Hostname: page-component-586b7cd67f-vdxz6 Total loading time: 0 Render date: 2024-11-27T21:57:14.412Z Has data issue: false hasContentIssue false
  • English
  • Français

Chronic idiopathic intestinal pseudo-obstruction: the need for a multidisciplinary approach to management

Published online by Cambridge University Press:  07 March 2007

D. B. A. Silk
D. B. A. Silk*
Affiliation:
Department of Gastroenterology and Nutrition, Central Middlesex Hospital and Division of Surgery, Anaesthetics and Intensive Care, Imperial College, London, UK
*
Corresponding author: Professor David Silk, fax +1 20 8453 2538.
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

At the outset of the research programme into irritable bowel syndrome (IBS) it was perceived that there was a need to develop a symptom-based classification for the patients. Four groups of patients were identified, those with spastic colon syndrome, diarrhoea-predominant spastic colon syndrome, functional diarrhoea and midgut dysmotility. While working with outpatients with IBS it was noted how some of them had suffered symptoms for many years; specifically, a group of patients satisfying the criteria for midgut dysmotility had also suffered from particularly severe and intractable intestinal symptoms. These patients underwent 24 h ambulatory studies of small intestinal motility and the majority were found to have manometric features of chronic idiopathic intestinal pseudo-obstruction (CIIP). To characterise the cause, laparoscopic full-thickness small intestine and colonic biopsies have been obtained in forty-five of the latter group of patients. Of these patients 58% have been found to have complete or partial deficiency of α-actin epitope staining in the inner circular layer of small intestinal smooth muscle. This deficiency is believed to represent an important biomarker rather than the cause of CIIP, since α-actin epitope deficiency has been observed in association with enteric neuropathy and myopathies. In relation to the management of CIIP patients, a multidisciplinary model is proposed incorporating management of co-morbid psychological and psychiatric pathology, abdominal and musculoskeletal pain, fatigue, urological symptoms and nutrition. A six-stage nutritional management plan for these patients is presented.

Keywords

Chronic idiopathic intestinal pseudo-obstructionIrritable bowel syndromeSymptom-based classificationMultidisciplinary management modelNutritional management plan
Type
The Pennington Lecture
Information
Proceedings of the Nutrition Society , Volume 63 , Issue 3 , August 2004 , pp. 473 - 480
Copyright
Copyright © The Nutrition Society 2004

