AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Intestinal motility disorders apply to abnormal intestinal contractions, such as spasms and intestinal paralysis. This phrase is used to describe a variety of disorders in which the gut has lost its ability to coordinate muscular activity because of endogenous or exogenous causes. Intestinal motility disorders may be primitive or secondary and may manifest in a variety of ways, including abdominal distension and recurrent obstruction; severe abdominal colicky pain; severe constipation; and gastroesophageal reflux disease or intractable, recurrent vomiting.

In a broad sense, any alteration in the transit of foods and secretions into the digestive tube may be considered an intestinal motility disorder. This would include several asymptomatic conditions, such as maldigestion, achalasia, or alkaline bile reflux from the duodenum to the stomach (and sometimes the esophagus). In a narrow sense, consider only intestinal pseudo-obstruction (Ogilvie syndrome), irritable bowel syndrome (IBS), fecal incontinence, and constipation as intestinal motility disorders.

Chronic intestinal pseudo-obstruction (CIP) is a clinical syndrome caused by ineffective intestinal propulsion and characterized by symptoms and signs of intestinal obstruction in the absence of an occluding lesion of the intestinal lumen. CIP is caused by a group of heterogeneous nerve and muscle disorders and results in obstructive intestinal symptoms in the absence of any mechanical obstruction. A consensus working group defined CIP as a "rare, severe disabling disorder characterized by repetitive episodes or continuous symptoms and signs of bowel obstruction, including radiographic documentation of dilated bowel with air-fluid levels, in the absence of a fixed, lumen-occluding lesion."¹ However, this definition is really only applicable to the most severe forms of CIP; air-fluid levels may not always be present.

Thus, the criteria for diagnosis should include definite symptoms and signs of obstruction, with documentation of an ileus or air-fluid levels on plain radiographs of the abdomen or a dilated duodenum, small intestine, or colon on barium radiographs. Even though severe dysmotility may otherwise be present, the term pseudo-obstruction should not be used when these radiographic findings are absent.

Degenerative disorders cause pseudo-obstruction along with other problems; however, in patients with pseudo-obstruction, only changes in the nervous and muscular systems have been observed.

Many drugs of common use (eg, tricyclic antidepressants, diuretics, laxatives) or with specific indications (eg, lithium salts, vinca alkaloids and other chemotherapy agents) may interfere with intestinal motility. Stypsis may be related to drug abuse. Drugs such as benzodiazepines, lithium salts, laxatives, and codeine cause secondary stypsis. The latter can produce narcotic bowel syndrome, which is usually observed in patients who abuse opiates for chronic pain.

Endocrine disorders (eg, myxedema) can also cause pseudo-obstruction.

IBS, the more commonly diagnosed disorder of intestinal motility, has been considered a disease of the colon for decades, but research on GI motility has demonstrated that underlying motility disturbances can occur in the small bowel.

Pathophysiology

Coordinated movements of the stomach and intestines are required to digest and propel intestinal contents along the digestive tube. The complex patterns of contraction and relaxation necessary for proper motility of the GI tract are generated in the nerves and muscles within the GI walls. Every day, at any time, many factors can influence GI motility (eg, physical exercise, emotional distress). The pathogenesis of primitive intestinal motility disorders probably is multifactorial, but neither biochemical abnormality nor structural abnormality has been demonstrated commonly, except in some forms of intestinal pseudo-obstruction.

Although the overall structural organization of the digestive tube is similar throughout, each part has distinct motor activities. The musculature of the digestive tract has either extrinsic innervation (both sympathetic and parasympathetic) or intrinsic innervation (Auerbach plexus or myenteric plexus). Intrinsic innervation is fundamental to coordinating GI motor activity. A neural network branching between longitudinal and circular muscle layers of the GI tract constitutes intrinsic innervation. Another nervous intrinsic plexus in the GI tract (Meissner plexus or submucosal plexus) helps to modify mucosal absorption and secretion without influencing motility.

