Chronic intestinal dysmotility A growing problem. Dr Simon Gabe Consultant Gastroenterologist St Mark s Hospital

Transcription

1 Chronic intestinal dysmotility A growing problem Dr Simon Gabe Consultant Gastroenterologist St Mark s Hospital

2 Chronic intestinal pseudo-obstruction Definition A severe digestive syndrome characterized by derangement of gut propulsive motility in the absence of a mechanical obstruction Antonucci et al, World J Gastroenterol 2008;14(19):

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4 Conditions that mimic or contribute to the presentation Organic obstruction Opiates Psychosocial problems Transition point Opiate withdrawal & chronic opiate usage (both manifest as abdominal pain) Functional GI disorders (severe IBS) Anorexia nervosa Atypical eating disorders

5 Myopathy Primary Neuropathy Mesenchymopathy Chronic intestinal pseudoobstruction Autonomic or enteric nerves Secondary Collagen diseases (eg Elhers Danlos) Endocrine & metabolic Other

6 Obstruction Opiates Psychosocial Undernutrition Narcotic Bowel Syndrome Anorexia nervosa IBS SMA syndrome INTESTINAL DYSMOTILITY Myopathy Neuropathy Primary Hollow visceral myopathy Jejunal diverticulosis Secondary Systemic sclerosis Amyloid Irradiation Muscular diseases Primary Hirsprung s Autoimune Infective Secondary General neurological disease Paraneoplastic Drugs

7 Symptoms Mann et al. Gut 1997;41:

8 Age of onset of symptoms Mann et al. Gut 1997;41:

9 Investigations Exclude mechanical causes BaFT, OGD, colonoscopy CT, CTE, MRE

10 Investigations Motility studies Gastric emptying Whole gut transit EGG SB manometry Oesophageal manometry Histology Full thickness biopsy Dilated & non-dilated SB Fix in formalin & liquid nitrogen Skeletal muscle biopsy If MNGIE suspected Essential to perform functional studies off opiates

11 Diagnoses prior to identification of correct diagnosis Initial diagnosis No of patients (%) Mechanical bowel obstruction 9 (45) Constipation 4 (20) Idiopathic megarectum or megacolon and constipation 3 (15) Sigmoid volvulus 1 (5) Pseudo-obstruction 1 (5) Vesico-ureteric distension and acute renal failure 1 (5) Abdominal migraine/periodic syndrome 1 (5) Mann et al. Gut 1997;41:

12 How to manage CIP Ensure no mechanical cause Manage symptoms Manage nutrition & fluid balance Address psychological issues Avoid opiates Avoid parenteral addictive medication Avoid surgery

13 Gastroparesis Common in neuropathic & myopathic CIPO De Georgio et al, Gastroenterol Clin North Am 2011;40:

14 Gastric pacemakers Diabetic gastroparesis Used to be the main indication No longer funded by the NHS Dysmotility patients Gastroparesis unlikely to occur without small bowel involvement Not a modality that we currently recommend

15 Venting PEG / gastrostomy Can be very helpful for symptom minimisation Trial of venting NG before placing a PEG But, there are some common issues Drainage dependent on Tube factors (tube gauge, male Luer connection) Position of the tube in the stomach Place low in the body of the stomach Siting can be a challenge

16 We need better venting PEG tubes - Currently designed for feeding - Need to develop the ideal tube

17 NJ PEGJ Jejunal feeding Surgical jejunostomy Direct PEJ

18 Surgical or endoscopic? Surgical jejunostomy Laparoscopic possible More invasive Surgical procedure to remove Tube has more limited lifespan Direct PEJ Endoscopic procedure under GA Less invasive Can be removed endoscopically Tube lasts longer

19 Click Do not to place edit Master a Foley title catheter! style

20 There is a need for better jejunal feeding tubes to be developed

21 Psychology There are almost always significant past issues Childhood abuse Disturbed childhood or young adult life Trauma: PTSD If you only deal with the physical problems you are only dealing WILL with FAIL half the issues

22 Nutrition support Patients are often malnourished Cause: inadequate food intake > malabsorption Oral nutrition Low fat & low fibre diet Liquid diet Enteral nutrition NG trial NJ trial PEGJ (medium term) Jejunostomy (long term) Parenteral nutrition Usually supportive (IVN) allows patients to eat as tolerated Occasionally exclusive (TPN)

23 IV nutrition Helpful to overcome nutritional consequences Rarely helpful for symptoms Tell patients Their symptoms will be the same IVN will only address the undernutrition Significant risk of infection, especially if on opiates Beware Underlying eating disorders (can become more apparent when trying to give IVN)

24 BAPEN: data from BANS IF due to dysmotility is on the increase Patients Numbers % % New registrations % Point prevalence Crohns Ulcerative colitis Ischaemia* Radiation enteritis Pseudo-obstruction Cancer

25 Summary tips Work as a team Be patient, listen and try your best to help Boundaries can be essential Make the boundaries clear Can compromise on some issues Involve the psychologists/psychiatrists Just as important for you as for the patient!

26 Intestinal transplantation Indications Refer / discuss Liver disease Fibrotic liver disease Progressive IFALD Irreversible IF, and Severe sepsis Life threatening (>1) Life threatening (1) Loss of venous access Poor QOL Limited to 3 major sites Correctable by transplantation Limited to 4 major sites Correctable by transplantation Partial or complete evisceration Need for other abdominal organ transplant Evisceration requiring MVTx (eg desmoid) eg renal Strategies to minimise surgical resection When transplant being considered