L. Cogliandro

Natural History of Chronic Idiopathic Intestinal Pseudo-Obstruction in Adults: A Single Center Study

BACKGROUND & AIMS Chronic idiopathic intestinal pseudo-obstruction (CIIP) is a rare disease characterized by episodes resembling mechanical obstruction in the absence of organic, systemic, or metabolic disorders. Intestinal motor abnormalities have long been identified in CIIP patients. Little is known of the natural history of the disease in adults. This study evaluated the clinical course of CIIP over time. METHODS Fifty-nine consecutive CIIP patients without underlying collagen, vascular diseases, or mitochondrial cytopathies were evaluated between 1985 and 2001. Family history, onset of digestive symptoms, previous surgeries, episodes suggestive of subacute intestinal obstruction, digestive symptoms, body mass index, and feeding habits were recorded. Small bowel manometry was performed by a perfusion technique, and abnormal motor patterns were visually identified. Full-thickness biopsies were available in 11 cases and were processed for immunohistochemical analysis of myogenic and neurogenic components of the gut wall. RESULTS Patients were prospectively followed up for a median of 4.6 years (range, 1-13 years). Diagnosis was often made several years after symptom onset (median, 8 years). Thus, the majority of patients (88%) underwent useless and potentially dangerous surgeries (mean, 2.96 per patient). Manometry invariably showed abnormal motor patterns. Pathologic findings included neuropathies in all investigated cases and abnormalities of interstitial cells of Cajal in 5 of 11 cases. Long-term outcome was generally poor despite surgical and medical therapies; 4 patients died of disease-related complications, 4 underwent small bowel transplantation, almost one third required long-term home parenteral nutrition, and two thirds had some sort of nutritional limitations. CONCLUSIONS CIIP is a severe, often unrecognized disease characterized by disabling and potentially life-threatening complications over time.

Dyspeptic symptoms and gastric emptying in the irritable bowel syndrome

OBJECTIVES:Irritable bowel syndrome (IBS) and dyspepsia often overlap. Delayed gastric emptying has been reported in IBS patients, although conflicting results exist. Whether overlapping dyspepsia correlates with gastric emptying abnormalities in IBS patients has not been clarified. This study aimed to evaluate gastric emptying of solids and its relationship with dyspeptic symptoms in IBS patients.METHODS:A total of 146 IBS outpatients seen in a referral center were evaluated for dyspeptic symptoms using a validated questionnaire. Gastric emptying of solids was evaluated scintigraphically in all patients and in 50 healthy controls.RESULTS:Overlapping dyspepsia was diagnosed in 96 (66%) IBS patients. On average, gastric emptying rates were lower in IBS patients (mean ± SEM, 33%± 1%/h) compared with controls (40%± 2%/h; p < 0.01). Specifically, gastric emptying was delayed in IBS patients with overlapping dyspepsia (31%± 1%/h; p < 0.01), whereas IBS patients without dyspeptic complaints showed gastric emptying rates (37%± 2%/h) that were similar to those of healthy controls (40%± 2%/h). Relevant postprandial fullness (OR = 4.7, 95% CI = 1.8–12.5) and relevant nausea (OR = 3.3, 95% CI 1.2–9.3) were independently associated with delayed gastric emptying.CONCLUSIONS:IBS patients without overlapping dyspepsia have normal gastric emptying of solids. A significant association exists in IBS patients between delayed gastric emptying and overlapping relevant postprandial fullness and nausea.

Natural History of Intestinal Failure Induced by Chronic Idiopathic Intestinal Pseudo-Obstruction

Chronic intestinal pseudo-obstruction is a severe, often unrecognized disease characterized by disabling and potentially life-threatening complications over time. The diagnosis is based on the evidence of typical clinical manifestations, radiological evidence of distended bowel loops with air-fluid levels, and the exclusion of any organic obstruction of the gut lumen. The radiological sign of intestinal occlusion allows the distinction from enteric dysmotility, which is characterized by better outcomes. Manometry can play a supportive role in defining the diagnosis, and differences in the manometric pattern of chronic intestinal pseudo-obstruction and enteric dysmotility have been shown. The disease is often unrecognized, and the diagnosis, therefore, delayed by several years. Thus, the majority of patients undergo useless and potentially dangerous surgeries. Long-term outcomes are generally poor despite surgical and medical therapies characterized by disabling and potentially life-threatening complications over time. A substantial percentage of patients requires parenteral nutrition. Failure of this nutritional support represents an indication for small bowel transplantation.

Patient-reported outcomes and gut dysmotility in functional gastrointestinal disorders.

Background  Unlike chronic idiopathic intestinal pseudo‐obstruction (CIIP), severe digestive syndromes that are not characterized by episodes resembling mechanical obstruction remain poorly characterized. The present study compared clinical features, small bowel motility, and quality of life (QoL) in patients with CIIP or severe functional gastrointestinal disorders (SFGID), compared to irritable bowel syndrome (IBS).