References

Accarino, AM, Azpiroz, F & Malagelada, J (1995) Selective dysfunction of mechanosensitive intestinal afferents in irritable bowel syndrome. Gastroenterology 108, 636–643.CrossRefGoogle ScholarPubMed
Bowling, TE, Raimundo, AH, Grimble, GK & Silk, DB (1993) Reversal of short-chain fatty acids of colonic fluid secretion induced by enteral feeding. Lancet 342, 1266–1268.CrossRefGoogle ScholarPubMed
Camilleri, M, Brown, ML & Malagelada, JR (1986) Impaired transit of chime in chronic intestinal pseudoobstruction: correction by cisapride. Gastroenterology 91, 619–626.CrossRefGoogle Scholar
Camilleri, M & Choi, M-G (1997) Review article: irritable bowel syndrome. Alimentary Pharmacology and Therapeutics 11, 3–15.CrossRefGoogle ScholarPubMed
Camilleri, M, Haslam, WL, Parkman, HP, Quigley, EM & Soffer, E (1998) Measurement of gastrointestinal motility in the GI laboratory. Gastroenterology 115, 747–762.CrossRefGoogle ScholarPubMed
Camilleri, M, Malagelada, JR, Abell, TL, Brown, ML, Hench, V & Zinsmeister, AR (1989) Effect of six weeks of treatment with cisapride in gastroparesis and intestinal pseudo-obstruction. Gastroenterology 96, 704–712.Google Scholar
Camilleri, M & Prather, CM (1992) The irritable bowel syndrome: mechanisms and a practical approach to management. Annals of Internal Medicine 116, 1001–1008.CrossRefGoogle Scholar
Castle, MZD, Silk, DBA & Libby, GW (2004) The rationale for antidepressant therapy in functional gastrointestinal disorders. Alimentary Pharmacology and Therapeutics 19, 1–11.CrossRefGoogle ScholarPubMed
Cole, SJ, Duncan, HD, Claydon, AH, Austin, D, Bowling, TJ & Silk, DBA (2002) Distal colonic motor activity in four subgroups of patients with irritable bowel syndrome. Digestive Diseases and Sciences 47, 345–355.CrossRefGoogle ScholarPubMed
Croft, P, Rigby, AS, Boswell, R, Schollum, J & Silman, A (1993) The prevalence of chronic widespread pain in the general population. Journal of Rheumatology 20, 710–713.Google ScholarPubMed
Drossman, DA (1999) The functional gastrointestinal disorders and the Rome II process. Gut 45, Suppl. 11. 111–115.Google ScholarPubMed
Dyer, NH, Dawson, AM, Smith, BF & Todd, IP (1969) Obstruction of bowel due to lesion in the myenteric plexus. British Medical Journal 1, 686–689.CrossRefGoogle ScholarPubMed
Fukuda, K, Strauss, S, Hickie, I, Sharpe, M, Dobbins, J & Komaroff, A (1994) The chronic fatigue syndrome; a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Annals of Internal Medicine 121, 953–959.CrossRefGoogle ScholarPubMed
Fukudo, S, Nomura, T & Hongo, M (1998) Impact of corticotrophin releasing hormone on gastrointestinal motility and adrenocorticotropic hormone in normal controls and patients with irritable bowel syndrome. Gut 42, 845–849.CrossRefGoogle ScholarPubMed
Gorard, DA, Libby, GW & Farthing, MJ (1994) Influence of antidepressants on whole gut and orocaecal transit times in health and irritable bowel syndrome. Alimentary Pharmacology and Therapeutics 8, 159–166.CrossRefGoogle ScholarPubMed
Gorard, DA, Libby, GW & Farthing, MJ (1995) Effect of a tricyclic antidepressant on small intestinal motility in health and diarrhoea-predominant irritable bowel syndrome. Digestive Diseases and Sciences 40, 86–95.CrossRefGoogle Scholar
Harvey, RF, Salih, SY & Read, AE (1983) Organic and functional disorders in 2000 gastroenterology outpatients. Lancet i, 632–634.CrossRefGoogle Scholar
Heaton, KW (1984) Irritable bowel syndrome. In Textbook of Gastroenterology, pp. 867–875 [Bouchier, IAD, Allen, RN, Hodgson, JHF, and Keighley, MRB, editors]. London: Bailiere Tindall.Google Scholar
Holdcroft, A & Power, I (2003) Management of pain. British Medical Journal 326, 635–639.CrossRefGoogle ScholarPubMed