Random, unorganized motor activity with occasional peristaltic and antiperistaltic complexes appears during feeding, and this allows gastric remixing of foods. After this, another motor activity appears during the interdigestive period. It is more regular and begins the peristaltic waves (ie, contractions of the circular musculature of the small intestine) that allow progression of undigested food through the intestines.

These events happen because the gastric pacemaker area, which originates electric slow waves with a frequency of 3 cycles per minute, occurs at the junction between the body and the antrum of the stomach. These electric waves, called migrating myoelectric complexes, determine the frequency of muscular contractions in the antral and pyloric areas through electromechanical coupling. Migrating myoelectric complexes regulate gastric emptying and move gastric contents distally. Every 90 minutes, a cluster of migrating myoelectric complexes arises in the stomach and migrates distally beyond the ileum. Vagal function; the release of nitric oxide, vasoactive intestinal polypeptide, and motilin; and nutrients of the meal and other enterohormones also affect GI motility.

Frequency

United States

According to some epidemiological reports, up to 30 million Americans have intestinal motility disorders.

International

Available data from the medical literature indicate that 30-45% of all GI conditions are referable to intestinal motility disorders.

Mortality/Morbidity

When intestinal motility disorders are idiopathic and not related to either malignancies or systemic diseases, morbidity is minimal and the mortality rate from complications is low (1-1.5%); these usually occur in patients with intestinal pseudo-obstruction.

Race

Primitive intestinal motility disorders are most common in white persons and are usually thought to be related to diet.

Sex

Most patients are female, with a female-to-male ratio of 2.8:1.

Age

Persons of any age group may be affected, depending on the specific intestinal motility disorder. For example, IBS occurs more frequently in people aged 20-40 years. Intestinal pseudo-obstruction may occur in either newborns or elderly patients.

CLINICAL

Section 3 of 11  

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History

The clinical presentation of patients with intestinal motility disorders is protean and may vary from simple nausea and maldigestion to severe abdominal pain, vomiting, diarrhea, an inability to eat, weight loss, and other symptoms.

Obtain a complete patient history, recording information about the following: (1) feelings of abdominal discomfort, cramping, nausea or vomiting, pain, excessive gas, and rectal fullness; (2) the frequency, amount, and timing of normal defecation and any recent change; (3) the amount, consistency, and color of last passed feces; and (4) the type of diet, use of laxatives or enemas, and drug use.

