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Wattchow DA, Brookes SJ, Spencer NJ, Heitmann PT, De Giorgio R, Costa M, Dinning PG. From the organ bath to the whole person: a review of human colonic motility. ANZ J Surg 2024; 94:320-326. [PMID: 37974532 DOI: 10.1111/ans.18779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
Motor function of the colon is essential for health. Our current understanding of the mechanisms that underlie colonic motility are based upon a range of experimental techniques, including molecular biology, single cell studies, recordings from muscle strips, analysis of part or whole organ ex vivo through to in vivo human recordings. For the surgeon involved in the clinical management of colonic conditions this amounts to a formidable volume of material. Here, we synthesize the key findings from these various experimental approaches so that surgeons can be better armed to deal with the complexities of the colon.
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Affiliation(s)
- David A Wattchow
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Simon J Brookes
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Nick J Spencer
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Paul T Heitmann
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Marcello Costa
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
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2
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Vlismas LJ, Wu W, Ho V. Idiopathic Slow Transit Constipation: Pathophysiology, Diagnosis, and Management. Medicina (Kaunas) 2024; 60:108. [PMID: 38256369 PMCID: PMC10819559 DOI: 10.3390/medicina60010108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Slow transit constipation (STC) has an estimated prevalence of 2-4% of the general population, and although it is the least prevalent of the chronic constipation phenotypes, it more commonly causes refractory symptoms and is associated with significant psychosocial stress, poor quality of life, and high healthcare costs. This review provides an overview of the pathophysiology, diagnosis, and management options in STC. STC occurs due to colonic dysmotility and is thought to be a neuromuscular disorder of the colon. Several pathophysiologic features have been observed in STC, including reduced contractions on manometry, delayed emptying on transit studies, reduced numbers of interstitial cells of Cajal on histology, and reduced amounts of excitatory neurotransmitters within myenteric plexuses. The underlying aetiology is uncertain, but autoimmune and hormonal mechanisms have been hypothesised. Diagnosing STC may be challenging, and there is substantial overlap with the other clinical constipation phenotypes. Prior to making a diagnosis of STC, other primary constipation phenotypes and secondary causes of constipation need to be ruled out. An assessment of colonic transit time is required for the diagnosis and can be performed by a number of different methods. There are several different management options for constipation, including lifestyle, dietary, pharmacologic, interventional, and surgical. The effectiveness of the available therapies in STC differs from that of the other constipation phenotypes, and prokinetics often make up the mainstay for those who fail standard laxatives. There are few available management options for patients with medically refractory STC, but patients may respond well to surgical intervention. STC is a common condition associated with a significant burden of disease. It can present a clinical challenge, but a structured approach to the diagnosis and management can be of great value to the clinician. There are many therapeutic options available, with some having more benefits than others.
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Affiliation(s)
- Luke J. Vlismas
- Deptartment of Gastroenterology, Campbelltown Hospital, Campbelltown, NSW 2560, Australia; (W.W.); (V.H.)
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2308, Australia
| | - William Wu
- Deptartment of Gastroenterology, Campbelltown Hospital, Campbelltown, NSW 2560, Australia; (W.W.); (V.H.)
- School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia
| | - Vincent Ho
- Deptartment of Gastroenterology, Campbelltown Hospital, Campbelltown, NSW 2560, Australia; (W.W.); (V.H.)
- School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia
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3
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Patel D, Jose F, Baker J, Moshiree B. Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract in Cystic Fibrosis. Curr Gastroenterol Rep 2024; 26:9-19. [PMID: 38057499 DOI: 10.1007/s11894-023-00906-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF REVIEW To discuss all the various motility disorders impacting people with Cystic Fibrosis (PwCF) and provide diagnostic and management approaches from a group of pediatric and adult CF and motility experts and physiologists with experience in the management of this disease. RECENT FINDINGS Gastrointestinal (GI) symptoms coexist with pulmonary symptoms in PwCF regardless of age and sex. The GI manifestations include gastroesophageal reflux disease, esophageal dysmotility gastroparesis, small bowel dysmotility, small intestinal bacterial overgrowth syndrome, distal idiopathic obstruction syndrome, constipation, and pelvic floor disorders. They are quite debilitating, limiting the patients' quality of life and affecting their nutrition and ability to socialize. This genetic disorder affects many organ systems and is chronic, potentially impacting fertility and future family planning, requiring a multidisciplinary approach. Our review discusses the treatments of motility disorders in CF, their prevalence and pathophysiology. We have provided a framework for clinicians who care for these patients that can help to guide their clinical management.
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Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, SSM Cardinal Glennon Children's Medical Center, Saint Louis University, St Louis, MO, USA
| | - Folashade Jose
- Pediatric Gastroenterology, Hepatology, and Nutrition, Clinical Associate Professor, Levine Childrens Hospital, Carolina Pediatric Gastroenterology, Charlotte, NC, USA
| | | | - Baha Moshiree
- Division of Gastroenterology, Atrium Health Wake Forest Medical University, Charlotte, NC, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Sakamoto N, Hamada S, Takahashi H, Satou R, Suzuki M, Maeno T. Improvement of Intestinal Pseudo-Obstruction by Total Parenteral Nutrition in a Young Woman With Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Stroke-Like Episodes: A Case Report. Cureus 2023; 15:e50075. [PMID: 38186459 PMCID: PMC10769865 DOI: 10.7759/cureus.50075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), a mitochondrial disease, develop various types of organ failure, including intestinal pseudo-obstruction (IPO). We treated a patient with IPO that improved with total parenteral nutrition. A 20-year-old woman with a two-year history of diabetes mellitus was taking sitagliptin but her hemoglobin A1c (HbA1c) levels began increasing. After receiving metformin, she suffered a stroke-like attack and was diagnosed with MELAS. After persistent anorexia, she presented with symptoms of IPO, such as vomiting and gastrointestinal dilatation. After about 10 days of total parenteral nutrition, intestinal peristalsis improved and bowel movements resumed. She was able to resume her normal diet, and glycemic control with insulin glargine has allowed her to return to her daily life without gastrointestinal symptoms for over six months. Total parenteral nutrition may be effective for MELAS with IPO, and good glycemic control can prevent the need for incretin-related drugs, thus reducing the likelihood of recurrent IPO.
