Dysmotility disorders: a nutritional approach

Chronic intestinal pseudo-obstruction: associations with gut microbiota and genes expression of intestinal serotonergic pathway

BACKGROUND

Pediatric chronic intestinal pseudo-obstruction (PIPO) is a rare disease characterized by symptoms and radiological signs suggestive of intestinal obstruction, in the absence of lumen-occluding lesions. It results from an extremely severe impairment of propulsive motility. The intestinal endocrine system (IES) jointly with the enteric nervous system (ENS) regulates secreto-motor functions via different hormones and bioactive messengers/neurotransmitters. The neurotransmitter 5-hydroxytryptamine (5-HT) (or serotonin) is linked to intestinal peristalsis and secretory reflexes. Gut microbiota and its interplay with ENS affect 5-HT synthesis, release, and the subsequent serotonin receptor activation. To date, the interplay between 5-HT and gut microbiota in PIPO remains largely unclear. This study aimed to assess correlations between mucosa associated microbiota (MAM), intestinal serotonin-related genes expression in PIPO. To this purpose, biopsies of the colon, ileum and duodenum have been collected from 7 PIPO patients, and 7 age-/sex-matched healthy controls. After DNA extraction, the MAM was assessed by next generation sequencing (NGS) of the V3-V4 region of the bacterial RNA 16 S, on an Illumina Miseq platform. The expression of genes implicated in serotoninergic pathway (TPH1, SLC6A4, 5-HTR3 and 5-HTR4) was established by qPCR, and correlations with MAM and clinical parameters of PIPO have been evaluated.

RESULTS

Our results revealed that PIPO patients exhibit a MAM with a different composition and with dysbiosis, i.e. with a lower biodiversity and fewer less connected species with a greater number of non-synergistic relationships, compared to controls. qPCR results revealed modifications in the expression of serotonin-related intestinal genes in PIPO patients, when compared to controls. Correlation analysis do not reveal any kind of connection.

CONCLUSIONS

For the first time, we report in PIPO patients a specific MAM associated to underlying pathology and an altered intestinal serotonin pathway. A possible dysfunction of the serotonin pathway, possibly related to or triggered by an altered microbiota, may contribute to dysmotility in PIPO patients. The results of our pilot study provide the basis for new biomarkers and innovative therapies targeting the microbiota or serotonin pathways in PIPO patients.

ESPEN guideline on chronic intestinal failure in adults - Update 2023

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.

Multi-disciplinary Insights from the First European Forum on Visceral Myopathy 2022 Meeting

Visceral myopathy is a rare, life-threatening disease linked to identified genetic mutations in 60% of cases. Mostly due to the dearth of knowledge regarding its pathogenesis, effective treatments are lacking. The disease is most commonly diagnosed in children with recurrent or persistent disabling episodes of functional intestinal obstruction, which can be life threatening, often requiring long-term parenteral or specialized enteral nutritional support. Although these interventions are undisputedly life-saving as they allow affected individuals to avoid malnutrition and related complications, they also seriously compromise their quality of life and can carry the risk of sepsis and thrombosis. Animal models for visceral myopathy, which could be crucial for advancing the scientific knowledge of this condition, are scarce. Clearly, a collaborative network is needed to develop research plans to clarify genotype-phenotype correlations and unravel molecular mechanisms to provide targeted therapeutic strategies. This paper represents a summary report of the first 'European Forum on Visceral Myopathy'. This forum was attended by an international interdisciplinary working group that met to better understand visceral myopathy and foster interaction among scientists actively involved in the field and clinicians who specialize in care of people with visceral myopathy.

Pharmacological and nutritional therapy of children and adults with chronic intestinal pseudo-obstruction

INTRODUCTION

Chronic intestinal pseudo-obstruction (CIPO) is a rare, heterogeneous and severe form of gastrointestinal dysmotility.