Kellow, JE & Phillips, SF (1987) Altered small bowel motility in the irritable bowel syndrome is correlated with symptoms. Gastroenterology 92, 1885–1893.CrossRefGoogle ScholarPubMed
Knowles, CH, Silk, DBA, Darzi, A, Feakins, R, Raimundo, AH, Veress, B, Crompton, T, Lindberg, G & Martin, JE (2004) Deranged smooth muscle alpha fetoprotein-actin: a biomarker of intestinal pseudo-obstruction: a controlled multinational case series. Gut CrossRefGoogle ScholarPubMed
Kumar, D & Wingate, DL (1985) The irritable bowel syndrome: a paroxysmal motor disorder. Lancet ii, 973–977.CrossRefGoogle Scholar
Lipton, AB & Knauer, CM (1977) Pseudo-obstruction of the bowel. Therapeutic trial of metoclopramide. American Journal of Digestive Diseases 22, 263–265.CrossRefGoogle ScholarPubMed
Macfarlane, GJ, Morris, S, Hunt, IM, Benjamin, S McBeth, J Papageorgiou, AC & Silman, AJ (1999) Chronic widespread pain in the community: the influence of psychological symptoms and mental disorder on healthcare seeking behaviour. Journal of Rheumatology 26, 413–419.Google Scholar
Mann, SD, Debinski, HS & Kamm, MA (1997) Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults. Gut 41, 675–681.CrossRefGoogle ScholarPubMed
Manning, AP, Thompson, WG, Heaton, KW & Morris, AF (1978) Towards a positive diagnosis of the irritable bowel syndrome. British Medical Journal ii, 653–654.CrossRefGoogle Scholar
Moore, SW, Schneider, JW & Kaschula, ROC (2002) Unusual variations of gastrointestinal smooth muscle abnormalities associated with chronic intestinal pseudo-obstruction. Pediatric Surgery International 18, 13–20.CrossRefGoogle ScholarPubMed
Moriarty, KJ & Dawson, AM (1982) Functional abdominal pain: further evidence that the whole gut is involved. British Medical Journal 284, 1670–1672.CrossRefGoogle Scholar
Perlemuter, G, Chaussade, S, Wechsler, B, Cacoub, P, Dapiogny, M, Kahan, A, Godeau, P & Courturier, D (1998) Chronic intestinal pseudo-obstruction in systemic lupus erythematosis. Gut 43, 117–122.CrossRefGoogle Scholar
Quigley, EM, Deprez, PH, Helstrom, P, Husebye, E, Soffer, EE, Stangh, V, Summers, RW, Wilmer, A & Wingate, DL (1997) Ambulatory intestinal manometry: a consensus report on its clinical role. Digestive Diseases and Sciences 42, 2395–2400.CrossRefGoogle ScholarPubMed
Raimundo, AH, Rogers, J, Grimble, G, Cahill, E & Silk, DBA (1988) Colonic inflow and small bowel motility during intraduodenal enteral nutrition. Gut 29, A1469–A1470.Google Scholar
Raimundo, AH, Rogers, J & Silk, DB (1990) Is enteral feeding related diarrhoea initiated by an abnormal colonic response to intragastic diet infusion?. Gut 31 A119 Google Scholar
Raimundo, AH, Rogers, J & Silk, DBA (1996) Prolonged ambulatory small intestinal and colonic motility monitoring: potential in irritable bowel syndrome – first report of prolonged ambulatory oesophageal, small intestinal and colonic motility in the same patient. European Journal of Gastroenterology and Hepatology 8, 81–84.CrossRefGoogle ScholarPubMed
Richards, DM, Scott, NA, Shaffer, JL & Irving, M (1997) Opiate and sedative dependence predicts a poor outcome for patients receiving home parenteral nutrition. Journal of Parenteral and Enteral Nutrition 21, 336–338.CrossRefGoogle ScholarPubMed
Ruuska, TH, Karikoski, R, Smith, VV & Milla, PJ (2002) Acquired myopathic intestinal pseudo-obstruction may be due to autoimmune enteric leiomyositis. Gastroenterology 122, 1133–1139.CrossRefGoogle ScholarPubMed
Schmidt, T, Hackelsberger, N, Widmer, R, Meisel, C, Pfeiffer, A & Kaess, H (1996) Ambulatory 24-hour jejunal motility in diarrhoea-predominant irritable bowel syndrome. Scandinavian Journal of Gasterenterology 31, 581–589.CrossRefGoogle Scholar