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Affiliation(s)
- Naoto Sakamoto
- Department of Primary Care and Medical Education, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Shuhei Hamada
- Department of Primary Care and Medical Education, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Hiroki Takahashi
- Department of General Medicine, Taito Municipal Hospital, Tokyo, JPN
| | - Rumi Satou
- Department of Internal Medicine, Kamisu Saiseikai Hospital, Kamisu, JPN
| | - Masatsune Suzuki
- Department of Primary Care and Medical Education, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Tetsuhiro Maeno
- Department of Primary Care and Medical Education, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
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Wilkie BD, Noori J, Johnston M, Woods R, Keck JO, Behrenbruch C. Pyridostigmine in chronic intestinal pseudo-obstruction - a systematic review. ANZ J Surg 2023; 93:2086-2091. [PMID: 37132128 DOI: 10.1111/ans.18478] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/08/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) may be a primary or secondary phenomenon and is often multifactorial. Treatment is largely directed at improving colonic motility. The use of cholinesterase inhibitors such as pyridostigmine has been hypothesized to increase acetylcholine in the bowel, improving symptoms and transit times. METHODS A systematic review of the use of pyridostigmine in CIPO was conducted using scientific and commercial search engines identifying scientific studies enrolling adult human subjects, published from 2000 to 2022 in the English language. RESULTS Four studies were identified including two randomized controlled trials (RCT) and two observational studies. The studies had heterogenous inclusion criteria, dosing regimens and reported outcomes. Two studies were identified as being at high risk of bias. All studies reported improved patient outcomes with use of pyridostigmine, and low rates (4.3%) of mild cholinergic side effects. No major side effects were reported. CONCLUSION The use of pyridostigmine in management of CIPO is biologically plausible due to its ability to increase colonic motility, and early studies on its role are uniformly suggestive of benefit with low side-effect profile. Four clinical studies have been conducted to date, with small sample sizes, heterogeneity and high risk of bias. Further high-quality studies are required to enable assessment of pyridostigmine's utility as an effective management strategy in CIPO.
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Affiliation(s)
- Bruce D Wilkie
- Department of Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
- Department of Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Jawed Noori
- Department of Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Michael Johnston
- Department of Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Rodney Woods
- Department of Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - James O Keck
- Department of Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Corina Behrenbruch
- Department of Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
- The University of Melbourne, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
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Abstract
PURPOSE OF REVIEW Acute Colonic Pseudo-obstruction (ACPO) is a cause of large intestinal dilation and obstruction without any physical transition point. It remains difficult to diagnose and treat. We review the recent updates on diagnosis and management of ACPO. RECENT FINDINGS Recent guidelines have posited that conservative management can be tried in most cases of ACPO, but that early decompression and surgery should be considered. Use of neostigmine is still a viable option but there is also promising data on pyridostigmine as well as prucalopride. Resolution of ACPO should be followed by daily use of polyethylene glycol (PEG) to help prevent recurrence. ACPO warrants early and accurate diagnosis with exclusion of alternate causes of large bowel dilation. Conservative management can be attempted for 48-72 h in those with cecal diameters < 12 cm and without signs of peritonitis and perforation. Early escalation of management should be attempted with neostigmine followed by endoscopy and/or surgery as needed, given that longer periods of dilation are associated with worse outcomes. There is promising new evidence for use of pyridostigmine and prucalopride, but further trials are needed prior to incorporating them into regular use. Finally, studies are lacking regarding prevention of ACPO after initial resolution.
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Affiliation(s)
- Ahana Sen
- Department of Medicine, Section of Gastroenterology & Hepatology, Baylor College of Medicine, 7200 Cambridge Avenue, Suite 8B, Houston, TX, 77030, USA
| | - Reena Chokshi
- Department of Medicine, Section of Gastroenterology & Hepatology, Baylor College of Medicine, 7200 Cambridge Avenue, Suite 8B, Houston, TX, 77030, USA.
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Alkan S, Cakir M, Sentiurk M, Varman A, Duyan AG. The efficacy and results of medical treatment in postoperative ileus. Niger J Clin Pract 2023; 26:497-501. [PMID: 37203116 DOI: 10.4103/njcp.njcp_618_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Background Postoperative paralytic ileus refers to the disruption of the normal coordinated propulsive motor activity of the gastrointestinal system following surgery. Surgery causes inflammation in the muscle walls of organs with an intestinal lumen that, in turn, leads to a decrease in intestinal motility. Aim The aim of this study was to investigate the efficacy of gastrografin, neostigmine, and their combined administration in patients diagnosed with paralytic ileus in the postoperative period. Patients and Methods One-hundred twelve patients were included from January 2017 and November 2019. The retrospective study is involving prolonged postoperative ileus cases following colorectal surgery. The effect of gastrografin, neostigmine, and gastrografin neostigmine combination was compared retrospectively in the treatment of prolonged ileus after surgery. Results The study covered 112 patients. Gastrografin was administered to 63 patients; neostigmine was administered to 29, while 20 patients received the combination of the two. Data pertaining to the comparison of the two groups revealed that patients in the gastrografin group were discharged earlier than those in the neostigmine group. Further, patients in the combined group had earlier gas and/or stool discharge and were also discharged from the hospital earlier than those in the neostigmine group. Conclusion Gastrografin and combined use of gastrografin and neostigmine are effective and viable methods for postoperative ileus cases. Gastrografin can safely be used in patients with anastomoses.
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Affiliation(s)
- S Alkan
- Department of General Surgery, Necmettin Erbakan University, Meram Medical Faculty, Turkey
| | - M Cakir
- Department of General Surgery, Necmettin Erbakan University, Meram Medical Faculty, Turkey
| | - M Sentiurk
- Department of General Surgery, Necmettin Erbakan University, Meram Medical Faculty, Turkey
| | - A Varman
- Department of General Surgery, Necmettin Erbakan University, Meram Medical Faculty, Turkey
| | - A G Duyan
- Department of General Surgery, Necmettin Erbakan University, Meram Medical Faculty, Turkey
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9
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de Geus A, Koppen IJN, Flint RB, Benninga MA, Tabbers MM. An Update of Pharmacological Management in Children with Functional Constipation. Paediatr Drugs 2023; 25:343-358. [PMID: 36941393 PMCID: PMC10097737 DOI: 10.1007/s40272-023-00563-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/23/2023]
Abstract
Functional constipation is a common problem in childhood worldwide and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. It is a clinical diagnosis based on the Rome IV criteria. Non-pharmacological treatment involves education, demystification, lifestyle advice, and toilet training. Pharmacological treatment consists of disimpaction, maintenance treatment, and eventually weaning if possible. Polyethylene glycol is considered as the first choice of laxative for both disimpaction and maintenance treatment. Different osmotic laxatives, stimulant laxatives, lubricants, and enemas are available as alternative pharmacological treatment options. Novel drugs are emerging but evidence to support the widespread application of these drugs in the pediatric population is often lacking and more high-quality research is needed in this field. If children remain symptomatic despite optimal pharmacological treatment, botulinum toxin injections in the anal sphincter can be considered as an alternative, more invasive treatment option. This review provides an update on currently available literature concerning the pharmacologic treatment of functional constipation in children.
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Affiliation(s)
- Anna de Geus
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Robert B Flint
- Department of Clinical Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Merit M Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands.
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Di Nardo G, Zenzeri L, Guarino M, Molfino A, Parisi P, Barbara G, Stanghellini V, De Giorgio R. Pharmacological and nutritional therapy of children and adults with chronic intestinal pseudo-obstruction. Expert Rev Gastroenterol Hepatol 2023; 17:325-341. [PMID: 36939480 DOI: 10.1080/17474124.2023.2193887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
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.
