Chronic intestinal dysmotility A growing problem Dr Simon Gabe Consultant Gastroenterologist St Mark’s Hospital

Chronic intestinal pseudo-obstruction Definition

A severe digestive syndrome characterized by derangement of gut propulsive motility in the absence of a mechanical obstruction

Antonucci et al, World J Gastroenterol 2008;14(19):2953–2961

Conditions that mimic or contribute to the presentation

Organic obstruction Transition point

Opiates Opiate withdrawal & chronic opiate usage (both manifest as abdominal pain)

Psychosocial problems

Functional GI disorders (severe IBS) Anorexia nervosa Atypical eating disorders

Chronic intestinal pseudoobstruction

Primary

Myopathy

Neuropathy

Mesenchymopathy

Secondary

Autonomic or enteric nerves

Collagen diseases (eg Elhers Danlos)

Endocrine & metabolic

Other

INTESTINAL DYSMOTILITY

Obstruction Psychosocial Narcotic Bowel Syndrome Anorexia nervosa

IBS SMA syndrome

Opiates Undernutrition

Primary Hollow visceral myopathy

Jejunal diverticulosis

Secondary Systemic sclerosis

Amyloid Irradiation

Muscular diseases

Primary Hirsprung’s Autoimune

Infective

Secondary General neurological disease

Paraneoplastic Drugs

Myopathy Neuropathy

Symptoms

Mann et al. Gut 1997;41:675-681

Age of onset of symptoms

Mann et al. Gut 1997;41:675-681

Investigations

Exclude mechanical causes

BaFT, OGD, colonoscopy

CT, CTE, MRE

Investigations Motility studies Histology

Gastric emptying Whole gut transit EGG SB manometry Oesophageal manometry

Full thickness biopsy Dilated & non-dilated SB Fix in formalin & liquid

nitrogen Skeletal muscle biopsy

If MNGIE suspected

Essential to perform functional studies off opiates

Diagnoses prior to identification of correct diagnosis

Initial diagnosis No of patients (%) Mechanical bowel obstruction 9 (45) Constipation 4 (20) Idiopathic megarectum or megacolon and constipation 3 (15) Sigmoid volvulus 1 (5) Pseudo-obstruction 1 (5) Vesico-ureteric distension and acute renal failure 1 (5) Abdominal migraine/periodic syndrome 1 (5)

Mann et al. Gut 1997;41:675-681

How to manage CIP Ensure no mechanical cause Manage symptoms Manage nutrition & fluid balance Address psychological issues Avoid opiates Avoid parenteral addictive medication Avoid surgery

Gastroparesis Common in neuropathic & myopathic CIPO

De Georgio et al, Gastroenterol Clin North Am 2011;40:787-807

Gastric pacemakers Diabetic gastroparesis

Used to be the main indication No longer funded by the NHS

Dysmotility patients Gastroparesis unlikely to occur

without small bowel involvement

Not a modality that we currently recommend

Venting PEG / gastrostomy Can be very helpful for symptom minimisation Trial of venting NG before placing a PEG But, there are some common issues Drainage dependent on

Tube factors (tube gauge, male Luer connection) Position of the tube in the stomach Place low in the body of the stomach Siting can be a challenge

We need better venting PEG tubes - Currently designed for feeding - Need to develop the ideal tube

Jejunal feeding

NJ PEGJ

Surgical jejunostomy Direct PEJ

Surgical or endoscopic? Surgical jejunostomy Direct PEJ

Laparoscopic possible More invasive Surgical procedure to

remove Tube has more limited

lifespan

Endoscopic procedure under GA

Less invasive Can be removed

endoscopically Tube lasts longer

Click to edit Master title style Do not place a Foley catheter!

There is a need for better jejunal feeding tubes to be developed

Psychology

There are almost always significant past issues Childhood abuse Disturbed childhood or young adult life Trauma: PTSD

If you only deal with the physical problems you are only dealing with half the issues WILL FAIL

Nutrition support Patients are often malnourished Cause: inadequate food intake > malabsorption

Oral nutrition

• Low fat & low fibre diet

• Liquid diet

Enteral nutrition

• NG trial • NJ trial • PEGJ (medium term) • Jejunostomy (long term)

Parenteral nutrition

• Usually supportive (IVN) • allows patients to eat

as tolerated • Occasionally exclusive

(TPN)

IV nutrition Helpful to overcome nutritional consequences Rarely helpful for symptoms Tell patients Their symptoms will be the same IVN will only address the undernutrition Significant risk of infection, especially if on opiates

Beware Underlying eating disorders (can become more apparent when trying to give IVN)

BAPEN: data from BANS

Patients 2000 2005 2010 2011 2012 2013 Numbers 32 66 79 87 137 152 % 9.1 10.4 15.1 14.2 15.4 14.0

% New registrations % Point prevalence 2000 2013 2000 2013

Crohns 25.0 16.1 34.3 22.3 Ulcerative colitis 3.4 2.1 2.9 3.3 Ischaemia* 14.8 10.4 17.7 15.0 Radiation enteritis 5.7 2.8 5.1 2.6 Pseudo-obstruction 4.5 10.0 9.1 14.0 Cancer 17.0 24.6 5.7 11.2

IF due to dysmotility is on the increase

Summary tips Work as a team

Be patient, listen and try your best to help

Boundaries can be essential Make the boundaries clear Can compromise on some issues

Involve the psychologists/psychiatrists Just as important for you as for the patient!

Intestinal transplantation Indications Refer / discuss

Irreversible IF, and

Liver disease Fibrotic liver disease Progressive IFALD

Severe sepsis Life threatening (>1) Life threatening (1)

Loss of venous access

Limited to 3 major sites Limited to 4 major sites

Poor QOL Correctable by transplantation

Correctable by transplantation

Partial or complete evisceration Evisceration requiring MVTx (eg desmoid)

Strategies to minimise surgical resection

Need for other abdominal organ transplant

eg renal When transplant being considered