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home - Colon - Colonic Motility Disorders - Chronic Intestinal Pseudo obstruction Written by Dr Sebastian Zeki
Knowledge

Shows understanding of contemporary knowledge of the range of
factors that control gastrointestinal motility, as well as the means by
which symptoms arising from the GI tract are perceived.

In particular, can describe the enteric nervous system and
understands the ways in which drugs can modify its functioning

Can describe the brain-gut axis and the role of psychological factors
in the genesis of symptoms

Can describe the symptomatology and range of clinical presentations
of patients with irritable bowel syndrome

Knows the diagnostic criteria
Realises the importance of careful clinical assessment as well as the
need for appropriate selection of investigations

Knows the evidence-based treatment options for IBS and the
importance of a holistic and individualised approach to patient
management

Skills
Can make an accurate clinical assessment of patients with irritable
bowel syndrome

Uses investigations selectively
Communicates the diagnosis clearly and sympathetically
Appreciates the degree to which functional gut problems can impair
quality of life. Involves patients in making choice of treatment options

Can explain, where appropriate, that a psychological treatment might
be helpful and refer appropriately

Behaviours
Show a sympathetic understanding of the relevance of symptoms to
the individual and never appears dismissive

Takes time to explain nature of the condition, the treatment options
and appreciates their (often) limited effectiveness

AL

Chronic Intestinal Pseudo obstruction

Definition It is defined as mon-mechanical obstruction of small or large bowel.If no dilatation is called dysmotility.Prognosis 1/3rd need home PN; 2/3 rds have some sort of nutritional limitation. Full-thickness intestinal biopsy —Rarely needed- can show neuropathy of enteric ganglia with inflammation. Treatments:Nutritional support.Antibiotics- rotating, for bacterial over-growth.C stool if the steatorrhoea is not respond-ing.Antibiotic free holidays to prevent resist-ance.Prokinetic agents.Cisapride — Assoc.with drug interactions (macrolide antibiotics, antifungals,phenothiazines) and fatal arrhythmias.Erythromycin —Not useful chronically.Metoclopramide —Short term only.Octreotide — Useful in scleroderma and idiopathic intestinal pseudo-obstruction, esp.with erythromycin.Neostigmine — Only for acute.Serotonin 4 receptor agonists — Under investigation.Surgery.Bypass of dilated segments in megaduo-denum can be usedbut often not useful.Pacing of the intestine, electrical stimula-tion of the stomach or intestine, and transplantation are experimental.Percutaneous endoscopic colostomy — Can help Causes:Megacolon and megarectum.Primary megacolon which is a neurogenic dysfunction- histological changes may be present.Secondary megacolon and megarectum due to chronic faecal retention.Underlying systemic disorder:.Amyloidosis;DM; Paraneoplastic; Scleroderma.Degenerative neuropathies.Paraneoplastic immune-mediated pseudo-obstruction.Paraneoplastic GI motility disorder(Small cell lung cancers or carci-noid tumors) can be antineuronal nuclear (anti-Hu) antibodies related.Genetic mutations.Waardenburgh-Shah syndrome (deafness and pigmentation + aganglionic megacolon), assoc with neural crest-derived cell muta-tions.Familial mitochondrial neurogastrointestinal encephalomyopathy (MNGIE), mutated gene:endothelial cell growth factor-1, ECGF1Also: Mutations in SOX10, POLG, filamin A genes. Known underlying disease? Y N No further testing needed Manometry of small bowel Manometry — Useful if abnormal motility on scintigra-phy, without underlying disease.Excludes mechanical obstruction of the intestine eg adhesions.Differentiates myopathy (low ampl-tude contractions), from neuropathy (disorganized contraction + normal amplitude) Scintigraphy confirms chronic pseudo-obstruction Radiologic testingTo assess for underlying condition only (eg systemic sclerosis) Autonomic testing — Useful if evidence of neuropathic dysmotility but no underlying neurologic disorder. Neuropathic process Myopathic process Assessment of nutritional status Investigations Immune-mediated pseudo-obstruction Can be assoc.with neuronal or smooth muscle involvement Some are assoc with antibodies vs neuronal ion channels (voltage-gated potassium channels and neuronal alpha3-AChR).JC virus infection —Suggested but not provenRadiotherapy and chemotherapy — Esp for gynae cancer Due to inc rectal compliance and elasticity, dec rectal sensation, and an increased threshold and smaller degree of relaxation of the internal anal sphincter in response to rectal distension.-Also seen in Hirschsprung's, meningomyelocele, lumbosacral cord, lesions and with poor toileting routines.The sensory and motor problems occasionally reversible Written by Dr Sebastian Zeki Chronic intestinal pseudo-obstruction

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