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Affiliation(s)
- Giovanni Di Nardo
- NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Letizia Zenzeri
- NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy.,Emergency Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Matteo Guarino
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Alessio Molfino
- Department of Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Pasquale Parisi
- NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Barbara
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna; Department of Medical and Surgical Sciences, University of Bologna, 40138, Bologna, Italy
| | - Vincenzo Stanghellini
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna; Department of Medical and Surgical Sciences, University of Bologna, 40138, Bologna, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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11
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Leung JG. Part
II
: Interactive case—Clinical pearls of clozapine. J Am Coll Clin Pharm 2023. [DOI: 10.1002/jac5.1765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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12
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McMahan ZH, Kulkarni S, Chen J, Chen JZ, Xavier RJ, Pasricha PJ, Khanna D. Systemic sclerosis gastrointestinal dysmotility: risk factors, pathophysiology, diagnosis and management. Nat Rev Rheumatol 2023; 19:166-181. [PMID: 36747090 DOI: 10.1038/s41584-022-00900-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 02/08/2023]
Abstract
Nearly all patients with systemic sclerosis (SSc) are negatively affected by dysfunction in the gastrointestinal tract, and the severity of gastrointestinal disease in SSc correlates with high mortality. The clinical complications of this dysfunction are heterogeneous and include gastro-oesophageal reflux disease, gastroparesis, small intestinal bacterial overgrowth, intestinal pseudo-obstruction, malabsorption and the requirement for total parenteral nutrition. The abnormal gastrointestinal physiology that promotes the clinical manifestations of SSc gastrointestinal disease throughout the gastrointestinal tract are diverse and present a range of therapeutic targets. Furthermore, the armamentarium of medications and non-pharmacological interventions that can benefit affected patients has substantially expanded in the past 10 years, and research is increasingly focused in this area. Here, we review the details of the gastrointestinal complications in SSc, tie physiological abnormalities to clinical manifestations, detail the roles of standard and novel therapies and lay a foundation for future investigative work.
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Affiliation(s)
| | - Subhash Kulkarni
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joan Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Jiande Z Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Ramnik J Xavier
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - P Jay Pasricha
- Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Scleroderma Program, Ann Arbor, MI, USA.
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13
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Bassotti G, Villanacci V, Corsetti M. Exploring Pharmacological Treatments for Chronic Idiopathic Constipation in Adults: A Look Back to the Future. J Clin Med 2023; 12:jcm12041702. [PMID: 36836237 PMCID: PMC9959210 DOI: 10.3390/jcm12041702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/14/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Despite great progress in pharmaceutical research, the medical treatment of chronic idiopathic constipation is far from ideal. The aim of the present article was to review literature data, focusing on poorly studied or commercially unavailable/unapproved drugs potentially useful for the treatment of chronic idiopathic constipation in adults. An extensive online literature search was conducted using the keywords "chronic constipation", "colon", "constipation", "drugs", "laxatives", and "treatment", in various combinations between January 1960 and December 2022. The literature search showed the presence of some drugs whose efficacy has only recently been demonstrated by modern investigations, and which are likely to be incorporated into future guidelines, of others that are proven effective and potentially effective on constipated patients but limited by small or relatively old studies, or by side effects which could be used in experienced hands, and of others that might be useful but lack a solid scientific background. Looking into the future for patients with chronic constipation might add some more tools to the therapeutic portfolio, especially for certain subgroups of these patients.
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Affiliation(s)
- Gabrio Bassotti
- Gastroenterology, Hepatology & Digestive Endoscopy Section, Department of Medicine and Surgery, University of Perugia, 06123 Perugia, Italy
- Correspondence:
| | | | - Maura Corsetti
- National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust UK, School of Medicine, University of Nottingham and Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham NG7 2RD, UK
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14
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Corsello A, Scatigno L, Govoni A, Zuccotti G, Gottrand F, Romano C, Verduci E. Gut dysmotility in children with neurological impairment: the nutritional management. Front Neurol 2023; 14:1200101. [PMID: 37213895 PMCID: PMC10196023 DOI: 10.3389/fneur.2023.1200101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 05/23/2023] Open
Abstract
Intestinal motility disorders represent a frequent problem in children with neurological impairment. These conditions are characterized by abnormal movements of the gut, which can result in symptoms such as constipation, diarrhea, reflux, and vomiting. The underlying mechanisms leading to dysmotility are various, and the clinical manifestations are often nonspecific. Nutritional management is an important aspect of care for children with gut dysmotility, as it can help to improve their quality of life. Oral feeding, when safe and in the absence of risk of ingestion or severe dysphagia, should always be encouraged. When oral nutrition is insufficient or potentially harmful, it is necessary to switch to an enteral by tube or parenteral nutrition before the onset of malnutrition. In most cases, children with severe gut dysmotility may require feeding via a permanent gastrostomy tube to ensure adequate nutrition and hydration. Drugs may be necessary to help manage gut dysmotility, such as laxatives, anticholinergics and prokinetic agents. Nutritional management of patients with neurological impairment often requires an individualized care plan to optimize growth and nutrition and to improve overall health outcomes. This review tries to sum up most significant neurogenetic and neurometabolic disorders associated with gut dysmotility that may require a specific multidisciplinary care, identifying a proposal of nutritional and medical management.
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Affiliation(s)
- Antonio Corsello
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Lorenzo Scatigno
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Annalisa Govoni
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Gianvincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Frédéric Gottrand
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, CHU Lille, University of Lille, Lille, France
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Elvira Verduci
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Health Science, University of Milan, Milan, Italy
- *Correspondence: Elvira Verduci,
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15
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Salamone S, Liu R, Staller K. Gastrointestinal Dysmotility in Critically Ill Patients: Bridging the Gap Between Evidence and Common Misconceptions. J Clin Gastroenterol 2022. [PMID: 36227004 DOI: 10.1097/MCG.0000000000001772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Disruption of normal gastrointestinal (GI) function in critical illness is linked to increased morbidity and mortality, and GI dysmotility is frequently observed in patients who are critically ill. Despite its high prevalence, the diagnosis and management of GI motility problems in the intensive care unit remain very challenging, given that critically ill patients often cannot verbalize symptoms and the general lack of understanding of underlying pathophysiology. Common clinical presentations of GI dysmotility issues among critically ill patients include: (1) high gastric residual volumes, acid reflux, and vomiting, (2) abdominal distention, and (3) diarrhea. In this review, we discuss the differential diagnosis for intensive care unit patients with symptoms and signs concerning GI motility issues. There are many myths and longstanding misconceptions about the diagnosis and management of GI dysmotility in critical illness. Here, we uncover these myths and discuss relevant evidence in each subject area, with the goal of re-conceptualizing GI motility disorders in critical care and providing evidence-based recommendations for clinical care.
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Abstract
Acute colonic pseudo-obstruction (ACPO) is a functional disorder of the large intestine distinguished by colonic dysmotility resulting in colonic distension in the absence of mechanical obstruction. The underlying pathophysiology of ACPO remains unclear despite technological advances in understanding the physiology of colonic motility, such as spatio-temporal mapping and high-resolution manometry. In many ways, the management of ACPO has remained relatively unchanged for 40 years. Patients with perforation or suspected ischemia undergo operative intervention, while patients without undergo initial conservative management with bowel rest, correction of electrolyte disturbances, and mobilization. Patients who fail conservative management or have prominent cecal dilatation undergo decompression with either neostigmine or colonoscopy. A subset of patients with ACPO will have recurrent symptoms despite endoscopic and medical management. For these patients who are difficult to manage, an underlying colonic functional disorder, such as slow-transit dysmotility or chronic intestinal pseudo-obstruction may be considered. The following review of ACPO aims to provide a concise update of the causes, diagnosis, and management of this emergency surgical condition.
