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Chronic Small Bowel Dysfunction

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Intestinal Failure

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Abstract

Severe chronic small bowel dysmotility occurs when there is a failure to propel the gut luminal contents without there being an organic obstructing lesion. Patients with dysmotility are challenging to manage both as the diagnosis can be difficult to make since other contributing factors (e.g. opioid/cyclizine, abdominal surgery, psychosocial problems and malnutrition) can all cause/exacerbate dysmotility. There are overlapping diagnostic sub-categories which include chronic intestinal pseudo-obstruction (CIPO) defined by a dilated small bowel and non-CIPO which does not. Enteric dysmotility is a sub-category of non-CIPO with abnormal small bowel manometry or transit. Histopathologically, CIPO patients are more likely to have a myopathy whilst non-CIPO/enteric dysmotility are more likely to have a neuropathy, and these may be either primary or secondary as part of a systemic disease. Most patients however will not receive a histopathological diagnosis and are termed idiopathic. The management starts with determining and ordering the primary symptoms/problems and assessing the contributing factors. Mechanical obstruction is excluded (CT abdomen with oral contrast) and a nutritional assessment made. If malnourished or at risk of becoming so nutritional treatment should be started taking into account the risks of refeeding problems. Tests for the underlying aetiology are performed and include excluding hypothyroidism, coeliac disease, diabetes, hypokalaemia or hypercalcaemia, thymoma or other neoplastic condition [chest X-ray (or CT/PET CT)]. 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 may be considered on a careful risk/benefit analysis, bearing in mind that the results rarely lead to any change in management or outcome at present. The patient may be taking medication that slows gut transit or is very malnourished both of which affect tests of motility (e.g. mamometry and isotope studies). These patients should not be given a definite diagnosis, but rather one of probable/possible or working diagnosis of dysmotility. The primary symptoms/problems are addressed (e.g. pain, distention, vomiting, constipation, malnutrition/bacterial overgrowth, psycho-social issues and quality of life). Bacterial overgrowth may be treated by giving rotating courses of antibiotics and supplements of fat soluble vitamins may be needed. Surgical options (full thickness jejunal biopsy/enteral tube/venting stoma/resection/transplantation) may be considered. Regular MDTs, which include psychological and pain team input should review and reconsider the diagnosis as the clinical situation changes. Opioid medication and cyclizine (especially intravenously) should be avoided due to associated harms.

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    Jeremy M. D. Nightingale

  2. Department of Gastroenterology, Salford Royal Foundation Trust, University of Manchester, Salford, UK

    Peter Paine

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Nightingale, J.M.D., Paine, P. (2023). Chronic Small Bowel Dysfunction. In: Nightingale, J.M. (eds) Intestinal Failure. Springer, Cham. https://doi.org/10.1007/978-3-031-22265-8_17

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