Professor El-Omar has chosen Dr Jeremy Nightingale, from the Department of Gastroenterology, St Marks Hospital, Harrow, UK and Dr Peter Paine from the Department of Gastroenterology, Salford Royal Foundation Trust, Salford, UK, to do the next #GUTBlog.
The #GUTBlog focusses on the latest BSG Guideline, “The management of adult patients with severe chronic small intestinal dysmotility” published in Gut in December 2020. Dr Nightingale and Dr Paine are the lead authors on this guideline, working together with a broad team of specialists to produce this paper:
“Many gastroenterologists, especially those providing nutritional support, will have sat in an overrunning clinic on their own wishing for help, as the patient they have been seeing for the last 45 minutes complains of pain after food and weight loss. The patient wants opioid analgesics and anti-emetics (preferably intravenous cyclizine); they are even keen to be considered for long-term parenteral nutrition. In the absence of objective measures it is very hard, without an MDT that includes psychological and pain management input, to resist the pressure to provide such treatments. The patient has often been given a label of intestinal dysmotility and this may be used to justify invasive treatments. We felt that there was not a logical way of assessing or managing these patients who often have psychosocial issues and are often taking many medications especially for pain relief. The guideline was to address this and give a structure for managing these often difficult and complex patients. This guideline has 36 strongly agreed recommendations however 33 are graded as level 5 (expert opinion without critical appraisal). Even though lacking strong evidence the document combines the experience of many experts and clinical reports about small bowel dysmotility.
Severe chronic small bowel dysmotility occurs when there is a failure to propel the luminal contents without an organic obstructing lesion. The symptoms must have been present for more than 6 months and the patient has become malnourished and/or dehydrated so needing nutritional/fluid support. General small bowel dysmotility divides into a predominantly myopathic process in which the gut is usually dilated (chronic intestinal pseudo – obstruction (CIPO)) and vomiting and symptoms from bacterial overgrowth dominate the clinical picture. The second more common and more difficult to manage type is when there is predominantly an enteric neuropathy (enteric dysmotility) and these patient have a non-dilated but hyperactive hypersensitive bowel that gives rise to pain especially when chyme arrives in the small bowel. A third common group is idiopathic when the cause of the dysmotility/hypersensitivity is unclear and/or invasive tests are deemed not feasible or inappropriate and may include some of those with hypermobile Ehlers-Danlos syndrome.
The management starts with determining and ordering the primary symptoms. Contributing factors which alone can cause a similar picture and certainly may worsen the condition are evaluated. These include previous surgery, drug therapy (especially opioids, anticholinergics including cyclizine), malnutrition, psychosocial and quality of life issues. Mechanical obstruction should be excluded (CT abdomen with oral contrast). A nutritional assessment should be made and a nutritional treatment started (consider/treat refeeding risks). Tests to help establish a clinical diagnosis may be done but only when the patient is not taking any drugs that affect motility (e.g. opioids, anticholinergics including cyclizine) and ideally when they have a normal BMI. Diagnosis can sometimes be made by radiology (contrast follow through, MRI and isotope studies), manometry and/or histology. If there is any doubt about the diagnosis of dysmotility the diagnosis should be possible/probable dysmotility. It is very difficult to remove a label once given.
Once the diagnosis or possible /probable diagnosis is established and organic obstruction excluded the underlying aetiology may be investigated. Screening is done to exclude hypothyroidism, coeliac disease, diabetes, hypokalaemia or hypercalcaemia, a chest X-ray (or CT/PET CT) to exclude a thymoma or other neoplastic condition. Antibodies for connective disorders and those associated with paraneoplastic conditions are performed along with tests for mitochondrial disorders.
If none of these are positive a full thickness jejunal biopsy might be considered and this may be performed if any other abdominal surgical procedure is being considered (e.g. a venting stoma or jejunal feeding tube)).
The primary symptoms/problems are addressed (e.g. pain, distention, vomiting, constipation malnutrition/bacterial overgrowth, psycho-social issues and quality of life). Giving rotating courses of antibiotics may treat bacterial overgrowth; every gastroenterologist has a different regimen (e.g. rifaxamin or co-amoxiclavfor 6 weeks). Surgical options (full thickness jejunal biopsy / enteral tube / resection / transplantation) may be considered. Regular MDTs, which include psychological and pain team input review and reconsider the diagnosis as the clinical situation changes. Opioid medication and cyclizine (especially intravenously) should be avoided.”
Dr Jeremy Nightingale and Dr Peter Paine