AREAS COVERED

Pertinent literature on pediatric and adult CIPO management has been assessed via PubMed, Scopus, and EMBASE from inception to June 2022. Prokinetics, aimed at restoring intestinal propulsion (e.g. orthopramides and substituted benzamides, acetyl cholinesterase inhibitors, serotonergic agents and others), have been poorly tested and the available data showed only partial efficacy. Moreover, some prokinetic agents (e.g. orthopramides and substituted benzamides) can cause major side effects. The CIPO-related small intestinal bacterial overgrowth requires treatment preferably via poorly absorbable antibiotics to avoid bacterial resistance. Apart from opioids, which worsen gut motility, analgesics should be considered to manage visceral pain, which might dominate the clinical manifestations. Nutritional support, via modified oral feeding, enteral or parenteral nutrition, is key to halt CIPO-related malnutrition.

EXPERT OPINION

There have been significant roadblocks preventing the development of CIPO treatment. Nonetheless, the considerable advancement in neurogastroenterology and pharmacological agents cast hopes to test the actual efficacy of new prokinetics via well-designed clinical trials. Adequate dietary strategies and supplementation remain of crucial importance. Taken together, novel pharmacological and nutritional options are expected to provide adequate treatments for these patients.

Pseudoileus caused by primary visceral myopathy in a Han Chinese patient with a rare MYH11 mutation: A case report

BACKGROUND

Chronic intestinal pseudo-obstruction (CIPO) is a syndrome of intestinal motor dysfunction caused by intestinal nerve, muscle, and/or Cajal stromal cell lesions. CIPO is a serious category of gastrointestinal dynamic dysfunction, which can eventually lead to the death of patients with intestinal failure. Due to considerable phenotypic heterogeneity, the estimated incidence of CIPO is 1/476190 and 1/416666 in men and women, respectively. According to the etiology, CIPO can be divided into idiopathic and secondary, of which the latter is the most common, often secondary to tumor, virus infection, connective tissue disease, neurological diseases, and endocrine diseases. Idiopathic CIPO in the intestinal tract is divided into visceral myopathy, neuropathy, and stromal cell lesions according to the location. Surgery is usually not recommended for CIPO, because it often does not benefit patients with CIPO, and postoperative intestinal obstruction is likely to occur, which may even worsen the condition.

CASE SUMMARY

Here, we describe the case of a 43-year-old male Han Chinese patient with a 15-year history of recurrent abdominal distention with no clear cause. The results of physical, biochemical, and other relevant examinations showed no clear abnormalities. Contrast-enhanced computed tomography (CT) indicated a large duodenum, clear expansion of the intestinal lumen, and CIPO. Whole exome sequencing (WES) of the patient and his mother confirmed the diagnosis of primary familial visceral myopathy type 2 chronic pseudoileus with a rare heterozygous gene mutation in MYH11. This is the second reported case of CIPO with a heterozygous MYH11 [NM_001040113.1: c.5819delC (p.Pro1940Hisfs*91)] mutation.

CONCLUSION

This case report indicates that physicians can perform routine clinical examinations, CT, and WES to achieve a diagnosis and treatment of CIPO in early disease stages.

When you are living and dying at the same time: A qualitative exploration of living with gastrointestinal motility disorders

BACKGROUND

An expanding base of evidence indicates that chronic gastrointestinal disorders not only impact physical wellbeing, but also affect many psychosocial aspects of life. However, less is known about gastrointestinal motility disorders. The present study aimed to explore how individuals experience gastrointestinal motility disorders and their impact on daily living.

METHODS

Eleven people with a gastrointestinal motility disorder participated in semi-structured interviews face-to-face or via telephone. The interviews explored how participants came to be diagnosed, their experiences with health professionals, as well as the impact of dysmotility on enjoyment of food, socialising, eating out and quality of life (QoL). Interviews were tape-recorded, transcribed and analysed using an inductive thematic analysis approach.

RESULTS

Analysis revealed an overarching theme of frustration that stemmed from three subthemes: (1) feeling misunderstood, judged and dismissed by health professionals leading to delayed diagnosis, misdiagnosis and multiple diagnoses; (2) severity and unpredictability of undesirable gastrointestinal symptoms; and (3) reduced QoL because of physical and social limitations, impairing their ability to have normal life experiences, including education, work and social activities.

CONCLUSIONS

Dysmotility is a complex illness that impacts almost all aspects of a person's life. In addition to managing reported physical symptoms, the social and psychological burden associated with dysmotility needs to be addressed to improve outcomes and QoL.

