Intestinal Motility Disorders Treatment & Management
- Author: Nafisa K Kuwajerwala, MD; Chief Editor: Julian Katz, MD more...
Because several different drugs can cause intestinal motility disorders, avoiding them, if possible, may resolve the condition. In selected patients, pharmacotherapy may be helpful. Gastric preprandial dysrhythmia may lead to impaired gastric emptying, thus contributing to irregular absorption of drugs from the small intestine and conducing to disabling response fluctuations of the therapy.
Cognitive interventions (eg, cognitive behavorial therapy, hypnotherapy) have been successful in managing abdominal pain in patients with irritable bowel syndrome; however, they have limited utility for routine use in daily practice owing to their labor intensiveness and tight availability.
Surgery is not usually performed to treat patients with primary intestinal motility disorders, except in the treatment of idiopathic constipation that does not respond to medical therapies and in the treatment of intestinal pseudo-obstruction. Surgery for these patients is always palliative. Only patients who are incapacitated by their symptoms or those whose nutritional status is adversely affected undergo surgery.
Neural stem cell transplantation may be beneficial for patients with intestinal motility disorders associated with enteric neuropathy. A murine study demonstrated that transplanted enteric neural progenitor cells could generate functional enteric neurons in the postnatal bowel.
Patients with intestinal motility disorders must be educated in ways of coping with their condition and instructed to avoid any situation or substance that may cause the symptoms to worsen. Psychological counseling may be helpful.
Avoidance of drugs that can cause intestinal motility disorders is recommended if doing so is feasible. In patients with primitive (idiopathic) intestinal motility disorders, the administration of some drugs may be useful to control symptoms.
Drugs used in the management of intestinal motility disorders include parasympathomimetics, prokinetic agents, opioid antagonists, antidiarrheals, and antibiotics. The agents that are most useful in the treatment of these disorders are neostigmine, bethanechol, metoclopramide, cisapride, and loperamide.[22, 23, 24, 25] Prucalopride appears promising for the treatment of chronic constipation ; its low side-effect and drug-interaction profile appear to allow it to be a safe option in elderly patients with chronic constipation.
Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) provide symptomatic relief, but this has been demonstrated only for TCAs in meta-analyses.
The use of injectable bulking treatment appears to be effective and safe in the long-term management of fecal incontinence. In one study, symptomatic reduction with non-animal stabilized hyaluronic acid/dextranomer (NASHA Dx) occurred in 52% of 136 patients at 6 months, with sustained results at 12 months (57%) and at 36 months (52%). Mean change from baseline Cleveland Clinic Florida Fecal Incontinence Score (CCFIS) and Fecal Incontinence Quality of Life Scale (FIQL) scores improved between baseline and at 36-month follow-up.
Broad-spectrum antibiotics (not discussed in detail in this topic) may be needed to treat stagnant loop syndrome with bacterial colonization. A 7-day course of antibiotics (eg, tetracycline, doxycycline, ampicillin, quinolones, metronidazole) may lead to remission of the diarrhea.
Endoscopy, Ostomy, and Bowel Resection
Before the decision is made to perform a particular operation, it is extremely important to determine which symptoms are being palliated and from which area of the intestine these symptoms emanate. Surgery is always indicated if the patient has complications such as perforation of the bowel or peritonitis.
In patients with acute intestinal pseudo-obstruction, endoscopic decompression is suitable and may resolve the problem. When indicated, endoscopic decompression should always be attempted before any open surgical intervention. Some patients may benefit from laparoscopy and lysis of adhesions. Surgical procedures such as feeding jejunostomies, decompressive gastrostomy, or ileostomy also may be necessary.
Transplantation of the small intestine is still in the experimental stages, but steady progress has been made, and improved survival is being reported.[30, 31]
Patients with chronic intestinal motility disorders may experience symptom relief after total colectomy in conjunction with near-total proctectomy. This surgical procedure is successful in nearly 90% of patients. Some surgeons prefer to perform a total proctocolectomy with ileoanal anastomosis on a J-pouch.
This procedure may be necessary in patients who have a megacolon and severe abdominal distention. However, even with such treatment, some patients continue to have severe symptoms from coexisting disease of the small intestine. In addition, colectomy may exacerbate diarrhea. Accordingly, palliative surgery should be undertaken only after careful consideration; unnecessary surgery must be avoided at all costs.
After any abdominal procedure, exclusion of mechanical obstruction caused by adhesions may be difficult if the patient returns with symptoms of intestinal obstruction. On the other hand, surgery may be necessary for acute problems, such as intestinal volvulus, perforation, or herniation, all of which can occur in patients with pseudo-obstruction.
Extensive, sometimes radical, small-bowel resection may be necessary in rare cases of unrelenting intestinal obstruction and massive intestinal fluid secretion that make it impossible to keep up with fluid losses or control severe obstructive symptoms. Some patients continue to have abdominal pain or such copious intestinal secretion that vomiting and fluid and electrolyte losses remain substantial. They may require a decompressive enterostomy or an extended small-bowel resection; in such cases, they are invariably on home parenteral nutrition.
If the patient is unable to maintain adequate nutritional intake or continues to have severe symptoms despite palliative treatment, long-term home parenteral nutrition may be necessary. Many patients who are on home parenteral nutrition seem to do well, though some develop sepsis and thrombotic complications of the central intravenous catheter, depression, prolonged suffering, and analgesic dependence.
Support groups, such as the American Association of Gastrointestinal Motility Disorders and the American Pseudo-Obstruction and Hirschsprung Society, provide advice, information, educational meetings, and psychological support to patients and their families.
Diet and Activity
Changes in dietary habits alone can help cure motility disorders. Correct fiber intake is useful in patients with either constipation or stool leakage. Fiber and water must be abundant in the diet of patients with constipation; fermentable foods should be avoided. Patients should take small frequent meals (6-8 times a day), avoid foods high in fat or lactose, and avoid residue- and gas-producing foods. Pureed foods (via a blender or other means) may be tolerated by some individuals.
Patients can receive supplementation with liquid formulations, vitamins, and minerals (eg, vitamin B-12, iron, calcium, folic acid, water-soluble vitamins, vitamin A, vitamin D, vitamin E, vitamin K, trace elements) as needed to meet the requirements. Consultation with a dietitian helps provide the patient with a number of options.
Mild physical exercise is not contraindicated and may be very useful for symptom relief in patients with irritable bowel syndrome or constipation.
A healthy lifestyle is the best prevention for intestinal motility disorders. A diet rich in fiber, especially insoluble fibers, cannot prevent colon cancer, but it may prevent constipation and impaction, its more severe complication. In addition, because insoluble fibers create a mass effect in the stomach, they may be helpful in weight control, preventing diseases related to obesity (eg, cardiovascular accidents and endocrine disturbances).
Prescriptions of laxatives, diuretics, benzodiazepines, and anticholinergic drugs should be limited. Such agents may interfere with gastrointestinal motility; they should be administered only if they are clearly useful for patients, and only for a limited time.
Any patients older than 50 years should be scheduled for colonoscopy, even if they are not symptomatic.
Patients with a history of abdominal surgery who have recurrent bowel habit disorders should be carefully evaluated with an eye to detecting eventual adhesions. The same consideration is valid for patients with a history of radiotherapy of the abdomen or pelvis.
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