Intestinal Motility Disorders Guidelines

In 2020, the European Society for Neurogastroenterology and Motility (ESNM) released their recommendations for conducting gastrointestinal motility and function testing in the early recovery phase of the 2019 coronavirus (COVID-19) pandemic. ^[41]  These guidelines suggest healthcare personnel evaluate the following:

• Urgency of the procedure
• Risk of infection relative to patient(s) and healthcare professional(s)
• Provision of the test planning
• Staff education and training
• Personnel protection equipment (PPE) use

Urgency of the procedure

Urgent procedures include the following:

• High-resolution manometry (HRM) for functional severe dysphagia with weight loss and/or aspiration risk
• HRM before treatment for achalasia with major impact, to assess the manometric disease pattern
• HRM and 24-hour pH-MII (pH-multichannel intraluminal impedance) for noncardiac chest pain with high impact in quality of life (QoL) (eg, repeated access to the emergency department [ED]), as well as for refractory esophageal symptoms with weight loss, persistent regurgitation, aspiration risk, and/or high impact in QoL
• Anorectal manometry plus balloon expulsion test in the pre- and postoperative assessment before colorectal surgery for cancer, and to exclude Hirschsprung disease

Elective procedures include HRM and 24-hour pH-MI for the following:

• Gastrointestinal (GI) symptoms of nonorganic origin, with incomplete response to medical therapy (Based on the symptomatic pattern, other tests may be considered.)
• Atypical symptoms of gastroesophageal reflux disease (GERD)
• Preoperative GERD assessment, when surgery is considered

In addition, anorectal manometry plus balloon expulsion test is also an elective procedure in the pre- and postoperative assessment of benign anorectal diseases.

Risk of COVID-19 infection relative to patient(s) and healthcare professional(s)

Stratify patients according to their risk of COVID‐19.

Confirmed COVID-19 cases are those individuals who have tested positive for COVID-19 on polymerase chain reaction (PCR) and those who have a COVID-19-positive high-resolution computed tomography (HR-CT) scan.

Individuals with suspected COVID-19 cases may have the following symptoms/signs:

• Common cold symptoms such as runny nose, sneezing, fatigue, and/or cough
• A body temperature of 37.5ºC or higher
• Severe fatigue, migrating body pain, and stuffiness
• Dysgeusia and anosmia without an apparent cause
• Digestive symptoms, such as diarrhea lasting 4-5 days without apparent cause

A high-risk state of COVID-19 includes a history of close contact with COVID-19 patients within a 2-week period and/or a history of travel to an area of COVID-19 outbreak within 2 weeks.

Screening options that confirm the low-risk status of the patient for COVID-19 include the following:

• Absence of symptoms and temperature below 37.2ºC
• A confirmed negative COVID-19 test by reverse transcriptase (RT)-PCR test 48 hours before the study
• Antibody test for immunoglobulin (Ig)-G-positive and IgM-negative
• Negative thoracic HR-CT scan

Risk stratification for a study/investigation in a patient is scored as follows:

• Healthcare professional: 0, if immunized; 1, if unknown
• Patient: 0, if immunized; 1, if unknown; 4, if suspected or at high infectious risk; 5, if confirmed infection
• Procedure: 1, if nonaerosol generation; 2, if aerosal generation

If the sum of the score is 0-2, the procedure is considered low risk. If the sum of the score is 3-4, the procedure is considered moderate risk. A high-risk procedure is one with a sum score above 4.

Provision of the test planning

Avoid crowding by planning the timing of the test and access to the unit.

Staff education and training

Educate and train staff for dealing with the risk of COVID‐19 infection, as well as appropriate cleaning and disinfection of the unit and decontamination of the equipment and any accessories.

For patients classified as low risk, staff PPEs include gloves, optional surgical cap, protective eyewear such as goggles or a face face shield, gowns, and surgical masks.

