Learned. Curr Gastroenterol Rep 2020; 22:14. [PMID: 32078071 DOI: 10.1007/s11894-020-0748-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Small bowel dysmotility is a broad heterogeneous term that encompasses a wide range of gastrointestinal disorders resulting from abnormal gut motility. Chronic intestinal pseudo-obstruction (CIPO) is a severe, rare, and complex small bowel motility disorder at the extreme end of this spectrum. It is characterized by failure of the intestinal tract to propel contents, which results in signs and symptoms of bowel obstruction albeit in the absence of any obstructive lesion(s). In this article, we discuss up-to-date diagnostic techniques, management options, and histopathological findings in CIPO. RECENT FINDINGS We will emphasize the latest diagnostic methodologies and therapeutic options as well as enteric histopathologic abnormalities in patients with CIPO. CIPO continues to be a clinical challenge. Several novel pharmacological agents hold promise including gastrointestinal hormone agonists and prokinetics. Furthermore, histopathologic findings may help guide therapy and provide further prognostic significance. At present, nutritional support, symptom management, and avoidance of long-term complications are the mainstay of treatment in CIPO.
Collapse
Affiliation(s)
- Zorisadday Gonzalez
- Department of Gastroenterology, GI Motility Training and Research, Texas Tech University Health Sciences Center El Paso, 4800 Alberta, MSC 41007, El Paso, TX, 79905, USA.
| | - Richard McCallum
- Division of Gastroenterology, Center for Neurogastroenterology and GI Motility, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta, MSC 41007, El Paso, TX, 79905, USA
| |
Collapse
|
17
|
Pironi L, Sasdelli AS. Management of the Patient with Chronic Intestinal Pseudo-Obstruction and Intestinal Failure. Gastroenterol Clin North Am 2019; 48:513-524. [PMID: 31668180 DOI: 10.1016/j.gtc.2019.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Chronic intestinal pseudo-obstruction (CIPO) is a severe form of intestinal dysmotility disorder, characterized by the impairment of gastrointestinal propulsion of the gut content in the absence of fixed occluding lesions. CIPO is a rare disease that can develop in both children and adults. CIPO is classified as primary/idiopathic, when no underlying disorder is demonstrated, or secondary, when related to systemic diseases. Diagnosis relies on the finding of chronic/recurrent obstructive type symptoms with radiological features of dilated intestine with air/fluid levels without any lumen occluding lesion. Therapy is based on nutrition, pharmacologic and surgical intervention and requires a multidisciplinary approach.
Collapse
Affiliation(s)
- Loris Pironi
- Chronic Intestinal Failure Unit, Department of Medical and Surgical Sciences, Saint Orsola Hospital, University of Bologna, Bologna, Italy.
| | - Anna Simona Sasdelli
- Chronic Intestinal Failure Unit, Department of Medical and Surgical Sciences, Saint Orsola Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
18
|
Boschetti E, Malagelada C, Accarino A, Malagelada JR, Cogliandro RF, Gori A, Bonora E, Giancola F, Bianco F, Tugnoli V, Clavenzani P, Azpiroz F, Stanghellini V, Sternini C, De Giorgio R. Enteric neuron density correlates with clinical features of severe gut dysmotility. Am J Physiol Gastrointest Liver Physiol 2019; 317:G793-G801. [PMID: 31545923 PMCID: PMC6962493 DOI: 10.1152/ajpgi.00199.2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastrointestinal (GI) symptoms can originate from severe dysmotility due to enteric neuropathies. Current methods used to demonstrate enteric neuropathies are based mainly on classic qualitative histopathological/immunohistochemical evaluation. This study was designed to identify an objective morphometric method for paraffin-embedded tissue samples to quantify the interganglionic distance between neighboring myenteric ganglia immunoreactive for neuron-specific enolase, as well as the number of myenteric and submucosal neuronal cell bodies/ganglion in jejunal specimens of patients with severe GI dysmotility. Jejunal full-thickness biopsies were collected from 32 patients (22 females; 16-77 yr) with well-characterized severe dysmotility and 8 controls (4 females; 47-73 yr). A symptom questionnaire was filled before surgery. Mann-Whitney U test, Kruskal-Wallis coupled with Dunn's posttest and nonparametric linear regression tests were used for analyzing morphometric data and clinical correlations, respectively. Compared with controls, patients with severe dysmotility exhibited a significant increase in myenteric interganglionic distance (P = 0.0005) along with a decrease in the number of myenteric (P < 0.00001) and submucosal (P < 0.0004) neurons. A 50% reduction in the number of submucosal and myenteric neurons correlated with an increased interganglionic distance and severity of dysmotility. Our study proposes a relatively simple tool that can be applied for quantitative evaluation of paraffin sections from patients with severe dysmotility. The finding of an increased interganglionic distance may aid diagnosis and limit the direct quantitative analysis of neurons per ganglion in patients with an interganglionic distance within the control range.NEW & NOTEWORTHY Enteric neuropathies are challenging conditions characterized by a severe impairment of gut physiology, including motility. An accurate, unambiguous assessment of enteric neurons provided by quantitative analysis of routine paraffin sections may help to define neuropathy-related gut dysmotility. We showed that patients with severe gut dysmotility exhibited an increased interganglionic distance associated with a decreased number of myenteric and submucosal neurons, which correlated with symptoms and clinical manifestations of deranged intestinal motility.
Collapse
Affiliation(s)
- Elisa Boschetti
- 1Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carolina Malagelada
- 2Digestive System Research Unit, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Anna Accarino
- 2Digestive System Research Unit, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Juan R. Malagelada
- 2Digestive System Research Unit, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | | | - Alessandra Gori
- 1Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elena Bonora
- 1Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fiorella Giancola
- 1Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca Bianco
- 1Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vitaliano Tugnoli
- 3Department of Biomedical and Neuro Motor Sciences, University of Bologna, Bologna, Italy
| | - Paolo Clavenzani
- 4Department of Veterinary Medicine, University of Bologna, Ozzano, Italy
| | - Fernando Azpiroz
- 2Digestive System Research Unit, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | | | - Catia Sternini
- 5Digestive Disease Division, Departments of Medicine and Neurobiology, University of California, Los Angeles, California
| | | |
Collapse
|
19
|
Paine P, McMahon M, Farrer K, Overshott R, Lal S. Jejunal feeding: when is it the right thing to do? Frontline Gastroenterol 2019; 11:397-403. [PMID: 32884631 PMCID: PMC7447283 DOI: 10.1136/flgastro-2019-101181] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 02/04/2023] Open
Abstract
The decision to commence jejunal feeding in patients with structural abnormalities, which prevent oral or intragastric feeding, is usually straightforward. However, decisions surrounding the need for jejunal feeding can be more complex in individuals with no clear structural abnormality, but rather with foregut symptoms and pain-predominant presentations, suggesting a functional origin. This appears to be an increasing issue in polysymptomatic patients with multi-system involvement. We review the differential diagnosis together with the limitations of available functional clinical tests; symptomatic management options to avoid escalation where possible including for patients on opioids; tube feeding options where necessary; and an approach to weaning from established jejunal feeding in the context of a multidisciplinary approach to minimise iatrogenesis.