Chronic Intestinal Pseudo-Obstruction: Is There a Connection with Gut Microbiota?

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.

Recent Advances in the Management of Severe Gastrointestinal Dysmotility

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.

Twenty Years of Gut Transplantation for Chronic Intestinal Pseudo-obstruction: Technical Innovation, Long-term Outcome, Quality of Life, and Disease Recurrence

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.

Latest developments in chronic intestinal pseudo-obstruction

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.

An international survey on clinicians' perspectives on the diagnosis and management of chronic intestinal pseudo-obstruction and enteric dysmotility

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.

Neuromechanism of acupuncture regulating gastrointestinal motility

Acupuncture has been used in China for thousands of years and has become more widely accepted by doctors and patients around the world. A large number of clinical studies and animal experiments have confirmed that acupuncture has a benign adjustment effect on gastrointestinal (GI) movement; however, the mechanism of this effect is unclear, especially in terms of neural mechanisms, and there are still many areas that require further exploration. This article reviews the recent data on the neural mechanism of acupuncture on GI movements. We summarize the neural mechanism of acupuncture on GI movement from four aspects: acupuncture signal transmission, the sympathetic and parasympathetic nervous system, the enteric nervous system, and the central nervous system.

Update on chronic intestinal pseudo-obstruction

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.

When is parenteral nutrition indicated in the hospitalized, acutely ill patient?

PURPOSE OF REVIEW

The current review discusses current practices regarding appropriate indications for parenteral nutrition in acutely ill hospitalized patients. We address-specific indications for parenteral nutrition in the perioperative period, and in inflammatory bowel disease, oncology, hepatobiliary, critical care and end-stage renal disease patients.

RECENT FINDINGS

Acutely ill hospitalized patients can develop intestinal failure requiring parenteral nutrition. Recent studies have provided insight into the main indications. The most common indications for inpatient parenteral nutrition include postsurgical complications, including prolonged ileus, sepsis, fistula and leaks, and bowel obstruction, predominantly malignant. Severe or complicated inflammatory bowel disease and cancer treatment-related mucosal enteropathies (mucositis, enterocolitis, gut graft-versus-host disease) are the next commonest indications. Less frequent indications are primary motility disorders and inability to secure enteral access for enteral nutrition. Gastrointestinal failure of the intensive care patient is a separate entity resulting from multiple mechanisms, including an enteropathy and dysmotility.

SUMMARY

Despite the wider availability of nutrition support teams, use of parenteral nutrition is not without risk. The risks and benefits of parenteral nutrition in the acute setting need to be carefully considered even when it is indicated.

Small Bowel Dysmotility, Pseudoobstruction, and Functional Correlation with Histopathology: Lessons Learned

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.

Management of the Patient with Chronic Intestinal Pseudo-Obstruction and Intestinal Failure

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.

Nutrition Management in Patients With Chronic Gastrointestinal Motility Disorders: A Systematic Literature Review

BACKGROUND

The aim of this study was to systematically review effects of nutrition interventions on outcomes in patients with chronic gastrointestinal (GI) motility disorders. There is currently a lack of evidence-based guidelines for nutrition management in this group, likely a result of the rarity of the conditions.

METHODS

A systematic review of all study types to evaluate current evidence-based nutrition interventions was performed using Medline, Embase, and CINAHL databases. Two independent reviewers participated in the process of this systematic review. A total of 15 studies and a total of 524 subjects were included.

RESULTS

Best treatment of this population group was found to include a stepwise process, progressing from oral nutrition to jejunal nutrition and lastly to parenteral nutrition. Small particle, low-fat diets were significantly better tolerated than the converse, with jejunal nutrition prior to consuming oral food significantly improving oral intake and motility. In more progressive cases, percutaneous endoscopic gastrostomy with jejunal extension nutrition had lower reported symptoms than other enteral routes. Exclusive long-term parenteral nutrition is a feasible option for advanced cases, with a 68% survival rate at 15 years duration, though oral intake with parenteral nutrition is associated with higher survival rates.