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Affiliation(s)
- Thomas Arthur
- Department of Colorectal Surgery, Austin Hospital, Melbourne, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
| | - Adele Burgess
- Department of Colorectal Surgery, Austin Hospital, Melbourne, Australia
- School of Medicine, University of Melbourne, Melbourne, Australia
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17
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Gutiérrez Pérez C, Lastra Aras E, Gómez Bravo R, Chivato Martín-Falquina I, Cuenca Zarzuela A, Rodríguez Ledesma I, García Girón C. Chronic intestinal pseudo-obstruction: diagnostic and prognostic utility of ANNA-1/Anti-Hu onconeural antibodies. Rev Esp Enferm Dig 2022; 114:175-176. [PMID: 34991323 DOI: 10.17235/reed.2021.8521/2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
We propose an algorithm for the early detection of cancer from a case of paraneoplastic syndrome.
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18
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Keller J, Wedel T, Seidl H, Kreis ME, van der Voort I, Gebhard M, Langhorst J, Lynen Jansen P, Schwandner O, Storr M, van Leeuwen P, Andresen V, Preiß JC, Layer P, Allescher H, Andus T, Bischoff SC, Buderus S, Claßen M, Ehlert U, Elsenbruch S, Engel M, Enninger A, Fischbach W, Freitag M, Frieling T, Gillessen A, Goebel-Stengel M, Gschossmann J, Gundling F, Haag S, Häuser W, Helwig U, Hollerbach S, Holtmann G, Karaus M, Katschinski M, Krammer H, Kruis W, Kuhlbusch-Zicklam R, Lynen Jansen P, Madisch A, Matthes H, Miehlke S, Mönnikes H, Müller-Lissner S, Niesler B, Pehl C, Pohl D, Posovszky C, Raithel M, Röhrig-Herzog G, Schäfert R, Schemann M, Schmidt-Choudhury A, Schmiedel S, Schweinlin A, Schwille-Kiuntke J, Stengel A, Tesarz J, Voderholzer W, von Boyen G, von Schönfeld J. Update S3-Leitlinie Intestinale Motilitätsstörungen: Definition, Pathophysiologie, Diagnostik und Therapie. Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM). Z Gastroenterol 2022; 60:192-218. [PMID: 35148561 DOI: 10.1055/a-1646-1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus in Hamburg, Hamburg, Deutschland
| | - Thilo Wedel
- Institut für Anatomie, Christian-Albrechts-Universität Kiel, Kiel, Deutschland
| | - Holger Seidl
- Klinik für Gastroenterologie, Hepatologie und Gastroenterologische Onkologie, Isarklinikum München, München, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité, Campus Benjamin Franklin, Berlin, Deutschland
| | - Ivo van der Voort
- Klinik für Innere Medizin - Gastroenterologie und Diabetologie, Jüdisches Krankenhaus Berlin, Deutschland
| | | | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum Bamberg, Bamberg, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, Berlin, Deutschland
| | - Oliver Schwandner
- Abteilung für Proktologie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Martin Storr
- Zentrum für Endoskopie, Gesundheitszentrum Starnberger See, Starnberg
| | - Pia van Leeuwen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, Berlin, Deutschland
| | - Viola Andresen
- Medizinische Klinik, Israelitisches Krankenhaus in Hamburg, Hamburg, Deutschland
| | - Jan C Preiß
- Klinik für Innere Medizin - Gastroenterologie, Diabetologie und Hepatologie, Klinikum Neukölln, Berlin
| | - Peter Layer
- Medizinische Klinik, Israelitisches Krankenhaus in Hamburg, Hamburg, Deutschland
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De Meulder S, Vanuytsel T. 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] [What about the content of this article? (0)] [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.
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20
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Traeger L, Kroon HM, Bedrikovetski S, Moore JW, Sammour T. The impact of acetylcholinesterase inhibitors on ileus and gut motility following abdominal surgery: a clinical review. ANZ J Surg 2021; 92:69-76. [PMID: 34927331 DOI: 10.1111/ans.17418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 12/22/2022]
Abstract
Postoperative ileus is a common complication in the days following colorectal surgery occurring in up to 50% of patients. When prolonged, this complication results in significant morbidity and mortality, doubling the total costs of hospital stay. Postoperative ileus (POI) results from the prolonged inflammatory phase that is mediated in part by the cholinergic anti-inflammatory pathway. Acetylcholinesterase inhibitors, such as neostigmine and pyridostigmine, delay the degradation of acetylcholine at the synaptic cleft. This increase in acetylcholine has been shown to increase gut motility. They have been effective in the treatment of acute colonic pseudo-obstruction, but there is limited evidence for the use of these medications for reducing the incidence of POI. This review was conducted to summarise the evidence of acetylcholinesterase inhibitors' effect on gut motility and discuss their potential use as part of an enhanced recovery protocols to prevent or treat POI.
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Affiliation(s)
- Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - James W Moore
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
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21
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Radocchia G, Neroni B, Marazzato M, Capuzzo E, Zuccari S, Pantanella F, Zenzeri L, Evangelisti M, Vassallo F, Parisi P, Di Nardo G, Schippa S. Chronic Intestinal Pseudo-Obstruction: Is There a Connection with Gut Microbiota? Microorganisms 2021; 9:2549. [PMID: 34946150 DOI: 10.3390/microorganisms9122549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [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.
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22
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Gutiérrez Pérez C, Lastra Aras E, Gómez Bravo R, Chivato Martín-Falquina I, Cuenca Zarzuela A, Rodríguez Ledesma I, García Girón C. Chronic intestinal pseudo-obstruction: diagnostic and prognostic utility of ANNA-1/Anti-Hu onconeural antibodies. Rev Esp Enferm Dig 2021. [PMID: 34470446 DOI: 10.17235/reed.2021.8186/2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 65-year-old woman who, in the context of dyspepsia and dismotility, was diagnosed with chronic intestinal pseudo-obstruction (CIPO) in small cell lung carcinoma (SCLC). In spite of a remarkable tumor response after the combination of chemotherapy and immunotherapy, an intestinal sepsis led to the patient's sudden death.