Collapse
Affiliation(s)
- Peter Paine
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, Salford, UK
| | - Marie McMahon
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, Salford, UK
| | | | - Ross Overshott
- Department of Liaison Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| |
Collapse
|
20
|
Lindberg G. Pseudo-obstruction, enteric dysmotility and irritable bowel syndrome. Best Pract Res Clin Gastroenterol 2019; 40-41:101635. [PMID: 31594655 DOI: 10.1016/j.bpg.2019.101635] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/18/2019] [Indexed: 02/06/2023]
Abstract
New diagnostic techniques have advanced our knowledge about the irritable bowel syndrome. The majority of patients that we believed to have a psychosomatic disorder have received other diagnoses explaining their symptoms. Endoscopy makes it possible to diagnose celiac disease before it leads to malnutrition and allows the detection of microscopic colitis as a cause of watery diarrhea. At the severe end of the symptom spectrum enteric dysmotility marks the border at which IBS ceases to be a functional disorder and becomes a genuine motility disorder. Joint hypermobility or Ehlers-Danlos syndrome is present in a substantial proportion of patients with enteric dysmotility. Chronic intestinal pseudo-obstruction is the end-stage of a large number of very rare disorders in which failed peristalsis is the common denominator. Nutritional needs and symptom control are essential in the management of pseudo-obstruction. Home parenteral nutrition is life saving in more than half of patients with chronic intestinal pseudo-obstruction.
Collapse
Affiliation(s)
- Greger Lindberg
- Karolinska Institutet, Department of Medicine, Huddinge and Karolinska University Hospital Huddinge, Patient Area Gastroenterology, Dermatology, and Rheumatology, SE-14186, Stockholm, Sweden.
| |
Collapse
|
21
|
Lee TH, Kim SE, Park KS, Shin JE, Park SY, Ryu HS, Kim JW, Lee YJ, Cho YS, Park S. Medical Professionals' Review of YouTube Videos Pertaining to Exercises for the Constipation Relief. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 72:295-303. [PMID: 30642148 DOI: 10.4166/kjg.2018.72.6.295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 12/11/2022]
Abstract
Background/Aims The primary aims of this study were to evaluate the content quality of YouTube videos on exercises to help relieve constipation and to assess whether the video source, exercise types, and popularity affected their quality. Methods Eight gastroenterologists independently evaluated the exercises presented in the constipation YouTube videos for seven items: image quality, usefulness in relieving constipation (quality 1), usefulness for general physical health (quality 2), difficulty in following, activity intensity, fun, and overall quality. Raters were asked open-ended questions to evaluate the strengths and weaknesses of the videos. Five-point ordinal scales were used to score each item aforementioned, with the exception of image quality and overall quality that used a six-point Likert scale. Results The 20 videos had a mean length of 268 seconds and a mean viewership of 32,694. The most common video source was commercial (n=10), and the most common type of physical activity was yoga (n=11). The median values of image quality, quality 1, quality 2, difficulty in following, activity intensity, fun, and overall quality were 3, 2, 2, 2, 2, 2, and 2, respectively. Yoga videos had significantly higher median quality 1 values (3) compared with massage videos (2, adjusted p=0.006) and 'others' videos (2, adjusted p<0.001). A lack of medical evidence was the most common answer to open-ended questions about the weaknesses of each video. Conclusions Overall, YouTube exercise videos presented a low-quality content. This study highlights the need for evidence-based comprehensive educational videos addressing exercises for treating constipation.
Collapse
Affiliation(s)
- Tae Hee Lee
- Institute for Digestive Research, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Medical Research institute, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seon-Young Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Han Seung Ryu
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yoo Jin Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Young Sin Cho
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | | |
Collapse
|
22
|
Song EM, Kim JW, Lee SH, Chang K, Hwang SW, Park SH, Yang DH, Jung KW, Ye BD, Byeon JS, Yang SK, Lee HJ, Yu CS, Kim CW, Park SH, Kim J, Myung SJ. Colonic Pseudo-obstruction With Transition Zone: A Peculiar Eastern Severe Dysmotility. J Neurogastroenterol Motil 2019; 25:137-147. [PMID: 30646485 PMCID: PMC6326194 DOI: 10.5056/jnm18121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/19/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Previous studies from Korea have described chronic intestinal pseudo-obstruction (CIPO) patients with transition zone (TZ) in the colon. In this study, we evaluated the pathological characteristics and their association with long-term outcomes in Korean colonic pseudo-obstruction (CPO) patients with TZ. Methods We enrolled 39 CPO patients who were refractory to medical treatment and underwent colectomy between November 1989 and April 2016 (median age at symptoms onset: 45 [interquartile range, 29–57] years, males 46.2%). The TZ was defined as a colonic segment connecting a proximally dilated and distally non-dilated segment. Detailed pathologic analysis was performed. Results Among the 39 patients, 37 (94.9%) presented with TZ and 2 (5.1%) showed no definitive TZ. Median ganglion cell density in the TZ adjusted for the colonic circumference was significantly decreased compared to that in proximal dilated and distal non-dilated segments in TZ (+) patients (9.2 vs 254.3 and 150.5, P < 0.001). Among the TZ (+) patients, 6 showed additional pathologic findings including eosinophilic ganglionitis (n = 2), ulcers with combined cytomegalovirus infection (n = 2), diffuse ischemic changes (n = 1), and heterotropic myenteric plexus (n = 1). During follow-up (median, 61 months), 32 (82.1%) TZ (+) patients recovered without symptom recurrence after surgery. The presence of pathological features other than hypoganglionosis was an independent predictor of symptom recurrence after surgery (P = 0.046). Conclusions Hypoganglionosis can be identified in the TZ of most Korean CPO patients. Detection of other pathological features in addition to TZ-associated hypoganglionosis was associated with poor post-operative outcomes.