For patients of uncertain status, staff PPEs include waterproof gowns, shoe covers, surgical caps, protective eyewear, and level 2 PPE with FFP2/FFP3/N95 mask, and two pairs of gloves.

PPE use

Patients and staff should use appropriate PPE, and follow proper donning and doffing procedures.

The ESNM guidelines also provide protective measures for specific procedures, including the following:

• Esophageal manometry
• pH, pH‐MII, and wireless pH‐capsule monitoring
• Anorectal manometry
• Breath tests ( ¹³C,  ¹⁴C, and H ₂‐based breath tests)

In 2018, the International Working Group for Disorders of Gastrointestinal Motility and Function released their expert consensus document regarding advances in the diagnosis of gastric and intestinal motility diorders, such as the following key advances ^[42] :

• There is poor concordance between symptoms with gastrointestinal (GI) dysfunction on clinical investigations of GI motility and function, which underscores the need for testing to guide treatment.
• Scintigraphy is the reference standard for measurement of gastric emptying; alternatively,  ¹³C-gastric emptying breath tests can be used.
• For all GI function tests, it is essential to adhere to adequately validated, standardized study protocols.
• In patients with treatment-refractory constipation who are being considered for colectomy, those who have major disorders of upper GI motility and evacuation disorders should be excluded owing to the negative influence of these disorders on therapeutic outcome.
• The presence of abnormal GI function on clinical investigation can direct management and predict responsiveness to medical therapy in several conditions.
• Valid reference values are available for many investigations of GI motility (particularly, gastric, colonic and anorectal function) based on results from healthy individuals and patient data, thus defining definitively pathologic results.

General considerations

Adherence to standardized and adequately validated study protocols is necessary.

Patient preparation for GI motor function testing usually requires overnight or prolonged fast and avoidance of medications that affect GI motility.

For gastric emptying testing, fasting blood glucose should be reasonably well controlled.

Detail in the clinical history and consider when interpreting test results other factors such as use of medications known to influence GI motility (eg, prokinetics, opioids, tricyclic antidepressants, laxatives, and others), prior surgery (eg, fundoplication, some forms of bariatric surgery or intestinal resections), and drug abuse (eg, of opioids or cannabinoids).

Consider behavioral conditions (eg, rumination syndrome, eating disorders) as a cause of symptoms.

There is a marked and unclear overlap in symptoms between patients with GI dysmotility and patients with functional GI disorders, in whom altered motility is thought to be one among several pathophysiologic mechanisms.

Clinical application of motility testing

Before investigation of GI motor function, rule out mucosal or structural diseases such as inflammatory or malignant disease.

Investigation of gastric motor function

Indications and clinical importance

Tests of gastric motor function comprise gastric emptying tests and intraluminal measurements of contractility.

• Clinical investigation of gastric motor function is indicated in patients in whom upper GI endoscopy is normal or does not provide a definitive diagnosis and in patients in whom there is suspicion of gastroparesis, unexplained nausea and vomiting or dumping syndrome.
• Abdominal symptoms of accelerated and delayed gastric emptying are similar; thus, gastric emptying tests can be necessary for delineation of motor dysfunction.
• The diagnosis of gastroparesis requires objective evidence of clearly delayed gastric emptying in symptomatic patients.
• In patients with upper GI surgery, diagnosis of dumping syndrome can be made on the basis of typical symptoms and findings such as postprandial hypoglycaemia or hypotension. In unclear cases, provocation tests that prove dumping syndrome are the basis of diagnosis, which is supported by evidence of accelerated gastric emptying, preferably of liquids.
• Investigation of gastric emptying can be useful in the following situations: poorly controlled diabetes mellitus; severe gastroesophageal reflux disease (GERD) unresponsive to acid suppressants (particularly before fundoplication); systemic sclerosis; after lung transplantation; Parkinson disease; generalized GI motility disorders; and patients under consideration for intestinal or colonic surgery or transplantation because of motility disorders.
• Consider investigation of antral or antropyloroduodenal contraction patterns in those with severely impaired function and marked symptoms in whom patient management requires knowledge of the pathophysiology and/or severity of a gastric or GI motility disorder.