CONCLUSION

Treatment of patients with GI motility disorders should first trial oral nutrition. For patients who progress to jejunal or parenteral feeds, the primary aim should be to maintain or reinstate oral intake to reduce morbidity and mortality risk. Higher-quality studies are still required in this area, particularly in the areas of chronic intestinal pseudo-obstruction and systemic sclerosis.

Accelerometer-Based Assessment of Intestinal Peristalsis: Toward Miniaturized Low-Power Solutions for Intestinal Implants

Intestinal electrical stimulation via implants is already used to treat several disorders like constipation or incontinence. Stimulation parameters are most often empiric and not based on systematic studies. One prerequisite to evaluate effects of intestinal electrical stimulation is a direct assessment of intestinal motility. Some common methods are strain gauge transducers or manometry. With both the methods, it is not possible to record the exact 3-D movement. Therefore, we established a new method to record gastrointestinal motility with ultraminiaturized accelerometers, directly glued to the outer surface of the stomach, small intestine, and colon. With this technique, we were able to record precise local motility changes after electrical stimulation. Due to the low energy demand and the small size of the system, it is potentially useful for chronic measurements at multiple sites of the intestinal tract. We will present our first results regarding stimulation-dependent motility changes using up to eight implanted accelerometers in an acute pig model.

Causes and prognosis of chronic intestinal pseudo-obstruction in 48 subjects: A 10-year retrospective case series

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.

Gastrointestinal dysmotility: A qualitative exploration of the journey from symptom onset to diagnosis

BACKGROUND

Gastrointestinal dysmotility (GID) covers a spectrum of disorders disrupting enteric neuromuscular co-ordination which, when severe, causes intractable gastrointestinal symptoms and malnutrition and is a recognized cause of chronic intestinal failure. To date, no study has provided an in-depth account of the experiences of patients with severe GID and their psychosocial needs. This study aimed to explore patients' experiences from symptom onset and the process of seeking and receiving a diagnosis. It specifically explored the psychological effect of this process and the effect on relationships.

METHODS

Participants (n = 20, mean age = 47.9, female n = 16, parenteral nutrition = 13) were recruited from a UK center with tertiary Neurogastroenterology and Intestinal Failure services. A qualitative exploratory design with semi-structured in-depth interviews was used. Data were analyzed using thematic analysis.

KEY RESULTS

Significant delays were experienced in obtaining a diagnosis. Participants reported having their mental health questioned and felt that they had to fight to prove their symptoms had a physical basis to access appropriate treatment. Although a diagnosis helped legitimize symptoms, the condition remained poorly understood by participants themselves, relatives, and health professionals. Participants discussed the impact that "feeling delegitimized" and the "lack of coherent understanding of GID" had on their relationships and mental health.

CONCLUSIONS & INFERENCES

The distressing experience of GID symptoms are compounded by a delay in validating symptoms and lack of coherent understanding. More knowledge of GID is needed by health professionals to speed up diagnosis and offer more coherent information. The psychological impact of a GID diagnosis should be acknowledged early to help facilitate adjustment.

Nutritional Interventions in Chronic Intestinal Pseudoobstruction

Although chronic intestinal pseudo-obstruction (CIPO) is a rare disorder, it presents a wide spectrum of severity that ranges from abdominal bloating to severe gastrointestinal dysfunction. In the worst cases, patients may become dependent upon artificial nutrition via parenteral nutrition or choose to have an intestinal transplant. However, whatever the severity, a patient's quality of life can be seriously compromised. This article defines the disorder and discusses the spectrum of disease and challenges to providing adequate nutrition to help improve a patient's quality of life.

Enteral Nutrients and Gastrointestinal Physiology

The gastrointestinal (GI) tract is a highly efficient organ system with specialized structures to facilitate digestion and absorption of nutrients to meet the body's needs. The presence of nutrients in the GI tract supports optimal structure and function, stimulates regulatory hormones, and supports the microbiota, the population of microorganisms residing in the GI tract. A lack of enteral nutrition (EN) results in impaired GI integrity and serious patient complications, making EN a priority. Normal GI physiology is reviewed, and the regulatory impact of luminal nutrients on GI function is discussed.