Collapse
Affiliation(s)
- Eun Mi Song
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi-do, Korea
| | - Sun-Ho Lee
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kiju Chang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Wook Hwang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Hyoung Park
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Hoon Yang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kee Wook Jung
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byong Duk Ye
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong-Sik Byeon
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Suk-Kyun Yang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hyo Jeong Lee
- Health Screening and Promotion Center, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chan Wook Kim
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seong Ho Park
- Departments of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jihun Kim
- Departments of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung-Jae Myung
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
23
|
Gallego D, Malagelada C, Accarino A, Gori A, Malagelada JR, Azpiroz F, De Giorgio R, Jimenez M. Functional neuromuscular impairment in severe intestinal dysmotility. Neurogastroenterol Motil 2018; 30:e13458. [PMID: 30178519 DOI: 10.1111/nmo.13458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/18/2018] [Accepted: 08/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) and enteric dysmotility (ED) are severe intestinal motility disorders usually associated with underlying neuromuscular abnormalities. OBJECTIVE To evaluate the in vitro neuromuscular function of patients with severe intestinal motility disorders. METHODS Full-thickness intestinal biopsies (16 jejunum and 3 ileum) obtained from patients with CIPO (n = 10) and ED (n = 9) were studied using muscle bath and microelectrode techniques. Control samples (n = 6 ileum and n = 6 jejunum) were used to establish the range of normality. KEY RESULTS Fourteen parameters were defined to assess muscle contractility and nerve-muscle interaction: five to evaluate smooth muscle and interstitial cells of Cajal (ICC) and nine to evaluate inhibitory neuromuscular transmission. For each sample, a parameter was scored 0 if the value was inside the normal range or a value of 1 if it was outside. Patients' samples (CIPO/ED) had more abnormal parameters than controls (P < 0.001 for both jejunum and ileum). Functional abnormalities were found to be heterogeneous. The most prevalent abnormality was a decreased purinergic neuromuscular transmission, which was detected in 43.8% of jejunal samples. CONCLUSIONS AND INFERENCES Abnormalities of neuromuscular intestinal function are detected in vitro in severe intestinal dysmotility. However, consistent with the heterogeneity of the disease pathophysiology, functional impairment cannot be attributed to a single mechanism. Specifically, defects of purinergic neuromuscular transmission may have an important role in motility disorders of the gastrointestinal tract.
Collapse
Affiliation(s)
- Diana Gallego
- Department of Cell Biology, Physiology and Immunology and Neurosciences Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Carolina Malagelada
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Accarino
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alessandra Gori
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Juan Ramón Malagelada
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Fernando Azpiroz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Marcel Jimenez
- Department of Cell Biology, Physiology and Immunology and Neurosciences Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| |
Collapse
|
24
|
Vasant DH, Kalaiselvan R, Ablett J, Bond A, Abraham A, Teubner A, Green D, Paine PA, Lal S. The chronic intestinal pseudo-obstruction subtype has prognostic significance in patients with severe gastrointestinal dysmotility related intestinal failure. Clin Nutr 2018; 37:1967-1975. [DOI: 10.1016/j.clnu.2018.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 12/16/2022]
|
25
|
Wixner J, Törnblom H, Karling P, Anan I, Lindberg G. Abnormal small bowel motility in patients with hereditary transthyretin amyloidosis. Neurogastroenterol Motil 2018; 30:e13354. [PMID: 29655299 DOI: 10.1111/nmo.13354] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/16/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Gastrointestinal complications are common in hereditary transthyretin amyloid (ATTRm) amyloidosis. The underlying mechanisms have not been fully elucidated, and the patients' small bowel function remains largely unexplored. The aim of the present study was to compare the small bowel motility in ATTRm amyloidosis patients with that in non-amyloidosis patient controls. METHODS ATTRm amyloidosis patients undergoing evaluation for liver transplantation were consecutively investigated with 24-hour duodenojejunal manometry (n = 19). The somatostatin analogue octreotide was used to induce fasting motility. Patients with age at onset of ≥50 years were defined as late-onset cases. For each patient, three age- and sex-matched patient controls (n = 57) were selected from the total pool of investigated patients. KEY RESULTS Manometry was judged as abnormal in 58% of the patients and in 26% of the patient controls (P = .01). Patients displayed significantly more daytime phase III migrating motor complexes than patient controls (median 4 vs 2, P < .01), and had a higher frequency of low-amplitude complexes (16% vs 4%; however, this difference did not reach statistical significance, P = .10). Furthermore, late-onset patients showed a delay in octreotide response (5.4 vs 3.8 minutes, P < .01), but this was not observed for early-onset patients or within the control group. CONCLUSIONS AND INFERENCES Patients with ATTRm amyloidosis displayed abnormalities in their small bowel motility more frequently than non-amyloidosis patient controls, and the manometric pattern was probably best consistent with a combined neuromyopathic disorder. The delayed octreotide response in late-onset patients warrants further investigation.
Collapse
Affiliation(s)
- J Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - H Törnblom
- Department of Medicine & Clinical Nutrition, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - P Karling
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - I Anan
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - G Lindberg
- Department of Medicine, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| |
Collapse
|
26
|
Lu W, Xiao Y, Huang J, Lu L, Tao Y, Yan W, Cao Y, Cai W. Causes and prognosis of chronic intestinal pseudo-obstruction in 48 subjects: A 10-year retrospective case series. Medicine (Baltimore) 2018; 97:e12150. [PMID: 30200110 PMCID: PMC6133590 DOI: 10.1097/md.0000000000012150] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the study was to evaluate the prognosis and survival of pediatric subjects with chronic intestinal pseudo-obstruction (CIPO) and investigate the independent risk factors affecting their prognosis.This was a retrospective case series of all pediatric subjects suffering from CIPO and treated at the Pediatric Surgical ward of Xinhua Hospital between January 2006 and January 2016.The overall mortality was 19/48 (39.6%). Because of delayed CIPO diagnosis, many subjects underwent a variety of surgical procedures. The rate of additional surgical procedures was high (35/48, 72.9%), but the number of surgical procedures, parenteral nutrition, and megacystis did not affect mortality. Mycotic infection was significantly associated with mortality, while onset at <1 year and hypoganglionosis showed a tendency to be associated with mortality.Mycotic infection was associated with mortality of children with CIPO. Despite improving treatment approaches, the overall prognosis of CIPO remains poor. The choice of the surgical intervention could be based on standard criteria.