Recommended diagnostic approaches

Scintigraphy is the reference standard for measurement of gastric emptying. ¹³C-gastric emptying breath tests (13C-GEBTs) can be used as an alternative to scintigraphy.

Markedly prolonged retention of the wireless motility capsule (WMC) might be a marker of delayed gastric emptying.

Antral or antropyloroduodenal manometry is the reference method for evaluation of gastric contraction patterns.

Investigation of small bowel motor function

Indications and clinical importance

• Tests of small intestinal motility are indicated in patients with suspected severe chronic small bowel dysmotility.
• Only those results of intestinal transit tests that deviate substantially from normal values are considered diagnostic of abnormality and indicative of either accelerated or delayed small bowel transit.
• Limit manometric evaluation of small bowel contraction patterns to patients with chronic severe and otherwise insufficiently explained symptoms, or such assessment should be used when knowledge of small bowel motility disturbances is required for management.
• Antroduodenojejunal manometry can serve to exclude major motility disturbances in patients with otherwise equivocal findings.
• Altered small bowel motility on manometry could suggest underlying myopathy or neuropathy. Severe motor pattern alterations in combination with documented episodes mimicking mechanical obstruction enable the diagnosis of chronic intestinal pseudo-obstruction (CIPO).

Recommended diagnostic approaches

Scintigraphy is the reference method for evaluation of small bowel transit time. The WMC can be used to measure small bowel transit.

The lactulose H₂ breath test (LHBT) is an inexpensive and noninvasive but less precise alternative marker of small bowel transit.

Small bowel manometry is the reference method for evaluation of intestinal contractile patterns.

Investigation of colonic motor function

Indications and clinical importance

• The main indication for colonic motor function testing is severe constipation refractory to conventional treatment and not explained by common imaging techniques. Certain measurements of colonic motility might provide useful information in a subset of patients with diarrhea.
• Exclude evacuation disorders as a potential cause of constipation symptoms before considering intraluminal tests of colonic motility .
• Colonic transit tests are required to distinguish normal from slow-transit constipation.
• Colonic scintigraphy and radio-opaque markers (ROM) can provide initial information to differentiate between diffuse and localized colonic dysmotility and/or evacuation disorders. However, transit measurements alone are not diagnostic of evacuation disorders and require confirmation by specialized tests of evacuation.
• Invasive therapeutic measures for severe constipation (ie, subtotal colectomy) require proof of colonic dysmotility. In such patients, colonic transit tests are mandatory. Tests of colonic contractility are desirable, including measurement of colonic tone or compliance in some cases.
• Measurement of compliance and tone by barostat confirms radiologically-identified overt megacolon and can identify less-severe cases of chronic megacolon.

Recommended diagnostic approaches

ROM studies and colonic scintigraphy are best suited for measurement of colonic transit time. The WMC can be used as an alternative to assess overall (although not regional) colonic transit.

Colonic manometry (high resolution preferred) is the reference method for evaluation of colonic contractile patterns.

A barostat enables the assessment of colonic compliance, tone, and phasic contractility.

Additional tests

Tests of neuromuscular function and structures

The clinical utility of the following tests is limited or subject to ongoing studies:

• Magnetic resonance imaging (MRI)
• Gastric barostat
• Abdominal ultrasonography
• Proximal gastric high-resolution manometry (HRM)
• Impedance planimetry for functional lumen imaging
• Cutaneous electrogastrography
• Single-photon emission computed tomography (SPECT) scanning
• Endoluminal image analysis
• Magnetic pill

A WMC can be used to obtain limited data on the amplitude of GI contractions.

In selected cases with severe disease, full-thickness biopsy could be useful for therapeutic decisions.

Other emerging technologies

Some emerging technologies include the following:

• High-resolution electrical mapping
• Biomarkers
• Autoimmune mechanisms
• Autonomic dysfunction