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23
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Dudi-Venkata NN, Kroon HM, Bedrikovetski S, Traeger L, Lewis M, Lawrence MJ, Hunter RA, Moore JW, Thomas ML, Sammour T. PyRICo-Pilot: pyridostigmine to reduce the duration of postoperative ileus after colorectal surgery - a phase II study. Colorectal Dis 2021; 23:2154-2160. [PMID: 34021689 DOI: 10.1111/codi.15748] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/04/2021] [Accepted: 05/16/2021] [Indexed: 02/05/2023]
Abstract
AIM Postoperative ileus (POI) is a major problem after colorectal surgery. Acetylcholinesterase inhibitors such as pyridostigmine increase gastrointestinal (GI) motility through a cholinergic anti-inflammatory pathway. The purpose of this phase II pilot study is to determine the safety of oral pyridostigmine after elective colorectal surgery. METHOD This is a Stage 2b safety study (IDEAL framework). All adult patients undergoing elective colorectal resection or formation or reversal of stoma at the Royal Adelaide Hospital between September 2020 and January 2021 were eligible. The primary outcomes were 30-day postoperative complications, reported adverse events and GI-2 - a validated composite outcome measure of recovery of GI function after surgery, defined as the interval from surgery until first passage of stool and tolerance of a solid intake for 24 h (in whole days) in the absence of vomiting. RESULTS Fifteen patients were included in the study. The median age was 58 (range 50-82) years and seven (47%) were men. Most participants had an American Society of Anesthesiologists grade ≥2 (53%) and the median body mass index was 27 (24-35) kg/m2 . There were 13 postoperative complications [seven were Clavien-Dindo (CD) 1, five CD 2 and one CD 3]. None appeared directly related to pyridostigmine administration, and none of the patients had any overt symptoms of excessive parasympathetic activity. Median GI-2 was 2 (1-4) days. CONCLUSION Oral pyridostigmine appears to be safe to use after elective colorectal surgery in a select group of patients. However, considering this is a pilot study with a small sample size, larger controlled studies are needed to confirm this finding and establish efficacy for prevention of POI.
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Affiliation(s)
- Nagendra N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Mark Lewis
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Matthew J Lawrence
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ronald A Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - James W Moore
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Michelle L Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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24
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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25
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Abstract
Chronic intestinal pseudo-obstruction (CIPO) is a rare syndrome associated with significant mortality and morbidity. It mimics the signs and symptoms of intestinal obstruction in the absence of an anatomic lesion causing obstruction. Here we present a case of a young male with severe alcohol abuse disorder who initially presented with signs and symptoms of alcohol withdrawal but was found to have abdominal distension. Imaging studies revealed severe small and large bowel dilatation without any organic lesion. He continued to have marked intestinal dilatation for the subsequent few months. Alcohol cessation eventually led to a marked reduction in his symptoms and a decrease in intestinal dilatation. The occurrence of CIPO because of alcohol abuse is rare, and we explore the possible association between the two entities.
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Affiliation(s)
- Asim Haider
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | | | - Harish Patel
- Gastroenterology and Hepatology, BronxCare Health System, New York, USA
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26
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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27
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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28
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Gan Y, Liang J, Diao W, Zhou X, Mu J, Pang L, Tan F, Zhao X. Lactobacillus plantarum KSFY06 and geniposide counteract montmorillonite-induced constipation in Kunming mice. Food Sci Nutr 2020; 8:5128-5137. [PMID: 32994973 PMCID: PMC7500764 DOI: 10.1002/fsn3.1814] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 12/17/2022] Open
Abstract
Constipation is a common clinical manifestation of digestive system disorders and occurs worldwide. This study investigated the ability of Lactobacillus plantarum KSFY06 (LP-KSFY06) to promote the action of geniposide in preventing montmorillonite-induced constipation in Kunming mice, with the aim of providing a successful solution. The effects of LP-KSFY06 and geniposide on constipation were measured, and the results showed that the protective effect of geniposide on constipation was enhanced by LP-KSFY06 and that the combination resulted in increased weight, moisture content, and particle number of feces. The first black stool defecation time was decreased from 182 min to 87 min, which clearly indicates that defecating difficulty was alleviated in constipated mice. The synergic intervention of LP-KSFY06 and geniposide (LP + G) assisted in maintaining the body weight of constipated mice. The LP + G intervention significantly increased serum levels of motilin (MTL, 167.8 pg/ml), acetylcholinesterase (AChE, 45.3 pg/ml), substance P (SP, 61.0 pg/ml), vasoactive intestinal peptide (VIP, 70.5 pg/ml), endothelin-1 (ET-1, 16.1 pg/ml), and gastrin (73.0 pg/ml) and remarkably decreased somatostatin (SS, 35.2 pg/ml) when compared to those indexes in the LP-KSFY06 group and geniposide group. The LP + G treatment also significantly increased the mRNA expression of cluster of differentiation 117 (c-Kit), stem cell factor (SCF), glial cell-derived neurotrophic factor (GDNF), and remarkably downregulated the expression of inducible nitric oxide synthase (iNOS), transient receptor potential vanilloid-1 (TRPV1), and cyclooxygenase-2 (COX-2). The experimental results showed that the combination treatment has the strongest prevention effect against constipation, and LP-KSFY06 promotes the ability of geniposide to prevent constipation. Therefore, LP-KSFY06 is a potential probiotic strain with the capacity to prevent montmorillonite-induced constipation.
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Affiliation(s)
- Yi Gan
- Chongqing Collaborative Innovation Center for Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Research Center of Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Laboratory for Research and Development of Functional FoodChongqing University of EducationChongqingChina
| | - Jie Liang
- Department of PediatricsChongqing Traditional Chinese Medicine HospitalChongqingChina
| | - Wenjing Diao
- Chongqing Collaborative Innovation Center for Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Research Center of Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Laboratory for Research and Development of Functional FoodChongqing University of EducationChongqingChina
| | - Xianrong Zhou
- Chongqing Collaborative Innovation Center for Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Research Center of Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Laboratory for Research and Development of Functional FoodChongqing University of EducationChongqingChina
| | - Jianfei Mu
- Chongqing Collaborative Innovation Center for Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Research Center of Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Laboratory for Research and Development of Functional FoodChongqing University of EducationChongqingChina
| | - Liang Pang
- Department of Oral and Maxillofacial SurgeryThe Affiliated Hospital of StomatologyChongqing Medical UniversityChongqingChina
| | - Fang Tan
- Department of Public HealthOur Lady of Fatima UniversityValenzuelaPhilippines
| | - Xin Zhao
- Chongqing Collaborative Innovation Center for Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Research Center of Functional FoodChongqing University of EducationChongqingChina
- Chongqing Engineering Laboratory for Research and Development of Functional FoodChongqing University of EducationChongqingChina
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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.
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Affiliation(s)
- Reena Sidhu
- Academic Department of Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Glossop Road, Sheffield, United Kingdom
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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.
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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
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Naveed M, Jamil LH, Fujii-Lau LL, Al-Haddad M, Buxbaum JL, Fishman DS, Jue TL, Law JK, Lee JK, Qumseya BJ, Sawhney MS, Thosani N, Storm AC, Calderwood AH, Khashab MA, Wani SB. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus. Gastrointest Endosc 2020; 91:228-35. [PMID: 31791596 DOI: 10.1016/j.gie.2019.09.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022]
Abstract
Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.
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Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol 2020; 17:21-39. [PMID: 31690829 DOI: 10.1038/s41575-019-0222-y] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Abstract
Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.
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Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael Camilleri
- C.E.N.T.E.R. Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Elsherbeny M, Abdelhay S. Obstructive complications after pull-through for Hirschsprung’s disease: different causes and tailored management. Ann Pediatr Surg 2019. [DOI: 10.1186/s43159-019-0003-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Most children have a successful outcome after a pull-through for Hirschsprung’s disease. Some may have persisting symptoms after the pull-through. They could be managed conservatively, need minor surgical procedures, or a redo pull-through will be required. In this study, we presented our results in the management of the obstructive complications after pull-through for Hirschsprung’s disease.