Collapse
Affiliation(s)
- Wei Lu
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Yongtao Xiao
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University
- Shanghai Institute for Pediatric Research
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Jianhu Huang
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Lina Lu
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Yiqing Tao
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Weihui Yan
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Yi Cao
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Wei Cai
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University
- Shanghai Institute for Pediatric Research
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| |
Collapse
|
27
|
Paediatric Intestinal Pseudo-obstruction: Evidence and Consensus-based Recommendations From an ESPGHAN-Led Expert Group. J Pediatr Gastroenterol Nutr 2018; 66:991-1019. [PMID: 29570554 DOI: 10.1097/mpg.0000000000001982] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Chronic intestinal pseudo-obstructive (CIPO) conditions are considered the most severe disorders of gut motility. They continue to present significant challenges in clinical care despite considerable recent progress in our understanding of pathophysiology, resulting in unacceptable levels of morbidity and mortality. Major contributors to the disappointing lack of progress in paediatric CIPO include a dearth of clarity and uniformity across all aspects of clinical care from definition and diagnosis to management. In order to assist medical care providers in identifying, evaluating, and managing children with CIPO, experts in this condition within the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition as well as selected external experts, were charged with the task of developing a uniform document of evidence- and consensus-based recommendations. METHODS Ten clinically relevant questions addressing terminology, diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to June 2017 using a number of established electronic databases as well as repositories. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to evaluate outcome measures for the research questions. Levels of evidence and quality of evidence were assessed using the classification system of the Oxford Centre for Evidence-Based Medicine (diagnosis) and the GRADE system (treatment). Each of the recommendations were discussed, finalized, and voted upon using the nominal voting technique to obtain consensus. RESULTS This evidence- and consensus-based position paper provides recommendations specifically for chronic intestinal pseudo-obstruction in infants and children. It proposes these be termed paediatric intestinal pseudo-obstructive (PIPO) disorders to distinguish them from adult onset CIPO. The manuscript provides guidance on the diagnosis, evaluation, and treatment of children with PIPO in an effort to standardise the quality of clinical care and improve short- and long-term outcomes. Key recommendations include the development of specific diagnostic criteria for PIPO, red flags to alert clinicians to the diagnosis and guidance on the use of available investigative modalities. The group advocates early collaboration with expert centres where structured diagnosis and management is guided by a multi-disciplinary team, and include targeted nutritional, medical, and surgical interventions as well as transition to adult services. CONCLUSIONS This document is intended to be used in daily practice from the time of first presentation and definitive diagnosis PIPO through to the complex management and treatment interventions such as intestinal transplantation. Significant challenges remain to be addressed through collaborative clinical and research interactions.
Collapse
|
28
|
Malagelada C, Karunaratne TB, Accarino A, Cogliandro RF, Landolfi S, Gori A, Boschetti E, Malagelada JR, Stanghellini V, Azpiroz F, De Giorgio R. Comparison between small bowel manometric patterns and full-thickness biopsy histopathology in severe intestinal dysmotility. Neurogastroenterol Motil 2018; 30. [PMID: 28941004 DOI: 10.1111/nmo.13219] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 09/04/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intestinal manometry is the current standard for direct evaluation of small bowel dysmotility. Patients with abnormal motility can either be diagnosed of pseudo-obstruction when there are radiological findings mimicking mechanical intestinal obstruction or of enteric dysmotility when these findings are absent. The aim of the present study was to prospectively compare small bowel manometric abnormalities with histopathological findings in intestinal full-thickness biopsies in patients with severe dysmotility disorders. METHODS We investigated 38 patients with intestinal manometry and a subsequent full-thickness intestinal biopsy. Manometric recordings were read by 4 investigators and a diagnostic consensus was obtained in 35 patients. Histopathological analysis, including specific immunohistochemical techniques of small bowel biopsies was performed and compared to manometric readings. KEY RESULTS Patients with abnormal intestinal manometry had abnormal histopathological findings in 73% of cases. However, manometric patterns did not match with the specific neuromuscular abnormalities. Among patients with a neuropathic manometry pattern and abnormal histopathology, only 23% had an enteric neuropathy, whereas 62% had neuromuscular inflammation, and 15% an enteric myopathy. On the other hand, patients with a myopathic manometry pattern all had abnormal histopathology, however, none of them with signs of enteric myopathy. CONCLUSION & INFERENCES Small bowel dysmotility detected by intestinal manometry is often associated with abnormal neuromuscular findings in full-thickness biopsies. However, there is no correlation between the specific manometric patterns and the histopathological findings.
Collapse
Affiliation(s)
- C Malagelada
- Digestive System Research Unit, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - T B Karunaratne
- Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.), University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - A Accarino
- Digestive System Research Unit, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - R F Cogliandro
- Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.), University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - S Landolfi
- Department of Pathology, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Barcelona, Spain
| | - A Gori
- Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.), University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - E Boschetti
- Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.), University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - J R Malagelada
- Digestive System Research Unit, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - V Stanghellini
- Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.), University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - F Azpiroz
- Digestive System Research Unit, University Hospital Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - R De Giorgio
- Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.), University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| |
Collapse
|
29
|
Mauro A, Basilisco G, Franchina M, Elvevi A, Pugliese D, Conte D, Penagini R. Oesophageal motor function in chronic intestinal idiopathic pseudo-obstruction: A study with high-resolution manometry. Dig Liver Dis 2018; 50:142-146. [PMID: 29089268 DOI: 10.1016/j.dld.2017.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 10/08/2017] [Accepted: 10/09/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic intestinal idiopathic pseudo-obstruction (idiopathic CIPO) is a rare heterogeneous condition for which the different phenotypes are difficult to be established. Oesophageal motility has shown to be impaired in patients with idiopathic CIPO at traditional manometry, whereas no studies have assessed it by high resolution manometry (HRM). AIMS To evaluate oesophageal motility by HRM in patients with idiopathic CIPO. METHODS 14 patients with idiopathic CIPO underwent oesophageal HRM. Multiple rapid swallows (MRS) were performed in order to evaluate contraction reserve. The Chicago Classification 3.0 was used to classify the oesophageal motility disorders. RESULTS One idiopathic CIPO patient had type-II achalasia, one aperistalsis and 12 had minor disorder of peristalsis (11 ineffective oesophageal motility and one fragmented peristalsis). These minor disorders were not significantly different from those of 50 other consecutive patients who underwent HRM for dysphagia or GERD and received the diagnosis of ineffective oesophageal motility. Three of the 12 idiopathic CIPO patients with minor disorder of peristalsis had no contraction reserve after MRS. CONCLUSIONS HRM is able to identify different grades of oesophageal motor impairment in patients with idiopathic CIPO. Presence of major oesophageal dismotility or absent contraction reserve suggest a more severe and widespread motor disorder.
Collapse
Affiliation(s)
- Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Italy.
| | - Guido Basilisco
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Italy
| | - Marianna Franchina
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Italy
| | - Alessandra Elvevi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Italy
| | - Delia Pugliese
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Italy
| |
Collapse
|
30
|
Fuyuki A, Ohkubo H, Higurashi T, Iida H, Inoh Y, Inamori M, Nakajima A. Clinical importance of cine-MRI assessment of small bowel motility in patients with chronic intestinal pseudo-obstruction: a retrospective study of 33 patients. J Gastroenterol 2017; 52:577-584. [PMID: 27549243 DOI: 10.1007/s00535-016-1251-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/06/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although chronic intestinal pseudo-obstruction (CIPO) is a rare and extremely severe functional digestive disorder, its clinical course and severity show various patterns. We assessed small bowel peristalsis in CIPO patients using cine-MRI (video-motion MRI) and their clinical characteristics to evaluate the clinical importance of performing cine-MRI in patients with this intractable disease. METHODS The medical records of 131 patients referred to our institution with a suspected diagnosis of CIPO between 2010 and 2015 were retrospectively evaluated. Thirty-three patients (22 female/11 male; age range 16-79 years) who met the criteria for CIPO and underwent cine-MRI were enrolled. Mean luminal diameter (MLD), contraction ratio (CR), and contraction cycle (CC) were determined and compared with these parameters in healthy volunteers. Clinical outcomes in patients with CIPO were also evaluated. RESULTS The median follow-up time was 25.2 months (range, 1-65 months). Of the 33 patients with CIPO, 23 (70 %) showed apparently disturbed small intestinal peristalsis, whereas 10 (30 %) did not. The percentage of patients requiring intravenous alimentation was significantly higher (p = 0.03), and the mean serum albumin level was significantly lower (p = 0.04), in patients with than without impaired small intestinal peristalsis. Although both cine-MRI and CT findings in the latter ten cases were within the normal range, MLD and CR differed significantly from healthy volunteers. CONCLUSIONS Cine-MRI is useful in predicting severe clinical features in patients with CIPO, and in detecting slightly impaired small contractility that cannot be detected on CT.
