Intestinal Motility Disorders Clinical Presentation

The clinical presentation of patients with intestinal motility disorders is protean and may range from simple nausea and indigestion to severe abdominal pain, vomiting, diarrhea, inability to eat, weight loss, and other symptoms. It should be kept in mind that during pregnancy, intestinal motility disorders may worsen as a consequence of uterine compression of intestinal loops.

Obtain a complete patient history, recording information about the following:

• Feelings of abdominal discomfort, cramping, nausea or vomiting, pain, excessive gas, and rectal fullness
• Frequency, amount, and timing of normal defecation and any recent change
• Amount, consistency, and color of last passed feces
• Type of diet, use of laxatives or enemas, and drug use

Chronic intestinal pseudo-obstruction

Patients with chronic intestinal pseudo-obstruction (CIP) generally experience abdominal distention, pain, dizziness, fatigue, nausea, and vomiting for several days or months before their condition is recognized.

One type of pain is directly related to intestinal distention and improves or temporarily disappears if intestinal distention decreases. A second type is probably secondary to smooth muscle spasm or visceral hyperalgesia and is independent of intestinal distention.

Abdominal distention ranges from almost none to the equivalent of a 9-month pregnancy, depending on the nature and extent of the underlying pathology. An audible succussion splash and loud borborygmi may be present. Pain and distention may be almost continuous or may be interrupted by periods of clinical improvement. The vomitus frequently consists of food ingested 12 or more hours previously and may be feculent.

In patients with predominant small intestinal involvement, bacterial overgrowth and stagnant loop syndrome often develop and may lead to steatorrhea and diarrhea. Predominant colonic involvement usually results in constipation, megacolon, or both. Patients with both types of involvement may cycle from diarrhea to constipation, depending on the severity of steatorrhea and the relative involvement of each organ.

Many patients have involvement of the esophagus, which may be asymptomatic or may produce dysphagia, chest pain, regurgitation, reflux, and heartburn. Visceral neuropathies may manifest as symptoms resembling achalasia or diffuse esophageal spasm.

Gastric involvement produces gastroparesis. The abdominal distention and pain produced by any combination of gastric, small intestine, and colonic involvement result in decreased food intake, weight loss, and malnutrition, especially when combined with malabsorption.

Patients with involvement limited to the colon and distal small bowel may have relatively normal weights because their unaffected proximal bowel allows for normal absorption. Patients may have a history of weight loss or previous abdominal operations with no obstructing lesion found, or they may have a family history positive for the condition.

Irritable bowel syndrome

Abdominal pain, nausea, and irregular bowel habits that intensify during stress are the most common symptoms in patients with irritable bowel syndrome (IBS).

Fecal incontinence

Fecal incontinence can be a life-threatening condition. In the mild form, patients may experience abdominal bloating and uproar, but in the severe form, they may experience serious abdominal pain. Patients may not experience symptoms if incontinence is related to a comorbid condition (eg, dementia, Parkinson disease, or a demyelinating disease of the spinal cord).

Constipation and fecal incontinence

Constipation can also be a life-threatening condition. Patients with constipation report abdominal discomfort, cramping, pain, rectal fullness, or, more rarely, nausea and vomiting.

The clinical picture of patients with intestinal motility disorders is protean and may vary greatly, depending on the specific condition present.

Always perform a digital rectal examination in any patient with an intestinal motility disorder to detect the presence of a mass (eg, feces, tumor, or a foreign body) or blood in the rectum.

Chronic intestinal pseudo-obstruction

Decreased or absent bowel sounds and progressive loss of bowel movements are the most common signs in patients with CIP.^[10] Patients’ symptoms increase in the 4-7 days before clinical onset and recognition of the disorder.

Physical examination findings may include weight loss, cachexia, and abdominal distention. Patients with small intestinal involvement usually have a succussion splash located in the midabdomen, whereas patients with gastric involvement may have a splash in the left upper quadrant.

Hypertympany to percussion is usually present, and contracting bowel loops are occasionally observed pushing up against the abdominal wall. Bowel sounds are of no value in making a diagnosis of pseudo-obstruction.

Evidence of central and peripheral nervous system disease should be sought, and autonomic nervous system testing should be performed when indicated.

Involvement of the genitourinary system may be indicated by the presence of a palpable urinary bladder. Patients may have positive neurologic findings with signs of systemic disease (eg, progressive sclerosis, amyloidosis, or myxedema).

Irritable bowel syndrome

Patients with IBS commonly have bloating, heartburn, burping, vomiting, and difficulty swallowing. Symptoms can fluctuate, disappearing during sleep and occurring again during stressing occasions. Heartburn, burping, and difficulty swallowing are usually due to concomitant gastroesophageal reflux disease, a very common condition in such patients.

Fecal incontinence

In the first stage of the disease, passing gas more than the normal 14-23 times a day characterizes fecal incontinence. In the second stage, liquid incontinence occurs, and patients are unaware that stools are being passed (stage of passive fecal incontinence). In the third stage, which is more severe, involuntary passage of feces through normal sphincter muscles occurs (stage of urge incontinence).

Constipation

The pattern of at least 3 stools per week and no more than 3 per day is considered normal defecation. Any reduction in the frequency of defecation may be considered constipation. Abdominal colicky pains are frequent in these patients.

Complications of intestinal motility disorders vary greatly, depending on the specific type of disorder under consideration.

Intestinal pseudo-obstruction is often associated with a high mortality (15-30%), in most cases due to delayed diagnosis.

Constipation may have a severe complication, impaction. If this condition is not recognized early, the patient may die. Impaction is the collection of dry and hardened feces in the rectum or colon. Symptoms of impaction may be similar to those of constipation or may be unrelated to the gastrointestinal system.

If abdominal distention occurs, movements of the diaphragm are compromised and cause insufficient aeration with subsequent hypoxia and left ventricular dysfunction. In addition, hypoxia can precipitate angina or tachycardia. When a vasovagal response begins, the patient may have hypotension. Patients with impaction may experience vomiting, diarrhea, and resultant dehydration. They may present in an acutely confused and disoriented state, with tachycardia, fever, and altered blood pressure.

IBS is not usually associated with complications. Fecal incontinence may cause psychological problems in affected patients.