Chronic intestinal pseudo‐obstruction: Progress in management?

Abstract

Chronic intestinal pseudo-obstruction (CIPO) is a severe form of gastrointestinal dysmotility (often due to derangement of the innervation/smooth muscle/interstitial cells of Cajal) with recurrent episodes of intestinal subocclusion mimicking a mechanical obstruction. Because of its complexity and heterogeneity, CIPO is often misdiagnosed or remains unrecognized until advanced stages. Management is a critical aspect in CIPO patient care. So far, most prokinetic drugs have not proven efficacy in restoring intestinal propulsion, thus nutritional support, fluid/electrolyte replacement, and antibiotics are the mainstay of treatment. In this issue of the journal, Ohkubo et al showed promising data indicating that percutaneous endoscopic gastro-jejunostomy (PEG-J) can be proposed as a measure for intestinal decompression, thereby improving CIPO-associated abdominal symptoms, including pain. In addition to a concise update of clinical and diagnostic features, the present minireview tackles management options, with a major emphasis on PEG-J, for CIPO patients.

Chronic functional constipation is strongly linked to vitamin D deficiency

“…Inclusion criteria were the following: Caucasian subjects ≥ 18 years old, body mass index (BMI) ≥ 18.5 kg/m 2 , affected by functional chronic constipation associated to delayed intestinal transit time, supported by Roma IV criteria[8,26,28]. Exclusion criteria were the following: Subjects > 75 years old, IBS, pregnancy, significant comorbidities such as cardiac, respiratory, chronic renal insufficiency, anorectal and pelvic floor dysfunctions, metabolic/endocrine (diabetes mellitus, hypothyroidism, hypercalcaemia, panhypopituitarism), medications (opiates, antihypertensive agents, iron preparations, anti-epileptic drugs, tryciclic antidepressants, anticholinergics or dopaminergics), organic (extra-intestinal mass, colorectal cancer, ischaemic or surgical stenosis, anal fissure, anal strictures, inflammatory bowel disease, intestinal malabsorption and diverticular diseases), neurological (Parkinson disease, multiple sclerosis, paraplegia, autonomic neuropathy, chronic intestinal pseudo-obstruction, gastroparesis, Hirschsprung disease and stroke), past psychiatric disease, and myogenic (scleroderma, amyloidosis and myotonic dystrophy dermatomyositis)[2,21,26]. In addition, we also assessed a control group of 86 healthy subjects (sex, age and BMI matched), recruited from a population-based cohort study of 150 healthy subjects, which underwent routine clinical exams in our Institute to check their healthy status, after excluding the presence of a functional chronic constipation during the clinical interview.…”

“…Moreover, the most severe form of intestinal motility disorder may be considered chronic intestinal pseudo-obstruction, which is a symptomatic and disabling disease, related to a visceral myopathy or/and neuropathy[26]. Hence, colonic transit time could be objectively measured by radiopaque markers (single or multiple capsule techniques), and this diagnostic tool is also used to rule out dyssynergia defecation[2,23].…”

Motility index measured by magnetic resonance enterography is associated with sex and mural thickness

“…Instead, examinations of the motor function and/or histopathology of bowel samples are necessary to make a correct diagnosis[ 20 ]. The different treatments for IBS and dysmotility[ 3 , 11 ] may lead to consequences for the patients[ 24 ]; therefore, it is essential to identify patients with dysmotility and give them a correct diagnosis to be able to appropriately treat them.…”

“…However, there is a need for improved diagnostic tools to correctly diagnose patients with enteric neuromuscular pathology (independent of inflammatory activity) at an earlier stage to be able to provide appropriate health care[ 11 ] rather than having these patients wait for several years until a correct diagnosis is made[ 12 ].…”

Autonomic and peripheral neuropathy with reduced intraepidermal nerve fiber density can be observed in patients with gastrointestinal dysmotility

“…Due to different treatment strategies between GI dysmotility and IBS, it is important to diagnose the diseases correctly. Functional bowel diseases are mainly treated with dietary advice in the form of regular meals with carbohydrate restriction and psychological therapy, whereas dysmotility is treated with prokinetic drugs and dietary supplemental therapy …”