Collapse
Affiliation(s)
- Akiko Fuyuki
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Hidenori Ohkubo
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takuma Higurashi
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Hiroshi Iida
- Department of Medical Education, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yumi Inoh
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Masahiko Inamori
- Department of Medical Education, Yokohama City University School of Medicine, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan.
| |
Collapse
|
31
|
Di Nardo G, Di Lorenzo C, Lauro A, Stanghellini V, Thapar N, Karunaratne TB, Volta U, De Giorgio R. Chronic intestinal pseudo-obstruction in children and adults: diagnosis and therapeutic options. Neurogastroenterol Motil 2017; 29. [PMID: 27683196 DOI: 10.1111/nmo.12945] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) represents the most severe form of gastrointestinal dysmotility with debilitating and potentially lethal consequences. Symptoms can be non-specific, and result in this condition being diagnosed incorrectly or too late with consequences for morbidity and even mortality. PURPOSE The present article aims to provide pediatric and adult gastroenterologists with an up to date review about clinical features, diagnosis and therapeutic options for CIPO. Although pediatric and adult CIPO share many clinical aspects distinctive features can be identified. There is no single diagnostic test or pathognomonic finding of CIPO, thus a stepwise approach including radiology, endoscopy, laboratory, manometry, and histopathology should be considered in the diagnostic work-up. Treatment of patients with CIPO is challenging and requires a multidisciplinary effort with participation of appropriately experienced gastroenterologists, pathologists, dieticians, surgeons, psychologists, and other subspecialists based on the presence of comorbidities. Current treatment options invariably involve surgery and specialized nutritional support, especially in children. Medical therapies are mainly aimed to avoid complications such as sepsis or intestinal bacterial overgrowth and, where possible, restore intestinal propulsion. More efficacious therapeutic options are eagerly awaited for such difficult patients.
Collapse
Affiliation(s)
- G Di Nardo
- Pediatric Unit, Orvieto Hospital, Orvieto, Italy.,Pediatric Gastroenterology Unit, International Hospital Salvator Mundi, Rome, Italy
| | - C Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - A Lauro
- Liver and Multiorgan Transplant Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - V Stanghellini
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - N Thapar
- Department of Gastroenterology, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - T B Karunaratne
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - U Volta
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - R De Giorgio
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| |
Collapse
|
32
|
Emmanuel A. Current management of the gastrointestinal complications of systemic sclerosis. Nat Rev Gastroenterol Hepatol 2016; 13:461-72. [PMID: 27381075 DOI: 10.1038/nrgastro.2016.99] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic sclerosis is a multisystem autoimmune disorder that involves the gastrointestinal tract in more than 90% of patients. This involvement can extend from the mouth to the anus, with the oesophagus and anorectum most frequently affected. Gut complications result in a plethora of presentations that impair oral intake and faecal continence and, consequently, have an adverse effect on patient quality of life, resulting in referral to gastroenterologists. The cornerstones of gastrointestinal symptom management are to optimize symptom relief and monitor for complications, in particular anaemia and malabsorption. Early intervention in patients who develop these complications is critical to minimize disease progression and improve prognosis. In the future, enhanced therapeutic strategies should be developed, based on an ever-improving understanding of the intestinal pathophysiology of systemic sclerosis. This Review describes the most commonly occurring clinical scenarios of gastrointestinal involvement in patients with systemic sclerosis as they present to the gastroenterologist, with recommendations for the suggested assessment protocol and therapy in each situation.
Collapse
Affiliation(s)
- Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, 235 Euston Road, London NW1 2BU, UK
| |
Collapse
|
33
|
Abstract
Nordic research on gastrointestinal motility has since 1965 made substantial contributions to our current understanding of gastrointestinal function. During the last decade, the term neurogastroenterology has widened the concept of motility research into the study of gastrointestinal sensory-motor function, including the complex central nervous system interaction. The discovery of a non-adrenergic non-cholinergic (NANC) innervation of the gut in the sixties was made by considerable contributions from the Nordic countries with the Martinson group in Sweden as central innovators. Important discoveries regarding the intramural nerve ganglia as mediators of the autonomic nervous input has also been produced from this research. In clinical motility research, the study of the migrating motor complex in the small bowel has revealed its ability to act as a retroperistaltic pump in the proximal duodenum (Sweden) and its important role for gut microbial homeostasis (Norway). Also in the development of methodology to study gut sensory-motor function, the Nordic countries has contributed. Examples are the physical characteristics of the esophageal manometry catheter (Denmark), the use of ultrasound for assessment of gastric function (Norway), a temporary electrical stimulation method in patients with severe nausea and vomiting (Sweden), a rectal barostat method for clinical evaluation of recto-anal function and a colonic transit time method utilizing radio-opaque markers (Sweden). In later years, the research collaborations have increasingly become worldwide in a manner making it less easy to define pure Nordic contributions.