Results
During the specified time period from January 2011 to December 2015, 21 patients presented to our department with persistent constipation or recurrent enterocolitis after a pull-through for Hirschsprung’s disease. Their age ranged between 4 months and 5 years (mean 2 years, median 2.5 years). They were 13 males and 8 females. Eleven patients underwent initial trans-anal endorectal pull-through, 4 underwent Duhamel procedure, and 6 underwent abdominal Soave technique. Three of the 11 patients with initial trans-anal endorectal pull-through had a tight anastomotic stricture which responded well to dilatation, 2 had a long muscular cuff which was incised laparoscopically, 4 had spasm of the internal anal sphincter which was relieved by sphincterotomy, and 2 had residual aganglionosis which required a redo pull-through. Two of the 4 patients who underwent initial Duhamel procedure had a long spur which was divided using a stapler, and the other 2 patients had residual aganglionosis which required a redo pull-through. One of the 6 patients who underwent abdominal Soave technique developed a long tight stricture and required a redo pull-through; in 1 patient, biopsy confirmed hypoganglionosis of the whole colon and was managed medically, and 4 patients had spasm of the internal anal sphincter which was relieved in 1 of them by sphincterotomy and in 2 by botulinum toxin injection while the remaining patient did not improve by either sphincterotomy or botulinum toxin injection.
Conclusion
Persistent constipation or recurrent enterocolitis after pull-through for Hirschsprung’s disease should be managed according to the cause; they could be managed medically by simple surgical procedures, or a redo pull-through may be required.
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Di Nardo G, Viscogliosi F, Esposito F, Stanghellini V, Villa MP, Parisi P, Morlando A, Caló G, De Giorgio R. Pyridostigmine in Pediatric Intestinal Pseudo-obstruction: Case Report of a 2-year Old Girl and Literature Review. J Neurogastroenterol Motil 2019; 25:508-514. [PMID: 31587541 PMCID: PMC6786444 DOI: 10.5056/jnm19078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/04/2019] [Accepted: 07/20/2019] [Indexed: 12/20/2022] Open
Abstract
Pediatric chronic intestinal pseudo-obstruction is a rare disorder characterized by a severe impairment of gastrointestinal motility leading to intestinal obstruction symptoms in the absence of mechanical causes. The diagnosis is usually clinical and diagnostic work is usually aimed to rule out mechanical obstruction and to identify any underlying diseases. Treatment is challenging and requires a multidisciplinary effort. In this manuscript we describe the youngest child successfully treated with the orally administrable, long-acting, reversible anti-cholinesterase drug, pyridostigmine. Like other drugs belonging to cholinesterase inhibitors, pyridostigmine enhances gut motility by increasing acetylcholine availability in the enteric nervous system and neuro-muscular junctions. Based on the direct evidence from the reported case, we reviewed the current literature on the use of pyridostigmine in severe pediatric dysmotility focusing on intestinal pseudo-obstruction. The overall data emerged from the few published studies suggest that pyridostigmine is an effective and usually well tolerated therapeutic options for patients with intestinal pseudo-obstruction. More specifically, the main results obtained by pyridostigmine included marked reduction of abdominal distension, reduced need of parenteral nutrition, and improvement of oral feeding. The present case and review on pyridostigmine pave the way for eagerly awaited future randomized controlled studies testing the efficacy of cholinesterase inhibitors in pediatric severe gut dysmotility.
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Affiliation(s)
- Giovanni Di Nardo
- NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Federica Viscogliosi
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy
| | | | - Vincenzo Stanghellini
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Maria Pia Villa
- NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Pasquale Parisi
- NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Alessia Morlando
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy
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Abstract
PURPOSE OF REVIEW This review provides important updates in systemic sclerosis (SSc)-related gastrointestinal disease, with a particular focus on the diagnosis and management of dysmotility. RECENT FINDINGS In the past 2 years, several studies were published that present interesting diagnostic insights into SSc and gastrointestinal dysmotility. Studies focusing on new therapies and the novel application of existing therapies, both in SSc and non-SSc-associated gastrointestinal dysmotility syndromes, demonstrate progress in the management of these challenging complications. SUMMARY SSc gastrointestinal disease is heterogeneous in its clinical presentation, which presents a challenge in diagnosis and management. Objective studies may help to identify patterns of gastrointestinal dysmotility and more specifically target therapy. A variety of drugs are now available or are under study in the management of gastrointestinal dysmotility, such as prucalopride, intravenous immunoglobulin, pyridostigmine, linaclotide, relamorelin, and others. These drugs may improve symptoms and quality of life in SSc gastrointestinal patients. Combination therapies are also under study. Electroacupuncture, dietary intervention (e.g. medical nutrition therapy, low FODmap diet), and medical cannibus may also play a role in alleviating patient symptoms; however, more data are needed to define the role of these interventions in SSc.
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Li X, Liu Y, Guan W, Xia Y, Zhou Y, Yang B, Kuang H. Physicochemical properties and laxative effects of polysaccharides from Anemarrhena asphodeloides Bge. in loperamide-induced rats. J Ethnopharmacol 2019; 240:111961. [PMID: 31102614 DOI: 10.1016/j.jep.2019.111961] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 03/20/2019] [Accepted: 05/14/2019] [Indexed: 05/22/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE As a traditional Chinese herbal medicine, Anemarrhena asphodeloides Bge. possesses the effects of nourishing yin, moistening dryness, clearing lungs and relieving fire. Simultaneously, it has been used to treat constipation for more than one thousand years in China. However, modern medical studies are limited and lacking on its therapeutic mechanism. AIM OF THE STUDY This current study was aimed to investigate the laxative activities and explore the potential mechanism of Anemarrhena asphodeloides Bge. polysaccharides (AABP) in loperamide-induced constipation rats. MATERIALS AND METHODS The structure of AABP was determined by using infrared spectrum, high performance gel permeation chromatography (HPGPC), and high performance liquid chromatography (HPLC). Real-time quantitative polymerase chain reaction (PCR), multitudinous methods were adopted to explore the underlining therapeutic mechanism of AABP in treating constipation, including enzyme-linked immunosorbent assay (ELISA), histopathological, immunohistochemistry and western blotting. RESULTS In the present study, the average molecular weight of AABP was determined as 1.11 × 103 kDa. The primary monosaccharide compositions were analyzed including D-mannose, L-rhamnose, D-galacturonic acid, D-glucose, D-galactose and L-arabinose (1, 0.04, 0.53, 0.11, 0.33, 0.25, respectively) by high-performance liquid chromatography (HPLC). AABP significantly increased the levels of gastrin (Gas), motilin (MTL), substance P (SP), 5-hydroxytryptamine (5-HT) and vasoactive intestinal peptide (VIP), and decreased the NO content of loperamide-induced rats to ameliorate constipation in the rats. Whilst, AABP repaired the damaged colons by regulating PCNA and ICAM-1 protein expressions. Additionally, AABP up-regulated the levels of SCF, c-Kit, AQP3 and VIP as well as down-regulated the expressions of AQP8, AQP4 and PGE2. CONCLUSION The present findings suggested that AABP were the laxative active ingredients isolated from Anemarrhena asphodeloides Bge., which could treat constipation through regulating the gastrointestinal hormones and neurotransmitters to improve the intestinal motility and water metabolism.