• Chronic intestinal pseudo-obstruction
• • Patients with intestinal pseudo-obstruction generally experience abdominal distension and pain, dizziness, fatigue, and nausea and vomiting for several days or months before their condition is recognized.
  • One type of pain is directly related to intestinal distention and improves or temporarily disappears if intestinal distention decreases. A second type is probably secondary to smooth muscle spasm or visceral hyperalgesia and is independent of intestinal distention.
  • Abdominal distention varies from almost none to the equivalent of a 9-month pregnancy, depending on the nature and extent of the underlying pathology. An audible succussion splash and loud borborygmi may be present. Pain and distention may be almost continuous or separated by periods of clinical improvement. The vomitus frequently consists of food ingested 12 or more hours previously and may be feculent.
  • In patients with predominant small intestinal involvement, bacterial overgrowth and stagnant loop syndrome often develop and may lead to steatorrhea and diarrhea. Predominant colonic involvement usually results in constipation, megacolon, or both. Patients with both types of involvement may cycle from diarrhea to constipation, depending on the severity of steatorrhea and the relative involvement of each organ. Many patients have involvement of the esophagus, which may be asymptomatic or may produce dysphagia, chest pain, regurgitation, reflux, and heartburn. Visceral neuropathies may manifest as symptoms resembling achalasia or diffuse esophageal spasm.
  • Gastric involvement produces gastroparesis. The abdominal distention and pain produced by any combination of gastric, small intestine, and colonic involvement result in decreased food intake, weight loss, and malnutrition, especially when combined with malabsorption. Patients with involvement limited to the colon and distal small bowel may have relatively normal weights because their unaffected proximal bowel allows for normal absorption. Patients may have a history of weight loss or previous abdominal operations with no obstructing lesion found, or they may have a family history positive for the condition.
• Irritable bowel syndrome: Accessional abdominal pain, nausea, and irregular bowel habits that intensify during stress are the most common symptoms in patients with IBS.
• Fecal incontinence
• • This can be a life-threatening condition. In its mild form, patients may experience abdominal bloating and uproar, but, in the severe form, they may experience serious abdominal pain.
  • Patients may not experience symptoms if incontinence is related to a comorbid condition (eg, dementia, Parkinson disease, demyelinating diseases of the spinal cord).
• Constipation and fecal incontinence
• • Constipation can also be a life-threatening condition.
  • Patients with constipation report abdominal discomfort, cramping, pain, rectal fullness, or, more rarely, nausea and vomiting.
• Knowles and Martin attempted to define a novel classification for intestinal motility disorders, developing the reported scheme²:
• • Well-defined entities
  • • Delayed colonic transit - Slow transit constipation (eg, enteric neuropathy, enteric myopathy, Parkinson disease, endocrine disorders, spinal injury)
    • Dilated colon (diffuse or segmental) - Ogilvie syndrome, megacolon
    • Absent rectoanal inhibitory reflex - Hirschsprung disease
  • Variable dysfunction-symptom relationship - Abnormally low anal canal pressures fecal incontinence (eg, diabetes mellitus, spinal injury)
  • Questionable entities - Accelerated transit bile salts, short bowel, rare endocrine and metabolic disorders
  • Entities associated with behavioral disorders
  • • Impaired pelvic floor relaxation prolonged storage in the rectosigmoid, outlet delay, anismus
    • Avoidance of defecation functional fecal retention (eg, poor pelvic floor training, poor diet, fear of pain, learned suppression)

Physical

The clinical picture of patients with intestinal motility disorders is protean and may vary greatly depending on specific conditions.

• Chronic intestinal pseudo-obstruction
• • Decreased or absent bowel sounds and progressive loss of bowel movements are the most common signs in patients with intestinal pseudo-obstruction. Patients' symptoms increase in the 4-7 days before clinical onset and recognition of the disorder.
  • Physical examination findings may include weight loss, cachexia, and abdominal distention. Patients with small intestinal involvement usually have a succussion splash located in the mid abdomen, whereas patients with gastric involvement may have a splash in the left upper quadrant.
  • Hypertympany to percussion is usually present, and, occasionally, contracting bowel loops are observed pushing up against the abdominal wall.
  • Bowel sounds are of no value in making a diagnosis of pseudo-obstruction.
  • Evidence of central and peripheral nervous system disease should be sought, and autonomic nervous system testing should be performed, when indicated.
  • Involvement of the genitourinary system may be indicated by the presence of a palpable urinary bladder. Patients may have positive neurologic findings with signs of systemic diseases (eg, progressive sclerosis, amyloidosis, myxedema).
• Irritable bowel syndrome
• • Patients with IBS commonly have bloating, heartburn, burping, vomiting, and difficulty swallowing.
  • Symptoms can fluctuate, disappearing during sleep and occurring again during stressing occasions.
  • Heartburn, burping, and difficulty swallowing are usually due to contemporaneous gastroesophageal reflux disease, a very common condition in such patients.
• Fecal incontinence
• • In the first stage, passing gas more than the normal 14-23 times a day characterizes fecal incontinence.
  • In the second stage of the disease, liquid incontinence occurs, and patients are unaware that stools are being passed (stage of passive fecal incontinence).
  • In the third stage, which is more severe, patients have involuntary passage of feces through normal sphincter muscles (stage of urge incontinence).
• Constipation
• • The pattern of at least 3 stools per week and no more than 3 per day is considered normal defecation.
  • Consider any reduction in frequency of defecation as constipation.
  • Abdominal colicky pains are frequent.

Causes

Causes of intestinal motility disorders seem to be multifactorial, and only a few have been detected.