Collapse
Affiliation(s)
- Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | | | | |
Collapse
|
34
|
Bonora E, Bianco F, Cordeddu L, Bamshad M, Francescatto L, Dowless D, Stanghellini V, Cogliandro RF, Lindberg G, Mungan Z, Cefle K, Ozcelik T, Palanduz S, Ozturk S, Gedikbasi A, Gori A, Pippucci T, Graziano C, Volta U, Caio G, Barbara G, D'Amato M, Seri M, Katsanis N, Romeo G, De Giorgio R. Mutations in RAD21 disrupt regulation of APOB in patients with chronic intestinal pseudo-obstruction. Gastroenterology 2015; 148:771-782.e11. [PMID: 25575569 PMCID: PMC4375026 DOI: 10.1053/j.gastro.2014.12.034] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 12/03/2014] [Accepted: 12/23/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Chronic intestinal pseudo-obstruction (CIPO) is characterized by severe intestinal dysmotility that mimics a mechanical subocclusion with no evidence of gut obstruction. We searched for genetic variants associated with CIPO to increase our understanding of its pathogenesis and to identify potential biomarkers. METHODS We performed whole-exome sequencing of genomic DNA from patients with familial CIPO syndrome. Blood and lymphoblastoid cells were collected from patients and controls (individuals without CIPO); levels of messenger RNA (mRNA) and proteins were analyzed by quantitative reverse-transcription polymerase chain reaction, immunoblot, and mobility shift assays. Complementary DNAs were transfected into HEK293 cells. Expression of rad21 was suppressed in zebrafish embryos using a splice-blocking morpholino (rad21a). Gut tissues were collected and analyzed. RESULTS We identified a homozygous mutation (p.622, encodes Ala>Thr) in RAD21 in patients from a consanguineous family with CIPO. Expression of RUNX1, a target of RAD21, was reduced in cells from patients with CIPO compared with controls. In zebrafish, suppression of rad21a reduced expression of runx1; this phenotype was corrected by injection of human RAD21 mRNA, but not with the mRNA from the mutated p.622 allele. rad21a Morpholino zebrafish had delayed intestinal transit and greatly reduced numbers of enteric neurons, similar to patients with CIPO. This defect was greater in zebrafish with suppressed expression of ret and rad21, indicating their interaction in the regulation of gut neurogenesis. The promoter region of APOB bound RAD21 but not RAD21 p.622 Ala>Thr; expression of wild-type RAD21 in HEK293 cells repressed expression of APOB, compared with control vector. The gut-specific isoform of APOB (APOB48) is overexpressed in sera from patients with CIPO who carry the RAD21 mutation. APOB48 also is overexpressed in sporadic CIPO in sera and gut biopsy specimens. CONCLUSIONS Some patients with CIPO carry mutations in RAD21 that disrupt the ability of its product to regulate genes such as RUNX1 and APOB. Reduced expression of rad21 in zebrafish, and dysregulation of these target genes, disrupts intestinal transit and the development of enteric neurons.
Collapse
Affiliation(s)
- Elena Bonora
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesca Bianco
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Michael Bamshad
- University of Washington Center for Mendelian Genomics, Seattle, USA
| | | | - Dustin Dowless
- Center for Human Disease Modeling Duke University, Durham, USA
| | - Vincenzo Stanghellini
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Rosanna F. Cogliandro
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | | | | | - Kivanc Cefle
- Istanbul Medical Faculty, Dept. of Internal Medicine, Division of Medical Genetics
| | | | - Sukru Palanduz
- Istanbul Medical Faculty, Dept. of Internal Medicine, Division of Medical Genetics
| | - Sukru Ozturk
- Istanbul Medical Faculty, Dept. of Internal Medicine, Division of Medical Genetics
| | - Asuman Gedikbasi
- Istanbul Medical Faculty, Dept. of Internal Medicine, Division of Medical Genetics
| | - Alessandra Gori
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Tommaso Pippucci
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Claudio Graziano
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Giacomo Caio
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Marco Seri
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Giovanni Romeo
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy.
| | - Roberto De Giorgio
- Department of Medical and Surgical Sciences, University of Bologna, and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro Unificato di Ricerca Biomedica Applicata, Bologna, Italy.
| |
Collapse
|
35
|
Lauro A, De Giorgio R, Pinna AD. Advancement in the clinical management of intestinal pseudo-obstruction. Expert Rev Gastroenterol Hepatol 2015; 9:197-208. [PMID: 25020006 DOI: 10.1586/17474124.2014.940317] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intestinal pseudo-obstruction is more commonly known in its chronic form (CIPO), a cluster of rare diseases characterized by gastrointestinal muscle and nerve impairment, so severe to result in a markedly compromised peristalsis mimicking an intestinal occlusion. The management of CIPO requires the cooperation of a group of specialists: the disease has to be confirmed by a number of tests to avoid mistakes in the differential diagnosis. The treatment should be aimed at relieving symptoms arising from gut dysmotility (ideally using prokinetic agents), controlling abdominal pain (possibly with non-opioid antinociceptive drugs) and optimizing nutritional support. Furthermore, a thorough diagnostic work-up is mandatory to avoid unnecessary (potentially harmful) surgery and to select patients with clear indication to intestinal or multivisceral transplantation.
Collapse
Affiliation(s)
- Augusto Lauro
- General Surgery and Transplant Unit, St. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | | | | |
Collapse
|
36
|
Nagaraja V, McMahan ZH, Getzug T, Khanna D. Management of gastrointestinal involvement in scleroderma. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015; 1:82-105. [PMID: 26005632 DOI: 10.1007/s40674-014-0005-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastrointestinal tract (GIT) commonly affects patients with systemic sclerosis (SSc). The GI involvement is quite heterogeneous varying from asymptomatic disease to significant dysmotility causing complications like malabsorption, weight loss and severe malnutrition. This review focuses on the management of GI involvement in SSc and has been categorized based on the segment of GIT involved. A brief discussion on the role of patient reported outcome measures in SSc-GI involvement has also been incorporated.
Collapse
Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | | | - Terri Getzug
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
37
|
Paine P, McLaughlin J, Lal S. Review article: the assessment and management of chronic severe gastrointestinal dysmotility in adults. Aliment Pharmacol Ther 2013; 38:1209-29. [PMID: 24102305 DOI: 10.1111/apt.12496] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 02/27/2013] [Accepted: 08/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The characterisation and management of chronic severe gastrointestinal (GI) dysmotility are challenging. It may cause intestinal failure requiring home parenteral nutrition (HPN). AIMS To review the presentation, aetiology, characterisation, management and outcome of chronic severe GI dysmotility, and to suggest a pragmatic management algorithm. METHODS PubMed search was performed up to December 2012 using appropriate search terms, restricted to human articles and reviewed for relevance. Segmental dysmotility, acute ileus, functional syndromes and non-English articles were excluded. Evidence and recommendations were evaluated using the GRADE system. RESULTS In total, 721 relevant articles were reviewed. A coherent and definitive picture is hampered by overlapping classification systems using multi-modal characterisation methods, subject to pitfalls and some requiring further validation. The literature is confined to case series with no randomised trials. Fewer than 20% undergo full thickness jejunal biopsy, which are otherwise labelled idiopathic. However, in studies with up to 80% biopsy rates, neuromuscular abnormalities may be found in 90%. Between 14% and 50% will require HPN, comprising 8-14% of all HPN patients, of which 2/3 are primary/idiopathic and 1/3 secondary, with scleroderma being the leading secondary cause. Ten-year mortality ranges from 13% to 35% and is worst in elderly scleroderma patients. Management includes limited treatments for secondary causes, prokinetics, symptom palliation, psychological support, nutrition, hydration and judicious surgery. CONCLUSIONS Severe dysmotility often remains idiopathic. It is rarely possible to alter disease trajectory; consequently, prognosis may be poor. Multi-disciplinary teams in a specialist setting can improve outcomes. Graded recommendations are enumerated and a pragmatic algorithm is suggested.