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Affiliation(s)
- Xiaomao Li
- Key Laboratory of Chinese Materia Medica (Ministry of Education), Heilongjiang University of Chinese Medicine, 24 Heping Road, Xiangfang District, Harbin, 150040, China
| | - Yan Liu
- Key Laboratory of Chinese Materia Medica (Ministry of Education), Heilongjiang University of Chinese Medicine, 24 Heping Road, Xiangfang District, Harbin, 150040, China
| | - Wei Guan
- Key Laboratory of Chinese Materia Medica (Ministry of Education), Heilongjiang University of Chinese Medicine, 24 Heping Road, Xiangfang District, Harbin, 150040, China
| | - Yonggang Xia
- Key Laboratory of Chinese Materia Medica (Ministry of Education), Heilongjiang University of Chinese Medicine, 24 Heping Road, Xiangfang District, Harbin, 150040, China
| | - Yuanyuan Zhou
- Key Laboratory of Chinese Materia Medica (Ministry of Education), Heilongjiang University of Chinese Medicine, 24 Heping Road, Xiangfang District, Harbin, 150040, China
| | - Bingyou Yang
- Key Laboratory of Chinese Materia Medica (Ministry of Education), Heilongjiang University of Chinese Medicine, 24 Heping Road, Xiangfang District, Harbin, 150040, China.
| | - Haixue Kuang
- Key Laboratory of Chinese Materia Medica (Ministry of Education), Heilongjiang University of Chinese Medicine, 24 Heping Road, Xiangfang District, Harbin, 150040, China.
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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.
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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.
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Frankel A, Gillespie C, Lu CT, Hewett P, Wattchow D. Subcutaneous neostigmine appears safe and effective for acute colonic pseudo-obstruction (Ogilvie's syndrome). ANZ J Surg 2019; 89:700-705. [PMID: 31083785 DOI: 10.1111/ans.15265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/01/2019] [Accepted: 04/06/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Intravenous neostigmine is a well-established treatment for acute colonic pseudo-obstruction (ACPO). Its use is hampered by the perceived requirement for continuous cardiac monitoring, and patients are often transferred to high-dependency units for close observation during treatment. Subcutaneous neostigmine has the potential to minimize adverse cardiovascular effects while maintaining efficacy. This study aims to assess the safety of subcutaneous neostigmine on ward inpatients with ACPO monitored with standard nursing care. METHODS This is a retrospective case series of 30 patients with ACPO who were treated with subcutaneous neostigmine between August 2008 and October 2012. Data were collected prospectively. All patients were diagnosed using clinical examination and radiology and were assessed for contraindications to neostigmine. Patients were treated on regular wards and monitored with standard nursing observations. The main outcomes were time to flatus and bowels working and complications. RESULTS No serious complications such as clinically evident bradycardia were encountered. Ninety-three percent of patients had clinically successful resolution of ACPO. Two patients (7%) developed caecal tenderness and proceeded to colonoscopic decompression, which was successful in both instances. CONCLUSIONS Subcutaneous neostigmine appears to be safe for the treatment of ACPO. No clinically evident serious adverse events occurred, meaning continuous cardiac monitoring as a routine may not be necessary. In our cohort, we achieved similar success rates compared with reported rates using intravenous neostigmine.
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Affiliation(s)
- Adam Frankel
- Department of Surgery, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Cu-Tai Lu
- Department of Surgery, Gold Coast University Hospital, Brisbane, Queensland, Australia
| | - Peter Hewett
- The University of Adelaide, Adelaide, South Australia, Australia
| | - David Wattchow
- Flinders University, Adelaide, South Australia, Australia
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Lee H, Park S, Oh JT, Kim HM, Kim S, Lee JS. Oral Pyridostigmine-responsive Visceral Myopathy With ACTG2 Mutations: A Case Series. J Pediatr Gastroenterol Nutr 2019; 68:e16-7. [PMID: 30334933 DOI: 10.1097/MPG.0000000000002183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Iida T, Hirayama D, Sudo G, Mitsuhashi K, Igarashi H, Yamashita K, Yamano H, Nakase H. Chronic intestinal pseudo-obstruction due to al amyloidosis: a case report and literature review. Clin J Gastroenterol 2018; 12:176-181. [PMID: 30232705 DOI: 10.1007/s12328-018-0909-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 09/13/2018] [Indexed: 02/07/2023]
Abstract
A 59-year-old woman presented to our hospital with a 6-month history of nausea, weight loss, and abdominal distension. Physical examination revealed abdominal distension without tenderness, and edema, numbness, and multiple peripheral neuropathy in the limbs. Blood test results showed anemia, hypoproteinemia, and hypoalbuminemia. Immunoelectrophoresis detected kappa-type Bence-Jones protein in both the serum and urine. Bone marrow examination did not reveal an increase of plasma cells. Computed tomography showed intestinal distension and retention of intestinal contents. No obstructive intestinal lesions were observed. Lower gastrointestinal endoscopy showed a decrease in the vascular visibility of the rectal mucosa. Histological findings showed amyloid deposition, which was positive for amyloid light-chain (AL) κ. Thus, she was diagnosed with chronic intestinal pseudo-obstruction (CIPO) due to gastrointestinal and neurological involvement of AL amyloidosis. Her abdominal symptoms were gradually improved by the insertion of an ileus tube and medication. Although we recommended chemotherapy for stopping her disease progression, she did not want to receive it. She died 1 year later because of her pneumonia. We should keep in mind that amyloidosis is an important cause of CIPO. Histopathological examination by endoscopic biopsy is required for exact diagnosis and appropriate treatment for CIPO due to amyloidosis.
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Affiliation(s)
- Tomoya Iida
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Daisuke Hirayama
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Gota Sudo
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Kei Mitsuhashi
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Hisayoshi Igarashi
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Kentaro Yamashita
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Hiroo Yamano
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
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Collins RRJ, Barth B, Megison S, Pfeifer CM, Rice LM, Harris S, Timmons CF, Rakheja D. ACTG2-Associated Visceral Myopathy With Chronic Intestinal Pseudoobstruction, Intestinal Malrotation, Hypertrophic Pyloric Stenosis, Choledochal Cyst, and a Novel Missense Mutation. Int J Surg Pathol 2018; 27:77-83. [PMID: 30019982 DOI: 10.1177/1066896918786586] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Primary visceral myopathy caused by a pathogenic mutation in the gene encoding the enteric smooth muscle actin gamma 2 ( ACTG2) affects gastrointestinal and genitourinary tracts and often presents as chronic intestinal pseudoobstruction. We present a case of pediatric onset chronic intestinal pseudoobstruction associated with a novel missense ACTG2 mutation c.439G>T/p.G147C. In addition to the known disease manifestations of feeding intolerance and intestinal malrotation, our patient had a late-onset hypertrophic pyloric stenosis and a late-onset choledochal cyst, the former of which has not previously been described in patients with ACTG2-associated visceral myopathy.