Predictors of gastroparesis in out-patients with secondary and idiopathic upper gastrointestinal symptoms

BACKGROUND Delayed gastric emptying occurs frequently in patients with upper gastrointestinal symptoms associated with functional or organic diseases. AIMS To evaluate whether: (i) the prevalence of delayed gastric emptying is influenced by the presence of organic disease; (ii) demographic or clinical factors predict modestly or markedly (gastroparesis) delayed emptying. PATIENTS A total of 327 consecutive out-patients with upper gastrointestinal symptoms. METHODS Routine diagnostic work-up and evaluation of demographic factors, gastrointestinal symptom evaluation and scintigraphic gastric emptying of solids were performed. RESULTS Organic diseases were detected in 227/327 (65%) patients: 33% had delayed emptying and 20% gastroparesis. Female gender (OR: 2.1; 95% C.I.: 1.3-3.4). overweight (0.5; 0.3-0.9), relevant postprandial fullness (1.8; 1.1-3.2) and relevant epigastric bloating (1.8; 1.1-2.9), but not the presence of organic diseases, were associated with delayed emptying. Female gender (3.9; 1.3-11.9) and relevant postprandial fullness (4.1; 1.7-10.2) were associated with gastroparesis. CONCLUSIONS (i) There is a high prevalence of delayed gastric emptying and gastroparesis in out-patients with upper gastrointestinal symptoms, which is not influenced by the presence of organic disease; (ii) female gender, low body weight, relevant fullness and bloating are associated with delayed emptying; female gender and relevant postprandial fullness predict gastroparesis.

Clinical use of manometry for the diagnosis of intestinal motor abnormalities

Digestive symptoms suggestive of intestinal motor disorders, such as abdominal pain and distension, fullness, vomiting, constipation and diarrhoea, are very common and non-specific, and may be clinical manifestations of both organic and functional diseases. Both radiology and endoscopy are important in the diagnosis of structural gastrointestinal lesions that can affect motility and offer indirect signs of impaired gastrointestinal functions, but the diagnosis of gut motility disorders currently relies on the manometric assessment of contractile activities. Small bowel manometry helps to identify normal motility features and consequently to identify abnormal motor patterns. Small bowel manometry can help to differentiate mechanical obstruction from pseudo-obstruction and neurogenic from myogenic motor disorders. Manometry is an invasive technique which is not well accepted by patients and requires specific skills from investigators. Also, manometric assessment is limited to referral centres with a specific interest in the field of digestive functions, in general, and motility, in particular. Only patients who remain undiagnosed after extensive traditional work-up and fail repeated courses with medical therapy should be referred for the manometric test. Understanding the underlying pathophysiologic mechanisms of abnormal motility and developing new therapies are the goals of the current research in this fascinating field of medicine.

Helicobacter pylori, mucosal inflammation and symptom perception – new insights into an old hypothesis

The role of Helicobacter pylori and the accompanying mucosal inflammatory response in functional dyspepsia is still undefined. Human and animal studies have clearly demonstrated a link between intestinal mucosal inflammation and changes in sensory‐motor function. Growing clinical and basic evidence supports the concept that a similar paradigm may occur in H. pylori‐related dyspepsia. The infection may both induce gastric dysmotility and trigger neuroplastic changes in the afferent neural pathways leading to visceral hyperalgesia. A reduction of central antinociceptive control systems may also play a pathophysiological role.

Widespread Eradication of Helicobacter pylori: A Debate

Helicobacter pylori eradication is recommended currently only in peptic ulcer patients. The accumulating evidence of a possible pathogenetic role of the germ in other pathological conditions, such as mucosa‐associated lymphoid tissue lymphomas and (possibly) also functional dyspepsia and gastric cancer, creates increasing pressure in favor of an expansion of such indication. However, at present, cultural and practical considerations should discourage widespread screening and eradication programs.

Small bowel motor abnormalities in malnourished symptomatic adults complaining of severe digestive symptoms with and without functional subocclusive episodes

Aim. To compare small bowel manometric findings in patients with severe digestive symptoms and inability to maintain a normal body weight, with or without recurrent subocclusive episodes in the absence of mechanical obstruction. Methods. Small bowel manometry was performed (fasting> 6h, post-prandial> Ih) by a traditional stationary perfused technique in 62 patients (34.5 ± 12.8 yrs, mean + SD; 57 F) with severe GI symptoms and inability to maintain a normal body weight (BMI 2) radiologically proven subocclusive episodes (distended intestinal loops I airfluid levels) (GROUP A), while the remaining 37 (34.0± 11.9 yrs, mean+SD; 35 F) had not (GROUP B). Organic. systemic and metabolic diseases were ruled out in all patients. The following abnormal motor patterns were visually analysed: abnormalactivity fronts (AbnAFs), bursts, hypermotility, inability to produce a fed pattern (No-FED), clustered contractions (clusters). RESULTS. Patients in GROUP A had undergone a higher number of abdominal surgeries before coming to our laboratory (3.80±2.51 vs 0.94±1.58; p<O.OOI, Mann-Whitney). At least one motor abnormality was recorded in all patients in both groups (see table). CONCLUSIONS. Small bowel motor abnormalities are invariably present in patients with severe digestive symptoms and inability to maintain a normal body weight, regardless of the presence of functional intestinal subocclusions. Patients with recurrent subocclusions have a significatively higher frequency of abnormal motor patterns suggestive of a greater derangement of the control mechanisms of gut motility.