Collapse
Affiliation(s)
- P Paine
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK; Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | | | | |
Collapse
|
38
|
Alfvén G, Casswall T, Lindberg G, Mårtensson T, Veress B. Another case of prolonged quest for the diagnosis of recurrent abdominal pain (discussion and diagnosis). Acta Paediatr 2013; 102:556-8. [PMID: 23565834 DOI: 10.1111/apa.12189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 01/31/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Gösta Alfvén
- Paediatric Department, Astrid Lindgren's Hospital, Karolinska University Hospital, Stockholm, Sweden.
| | | | | | | | | |
Collapse
|
39
|
Affiliation(s)
| | - Brian E. Lacy
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
40
|
Amiot A, Joly F, Cazals-Hatem D, Merrouche M, Jouet P, Coffin B, Bouhnik Y. Prognostic yield of esophageal manometry in chronic intestinal pseudo-obstruction: a retrospective cohort of 116 adult patients. Neurogastroenterol Motil 2012; 24:1008-e542. [PMID: 22762287 DOI: 10.1111/j.1365-2982.2012.01973.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) refers to a wide and heterogeneous group of neuromuscular disorders, which classically involve the small intestine. However, further investigation is required to determine if motility disturbances involve all parts of the gastrointestinal (GI) tract. METHODS Medical records and follow-up examinations of 116 adult CIPO patients [70F, median age 28 (0-79) years] were reviewed and performed at our institution since 1980. Manometry (esophageal, small bowel and anorectal) and gastric emptying scintigraphy reports were retrieved and analyzed. Survival, home parenteral nutrition requirement, and the inability to maintain sufficient oral feeding was analyzed using univariate and multivariate analysis. KEY RESULTS The median follow-up time was 6 (0.1-30) years. In all, 90% of patients who underwent at least one motility test, with the exception of small bowel manometry, exhibited at least one abnormal pattern. Esophageal manometry was abnormal in 73% of the cases, including 51% with severe ineffective esophageal motility. Anorectal manometry was abnormal in 59% of the cases, including only 17% with severe abnormalities. Gastric emptying was abnormal in 61% of the cases. Only esophageal motor disorders had significant predicting values for survival, home parenteral nutrition requirement, and an inability to maintain sufficient oral feeding. CONCLUSIONS & INFERENCES Our study showed that CIPO was associated with a diffuse involvement of all parts of the GI tract and was not restricted to the small intestine in 90% of the cases studied. Esophageal manometry had a significant prognostic yield and should be systematically performed in CIPO patients.
Collapse
Affiliation(s)
- A Amiot
- Department of Gastroenterology and Nutrition Support, Beaujon Hospital, APHP, Clichy, France. aurelien.amiot.aphp.fr
| | | | | | | | | | | | | |
Collapse
|
41
|
|
42
|
Törnblom H, Lindberg G. A 21st century look at the spectrum of gastrointestinal motility disorders. What is dysmotility; what is functional? Gastroenterol Clin North Am 2011; 40:715-23. [PMID: 22100113 DOI: 10.1016/j.gtc.2011.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Taken together, the above examples indicate that physiology-based diagnosis has a substantial overlap with symptom-based diagnosis. Neither symptomatic treatment nor therapy aimed at restoring normal physiology has had much success. It is still uncertain if measurement of physiologic parameters facilitates the doctor-patient relationship, whether results are abnormal or normal. However, the addition of physiology parameters to the evaluation of therapeutic interventions aimed at symptom reduction in FGIDs can possibly facilitate the identification of subgroups with a higher probability of treatment success. Unfortunately, our experience from clinical trials in this area is that physiology testing usually disappears as a new drug moves from phase II to phase III trials. In the ideal situation, the development of measurement methods with better availability and standardization, like different ingestible capsules, will help us to merge physiology and symptoms regarding both diagnosis and treatment evaluation.
Collapse
Affiliation(s)
- Hans Törnblom
- Karolinska Institutet, Department of Medicine, Karolinska University Hospital, SE-141 86, Stockholm, Sweden
| | | |
Collapse
|
43
|
Abstract
The recent development of consensus guidelines for the preparation and staining of tissues, the publication of the London Classification, and reviews of what is normal in the enteric neuromusculature have been significant steps forward in this field. Increased accessibility to full-thickness biopsies of the bowel wall facilitated by advances in laparoscopic surgery have also played a part in making the decision to ask for a tissue diagnosis easier. Better antibodies for immunohistochemistry and a better understanding of disease processes at work, such as those seen in filamin mutations, all help inform the range of information that can be gleaned from what is usually a very limited sample. Clinical phenotyping remains difficult in many patients, but the availability of specialist pathologic review and the standardization of staining between laboratories are leading to better defined histologic phenotypes, that inform, in turn, possible biological processes at work in these patients. In many instances, a diagnosis may come to light only after some time, and the retention of pathologic samples in paraffin wax, as is standard practice in most laboratories, is of great value in reassessing samples, often after many years, in the light of new advances. The highest quality information, and the best answer for the patient, is, as ever, achieved by close working relationships and excellent communication between clinicians and pathologists.
Collapse
Affiliation(s)
- Charles H Knowles
- Academic Surgical Unit, Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University London, UK.
| | | |
Collapse
|
44
|
De Giorgio R, Cogliandro RF, Barbara G, Corinaldesi R, Stanghellini V. Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy. Gastroenterol Clin North Am 2011; 40:787-807. [PMID: 22100118 DOI: 10.1016/j.gtc.2011.09.005] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CIPO is the very “tip of the iceberg” of functional gastrointestinal disorders, being a rare and frequently misdiagnosed condition characterized by an overall poor outcome. Diagnosis should be based on clinical features, natural history and radiologic findings. There is no cure for CIPO and management strategies include a wide array of nutritional, pharmacologic, and surgical options which are directed to minimize malnutrition, promote gut motility and reduce complications of stasis (ie, bacterial overgrowth). Pain may become so severe to necessitate major analgesic drugs. Underlying causes of secondary CIPO should be thoroughly investigated and, if detected, treated accordingly. Surgery should be indicated only in a highly selected, well characterized subset of patients, while isolated intestinal or multivisceral transplantation is a rescue therapy only in those patients with intestinal failure unsuitable for or unable to continue with TPN/HPN. Future perspectives in CIPO will be directed toward an accurate genomic/proteomic phenotying of these rare, challenging patients. Unveiling causative mechanisms of neuro-ICC-muscular abnormalities will pave the way for targeted therapeutic options for patients with CIPO.