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Affiliation(s)
- Rebecca R J Collins
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Bradley Barth
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Stephen Megison
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Cory M Pfeifer
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Luke M Rice
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Samar Harris
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Charles F Timmons
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Dinesh Rakheja
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
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45
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Abstract
Chronic intestinal pseudo-obstruction (CIPO) is a rare disorder characterized by an impairment of coordinated propulsive activity in the gastrointestinal (GI) tract, which clinically mimics mechanical intestinal obstruction. CIPO is the most severe and debilitating form of GI dysmotility. CIPO may be primary or be secondary to pathology at any level of the brain-gut axis as well as systemic disease. The clinical features of CIPO are pleomorphic and largely depend on the site and extent of the segment of the GI tract involved. The diagnostic approach includes the need for investigations to exclude mechanical GI obstruction, screening for causes of secondary CIPO and the identification of the disease phenotype as well as the prompt recognition and treatment of complications such as malnutrition and small intestinal bacterial overgrowth. In managing this disorder, a holistic, multidisciplinary approach is needed with judicious use of pharmacotherapeutic agents. While currently there are no specific therapeutic modalities for CIPO, treatment is largely directed at maintaining adequate nutrition and electrolyte balance and enhancing coordinated GI motility. Surgery should be avoided unless advisable for carefully selected patients and may include stoma formation. This narrative review provides a concise overview of the literature on this rare, severe and complex disorder, and highlights the need and areas for further research to improve both diagnostics and therapeutics.
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Affiliation(s)
- Thomas J Downes
- Department of Gastroenterology, University Hospitals of the North Midlands, Stoke-on-Trent, Staffordshire
| | - Manikandar S Cheruvu
- Department of Gastroenterology, University Hospitals of the North Midlands, Stoke-on-Trent, Staffordshire
| | - Tennekoon B Karunaratne
- Department of Medical and Surgical Sciences, St.Orsola-Malpighi Hospital, University of Bologna, Bologna
| | - Roberto De Giorgio
- Department of Medical Sciences, Nuovo Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Adam D Farmer
- Department of Gastroenterology, University Hospitals of the North Midlands, Stoke-on-Trent, Staffordshire.,Centre for Trauma and Neuroscience, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London.,Institute of Applied Clinical Science, University of Keele, Keele, UK
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46
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Thapar N, Saliakellis E, Benninga MA, Borrelli O, Curry J, Faure C, De Giorgio R, Gupte G, Knowles CH, Staiano A, Vandenplas Y, Di Lorenzo C. 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: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [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.
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47
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Abstract
BACKGROUND Gastrointestinal (GI) motility disorders are common in children. Treatment is challenging with limited medical and surgical options. Pyridostigmine, an acetyl cholinesterase inhibitor, increases acetylcholine at the neuromuscular junction promoting intestinal contractions. Little is known about the role and dosing of pyridostigmine in pediatric GI motility disorders. METHODS We present a case series of children with GI dysmotility managed with oral pyridostigmine. Patients' diagnoses include chronic intestinal pseudo-obstruction, gastroparesis with delayed small bowel transit, chronic constipation with failure to thrive, and prolonged ileus after pelvic surgery with chronic opioid use. RESULTS Pyridostigmine was effective and safe in all cases. Pyridostigmine decreased abdominal distention, increased bowel movement frequency, and improved enteral feeding tolerance. Effective dosing ranged between 0.25-2.0 mg/kg/day. One patient experienced cramping abdominal pain while on pyridostigmine, but pain resolved after medication was discontinued. CONCLUSION We found oral pyridostigmine to be helpful in children with different GI motility problems. Pyridostigmine should be considered in such patients when other treatment interventions have not been beneficial.
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Affiliation(s)
- Mhd Louai Manini
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | | | - Rayna Grothe
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
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48
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Choudhury A, Rahyead A, Kammermeier J, Mutalib M. The Use of Pyridostigmine in a Child With Chronic Intestinal Pseudo-Obstruction. Pediatrics 2018; 141:S404-S407. [PMID: 29610160 DOI: 10.1542/peds.2017-0007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2017] [Indexed: 11/24/2022] Open
Abstract
Chronic intestinal pseudo-obstruction is a rare disorder that affects the motility of the gastrointestinal tract. It results in acute or subacute intestinal obstruction symptoms in the absence of mechanical lesion. It can lead to intestinal failure in children with significant strain on nutrition, growth, and development. There is no universally agreed protocol for management of chronic intestinal pseudo-obstruction in children, and there is wide variation in clinical practice.
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Affiliation(s)
- Ahamodur Choudhury
- Faculty of Life Sciences and Medicine, Kings College London, London, United Kingdom; and
| | - Abdul Rahyead
- Faculty of Life Sciences and Medicine, Kings College London, London, United Kingdom; and
| | - Jochen Kammermeier
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, United Kingdom
| | - Mohamed Mutalib
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, United Kingdom
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49
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Ahuja NK, Mische L, Clarke JO, Wigley FM, McMahan ZH. Pyridostigmine for the treatment of gastrointestinal symptoms in systemic sclerosis. Semin Arthritis Rheum. 2018;48:111-116. [PMID: 29397195 DOI: 10.1016/j.semarthrit.2017.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 11/18/2017] [Accepted: 12/18/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE Symptoms of gastrointestinal dysmotility are common among patients with systemic sclerosis (SSc), and the management of severe cases is often limited by a relative lack of effective interventions. The objective of this case series was to review our experience with pyridostigmine as a treatment for patients with SSc and symptomatic gastrointestinal disease. METHODS This study evaluated rates of symptom improvement, side effects, medication adherence, and dose ranges for SSc patients prescribed pyridostigmine for refractory gastrointestinal symptoms over a 10-year period at a quaternary referral center. Patients were defined as responders if they remained on pyridostigmine for at least 4 weeks and clinical benefit was documented by the recorded response of the patient or by the treating physician RESULTS: Of 31 patients treated with pyridostigmine for at least 4 weeks, 51.6% reported symptomatic improvement. Constipation was the most commonly improved symptom based on prevalence prior to therapy (noted by 6/20 patients suffering with constipation). Fifteen of 31 patients reported adverse effects, most commonly diarrhea. Throughout the duration of follow-up (median 126 days, range: 28-506 days), pyridostigmine was continued by 81.3% of patients who reported symptomatic benefit and 58.1% of patients overall. CONCLUSIONS Pyridostigmine holds promise for the treatment of various gastrointestinal symptoms in SSc patients, particularly in patients with refractory constipation. Though side effects may limit its use, most patients who experienced benefit chose to continue therapy.
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50
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Di Nardo G, Karunaratne TB, Frediani S, De Giorgio R. Chronic intestinal pseudo-obstruction: Progress in management? Neurogastroenterol Motil 2017; 29. [PMID: 29143474 DOI: 10.1111/nmo.13231] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 09/17/2017] [Indexed: 12/13/2022]
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.
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Affiliation(s)
- G Di Nardo
- Pediatric Gastroenterology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy.,Pediatric Gastroenterology Unit, International Hospital Salvator Mundi, Rome, Italy
| | - T B Karunaratne
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - S Frediani
- Pediatric Surgery Unit, Sapienza - University of Rome, Italy
| | - R De Giorgio
- Department of Clinical Science, University of Ferrara, Italy
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