Scott, SM, Picon, L, Knowles, CH, Forquet, F, Yazaki, E, Williams, NS, Lunniss, PJ & Wingate, DL (2003) Automated quantitative analysis of nocturnal jejunal motor activity identifies abnormalities in individuals and subgroups of patients with slow transit constipation. American Journal of Gastroenterology 98, 1123–1134.CrossRefGoogle ScholarPubMed
Silk, DB (1998) Patients' views on IBS. International Journal of Gastroenterology 3, 20–22.Google Scholar
Silk, DBA (1995a) Clinical presentation of IBS. IBS Monitor 1, 4–6.Google Scholar
Silk, DBA (1995b) A logical approach to IBS. IBS Monitor 2, 2–4.Google Scholar
Silk, DBA (2001) Impact of irritable bowel syndrome on personal relationships and working practices. European Journal of Gastroenterology and Hepatology 13, 1327–1332.CrossRefGoogle ScholarPubMed
Silk, DBA (2003) Management of IBS: start of a new era?. European Journal of Gastroenterology and Hepatology 15, 679–696.CrossRefGoogle Scholar
Small, PK, Loudon, MA, Hau, CM, Noor, H & Campbell, FC (1997) Large-scale ambulatory study of postprandial jejunal motility in irritable bowel syndrome. Scandinavian Journal of Gastroenterology 32, 39–47.CrossRefGoogle ScholarPubMed
Smith, VV, Lake, BD, Kamm, MA & Nicholls, RJ (1992) Intestinal pseudo-obstruction with deficient smooth muscle alpha fetoprotein-actin. Histopathology 21, 535–542.CrossRefGoogle Scholar
Spiller, RC, Trotman, IF, Adrian, TE, Bloom, SR, Misiewicz, JJ & Silk, DBA (1988) Further characterization of the 'ileal brake' reflex in man – Effect of ileal perfusion of partial digests of fat, protein and starch on jejunal motility and release of neuro-tension, enteroglucagen and peptide YY. Gut 29, 1042–1051.CrossRefGoogle Scholar
Spiller, RC, Trotman, IF, Higgins, BE, Ghatei, MA, Grimble, GK, Lee, YC, Bloom, SR, Misiewicz, JJ & Silk, DBA (1984) The ileal brake – inhibition of jejunal motility after ileal fat infusion in man. Gut 25, 365–374.CrossRefGoogle Scholar
Stanghellini, V, Camilleri, M & Malagelada, JR (1987) Chronic idiopathic intestinal pseudo-obstruction: clinical and intestinal manometric findings. Gut 28, 5–12.CrossRefGoogle ScholarPubMed
Thompson, WG, Longstreth, GF, Drossman, DA, Heaton, KW, Irvine, EJ & Muller-Lissner, S (1999) Functional bowel disorders and functional abdominal pain. Gut 45, 1143–1147.CrossRefGoogle ScholarPubMed
Trotman, IF & Price, CC (1986) Bloated irritable bowel syndrome defined by dynamic 99mTc brain scan. Lancet ii, 364–366.CrossRefGoogle Scholar
Verne, GN, Eaker, EY, Hardy, E & Sninsky, C (1995) Effect of octreotide and erythromycin on idiopathic and scleroderma-associated intestinal pseudo-obstruction. Digestive Diseases and Sciences 40, 1892–1901.CrossRefGoogle Scholar
Weber, FH & McCullum, RW (1992) Clinical approaches in irritable bowel syndrome. Lancet 340, 1447–1451.CrossRefGoogle ScholarPubMed
Whorwell, PJ, Lupton, EW, Erduran, D & Wilson, K, (1986a) Bladder smooth muscle dysfunction in patients with irritable bowel syndrome. Gut 27, 1014–1017.CrossRefGoogle ScholarPubMed
Whorwell, PJ McCallum, M Greed, FH & Roberts, CT, (1986b) Non colonic features of irritable bowel syndrome. Gut 27, 37–40.CrossRefGoogle ScholarPubMed
Wingate, D, Hongo, M, Kellow, J, Lindberg, G & Smout, A (2002) Disorders of gastrointestinal motility: towards a new classification. Journal of Gastroentrology and Hepatology 17, Suppl. S1– S14.Google ScholarPubMed
Wolfe, F, Smythe, HA, Yunus, MB, Bennett, RM, Bombardier, C, Goldenberg, DI. et al. (1990) The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism 33, 160–172.CrossRefGoogle ScholarPubMed