Collapse
|
45
|
Bengtsson M, Hammar O, Mandl T, Ohlsson B. Evaluation of gastrointestinal symptoms in different patient groups using the visual analogue scale for irritable bowel syndrome (VAS-IBS). BMC Gastroenterol 2011; 13:201. [PMID: 24191889 PMCID: PMC3826525 DOI: 10.1186/1471-2393-13-201] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 10/31/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Irritable bowel syndrome (IBS) and gastrointestinal (GI) dysmotility disorders have a similar clinical picture, although dysmotility disorders require the attention of a specialist. Patients with primary Sjögren's syndrome (pSS) have also been described to suffer from IBS-like symptoms. No objective marker is available to distinguish between the patients. A visual analogue scale has been developed for IBS patients (VAS-IBS) to measure treatment response of GI symptoms and well-being in patients with IBS. The aim of the present study was to examine if VAS-IBS could be used to compare the degree of GI complaints in different patient populations, to get an objective marker to differentiate between the patients. METHODS The VAS-IBS consists of 7 VAS scales, namely, abdominal pain, diarrhoea, constipation, bloating and flatulence, vomiting and nausea, psychological well-being and the intestinal symptoms' influence on daily life. Consecutive female patients suffering from IBS, dysmotility disorders and pSS were asked to complete the VAS-IBS questionnaire when visiting the out-patient clinics. In addition, a control population consisting of healthy female volunteers was included. RESULTS Healthy volunteers had almost no GI symptoms, whereas all 3 patient groups expressed symptoms. There was no statistical significant difference between IBS and dysmotility in any of the scales besides vomiting and nausea (p = 0.044). Except for constipation, patients with pSS had less severe symptoms than the others. CONCLUSION The VAS-IBS questionnaire could be used to assess the level of GI symptoms. However, VAS scores do not help the clinicians to differentiate between IBS and other dysmotility disturbances.
Collapse
Affiliation(s)
- Mariette Bengtsson
- Department of Nursing, Faculty of Health and Society, Malmö University, Sweden
| | | | | | | |
Collapse
|
46
|
Evaluation of gastrointestinal symptoms in different patient groups using the visual analogue scale for irritable bowel syndrome (VAS-IBS). BMC Gastroenterol 2011; 11:122. [PMID: 22073983 PMCID: PMC3248355 DOI: 10.1186/1471-230x-11-122] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 11/10/2011] [Indexed: 12/13/2022] Open
Abstract
Background Irritable bowel syndrome (IBS) and gastrointestinal (GI) dysmotility disorders have a similar clinical picture, although dysmotility disorders require the attention of a specialist. Patients with primary Sjögren's syndrome (pSS) have also been described to suffer from IBS-like symptoms. No objective marker is available to distinguish between the patients. A visual analogue scale has been developed for IBS patients (VAS-IBS) to measure treatment response of GI symptoms and well-being in patients with IBS. The aim of the present study was to examine if VAS-IBS could be used to compare the degree of GI complaints in different patient populations, to get an objective marker to differentiate between the patients. Methods The VAS-IBS consists of 7 VAS scales, namely, abdominal pain, diarrhoea, constipation, bloating and flatulence, vomiting and nausea, psychological well-being and the intestinal symptoms' influence on daily life. Consecutive female patients suffering from IBS, dysmotility disorders and pSS were asked to complete the VAS-IBS questionnaire when visiting the out-patient clinics. In addition, a control population consisting of healthy female volunteers was included. Results Healthy volunteers had almost no GI symptoms, whereas all 3 patient groups expressed symptoms. There was no statistical significant difference between IBS and dysmotility in any of the scales besides vomiting and nausea (p = 0.044). Except for constipation, patients with pSS had less severe symptoms than the others. Conclusion The VAS-IBS questionnaire could be used to assess the level of GI symptoms. However, VAS scores do not help the clinicians to differentiate between IBS and other dysmotility disturbances.
Collapse
|
47
|
Kopelman Y, Triadafilopoulos G. Endoscopy in the diagnosis and management of motility disorders. Dig Dis Sci 2011; 56:635-54. [PMID: 21286936 DOI: 10.1007/s10620-011-1584-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/14/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal illness may result from either an underlying structural abnormality (e.g. neoplastic obstruction), or a functional disorder (e.g. motor diarrhea), or both (e.g. achalasia with squamous esophageal cancer). AIMS The purpose of this study was to highlight the potential value and role of endoscopy in the recognition and management of patients with functional and motility disorders. METHODS We performed a literature review in PubMed. RESULTS Diagnostic and therapeutic endoscopy may be under-used by motility-oriented gastroenterologists; in contrast, motility and other functional studies may be under-used by endoscopists. Yet, many areas of cross-exchange exist. CONCLUSIONS This review aims to guide the appropriate indications for the use of endoscopy in diagnosing and treating functional GI and motility disorders and serve as a bridge and a forum of exchange between endoscopists and motility specialists.
Collapse
Affiliation(s)
- Yael Kopelman
- Stanford University School of Medicine, Stanford, CA, USA
| | | |
Collapse
|
48
|
Stanghellini V, Cogliandro RF, De Giorgio R, Barbara G, Cremon C, Antonucci A, Fronzoni L, Cogliandro L, Naponelli V, Serra M, Corinaldesi R. Natural history of intestinal failure induced by chronic idiopathic intestinal pseudo-obstruction. Transplant Proc 2010; 42:15-8. [PMID: 20172271 DOI: 10.1016/j.transproceed.2009.12.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Chronic intestinal pseudo-obstruction is a severe, often unrecognized disease characterized by disabling and potentially life-threatening complications over time. The diagnosis is based on the evidence of typical clinical manifestations, radiological evidence of distended bowel loops with air-fluid levels, and the exclusion of any organic obstruction of the gut lumen. The radiological sign of intestinal occlusion allows the distinction from enteric dysmotility, which is characterized by better outcomes. Manometry can play a supportive role in defining the diagnosis, and differences in the manometric pattern of chronic intestinal pseudo-obstruction and enteric dysmotility have been shown. The disease is often unrecognized, and the diagnosis, therefore, delayed by several years. Thus, the majority of patients undergo useless and potentially dangerous surgeries. Long-term outcomes are generally poor despite surgical and medical therapies characterized by disabling and potentially life-threatening complications over time. A substantial percentage of patients requires parenteral nutrition. Failure of this nutritional support represents an indication for small bowel transplantation.
Collapse
Affiliation(s)
- V Stanghellini
- Department of Clinical Medicine, University of Bologna, Bologna, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Ileocecal intussusception with histomorphological features of inflammatory neuropathy in adenovirus infection. Gastroenterol Res Pract 2010; 2009:579501. [PMID: 20169089 PMCID: PMC2821763 DOI: 10.1155/2009/579501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 11/08/2009] [Accepted: 12/16/2009] [Indexed: 01/24/2023] Open
Abstract
The pathophysiological mechanisms for ileocecal intussusception in children with adenovirus infection are not well characterized. Here we demonstrate coincidence of adenovirus infection and inflammatory neuropathy of myenteric plexus in two children with ileocecal intussusception. Inflammatory neuropathy, an unspecific morphological feature which is found in peristalsis disorders, was morphologically characterized by the influx of CD3 positive lymphocytes in nervous plexus. To our knowledge, this is the first report suggesting peristalsis disorders from inflammatory neuropathy as additional mechanism in the pathophysiological concept of adenovirus-associated ileocecal intussusception.
Collapse
|