Clinical aspects of neurointestinal disease: Pathophysiology, diagnosis, and treatment

The enteric nervous system (ENS) is involved in the regulation of virtually all gut functions. Conditions referred to as enteric neuropathies are the result of various mechanisms including abnormal development, degeneration or loss of enteric neurons that affect the structure and functional integrity of the ENS. In the past decade, clinical and molecular research has led to important conceptual advances in our knowledge of the pathogenetic mechanisms of these disorders. In this review we consider ENS disorders from a clinical perspective and highlight the advancing knowledge regarding their pathophysiology. We also review current therapies for these diseases and present potential novel reparative approaches for their treatment.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

Electroacupuncture at ST25 inhibits jejunal motility: Role of sympathetic pathways and TRPV1

AIM: To investigate whether electroacupuncture (EA) at ST25 affects jejunal motility in vivo and if so, whether a sympathetic pathway is involved.

METHODS: Jejunal motility was assessed using a manometric balloon placed in the jejunum approximately about 3-5 cm away from the suspensory ligament of the duodenum in anesthetized animals. The effects of EA at ST25 were measured in male Sprague-Dawley rats, some of which were treated with propranolol or clenbuterol (EA intensities: 1, 3, 5, 7, and 9 mA), and in male transient receptor potential vanilloid-1 (TRPV1) (capsaicin receptor) knockout mice (EA intensities: 1, 2, and 4 mA).

RESULTS: Anesthetized rats exhibited three types of fasting jejunal motor patterns (types A, B, and C), and only type C rats responded to EA stimulation. In type C rats, EA at ST25 significantly suppressed the motor activity of the jejunum in an intensity-dependent manner. The inhibitory effect of EA was weakened by propranolol (β adrenoceptor antagonist) and disappeared with clenbuterol (β adrenoceptor agonist) induced inhibition of motility, suggesting that the effect of EA on motility is mediated via a sympathetic pathway. Compared with wild-type mice, EA at ST25 was less effective in TRPV1 knockout mice, suggesting that this multi-modal sensor channel participates in the mechanism.

CONCLUSION: EA at ST25 was found to inhibit jejunal motility in an intensity-dependent manner, via a mechanism in which sympathetic nerves and TRPV1 receptors play an important role.

Intestinal Leiomyositis: A Cause of Chronic Intestinal Pseudo-Obstruction in 6 Dogs

BACKGROUND

Intestinal leiomyositis is a suspected autoimmune disorder affecting the muscularis propria layer of the gastrointestinal tract and is a cause of chronic intestinal pseudo-obstruction in humans and animals.

OBJECTIVE

To characterize the clinical presentation, histopathologic features, and outcome of dogs with intestinal leiomyositis in an effort to optimize treatment and prognosis.

ANIMALS

Six client-owned dogs.

METHODS

Retrospective case series. Medical records were reviewed to describe signalment, clinicopathologic and imaging findings, histopathologic diagnoses, treatment, and outcome. All biopsy specimens were reviewed by a board-certified pathologist.

RESULTS

Median age of dogs was 5.4 years (range, 15 months-9 years). Consistent clinical signs included vomiting (6/6), regurgitation (2/6), and small bowel diarrhea (3/6). Median duration of clinical signs before presentation was 13 days (range, 5-150 days). Diagnostic imaging showed marked gastric distension with dilated small intestines in 4/6 dogs. Full-thickness intestinal biopsies were obtained in all dogs by laparotomy. Histopathology of the stomach and intestines disclosed mononuclear inflammation, myofiber degeneration and necrosis, and fibrosis centered within the region of myofiber loss in the intestinal muscularis propria. All dogs received various combinations of immunomodulatory and prokinetic treatment, antimicrobial agents, antiemetics, and IV fluids, but none of the dogs showed a clinically relevant improvement with treatment. Median survival was 19 days after diagnosis (range, 3-270 days).

CONCLUSIONS AND CLINICAL IMPORTANCE

Intestinal leiomyositis is a cause of intestinal pseudo-obstruction and must be diagnosed by full-thickness intestinal biopsy. This disease should be considered in dogs with acute and chronic vomiting, regurgitation, and small bowel diarrhea.