• Chronic intestinal pseudo-obstruction: Usually, CIP occurs in patients with severe comorbid clinical conditions or after traumas (even surgical) or in patients with other underlying medical diseases. In children, this condition is usually congenital and caused by a lack of ganglionic development in the intestine (Hirschsprung disease).
• Irritable bowel syndrome
• • The causes of IBS remain unknown.
  • According to some reports, the small intestine and colon of patients with IBS are more sensitive and reactive to mild stimuli than usual.
  • IBS could be related to immature status of muscles and nerves in the intestinal wall of these persons.
• Fecal incontinence
• • Aging, dementia, strokes, Parkinson disease, spinal cord injuries, rectal tears during birthing, diabetes, surgical complications, and neuromuscular disorders (eg, myasthenia gravis) may cause fecal incontinence.
  • Occasional fecal incontinence may occur after ingesting some foods. Sugars, insoluble fibers, and starches (except rice) are broken down in the intestines, forming a variable amount of gas that must be expelled. Most people who have lactase deficiency cannot digest lactose, a sugar common in several foods (eg, milk, cakes). People who have lactose deficiency may experience uncontrolled liquid diarrhea after lactose ingestion.
• Constipation
• • This commonly has several causes, either primitive or secondary. The most frequent causes include the following:
  • • Diet very poor in fiber and high in animal fats and refined sugars
    • Pregnancy
    • Psychological constipation related to lifestyle changes (eg, travel, new job, divorce) in which the patient ignores the urge to defecate
    • Hypothyroidism
    • Electrolytic imbalance, especially if affecting Ca⁺⁺ and K⁺
    • Tumors producing mechanical compression on an intestinal tract, either internally or externally
    • Nervous system injuries
    • Intoxication from lead, mercury, phosphorus, or arsenic
  • Constipation also may be secondary to rhagades (anal fissures) and piles.

DIFFERENTIALS

Section 4 of 11  

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Other Problems to be Considered

Alcohol-related neuropathies
Electrolytic imbalance
Poisoning due to environmental agents
Maldigestion

WORKUP

Section 5 of 11  

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Lab Studies

• A complete workup should be performed to exclude an organic cause for the patient's symptoms. For example, rule out a mechanical bowel obstruction. Only after the complete workup can the patient be deemed to have a functional problem.
• Routine laboratory examinations are not very useful to help diagnose primitive intestinal motility disorders, except pseudo-obstructive attacks. Lab studies may be helpful for diagnosing motility disorders of the gut due to intestinal cancers or irritable bowel disease.
• • The CBC count is usually altered in patients with intestinal cancers (may show anemia) and in patients with irritable bowel disease (leukocytosis is the more frequent result). In such patients, the protein electrophoresis pattern may show alterations of both albumin and globulins (especially alpha-1 and gamma globulins).
  • Electrolyte imbalance is common in patients with intestinal pseudo-obstruction. Serum levels of triiodothyronine, thyroxine, and glucose are also altered in these patients. Vitamin B-12 levels are reduced in persons with malabsorption.
  • Transaminase levels can be altered in patients with liver metastases.
  • A stool sample should be sent for analysis if the diagnosis of steatorrhea from small bowel bacterial overgrowth is suggested.
• Tumor markers may be studied in patients who may have cancer of the digestive system.
• • The most useful tumor markers for these patients are carbohydrate antigen 19-9, cancer antigen 125, and carcinoembryonic antigen. Carcinoembryonic antigen is nonspecific but is useful in follow-up evaluations.
  • Alpha-fetoprotein evaluation may help detect liver involvement by metastases from intestinal cancers.
• Urinalysis is not useful in establishing a diagnosis of intestinal motility disorders.

Imaging Studies

• Plain x-ray films of the abdomen may show bowel blockage (without any actual mechanical bowel obstruction) in patients with intestinal pseudo-obstruction, but findings are usually negative in patients with IBS or constipation.
• A barium meal is a helpful study in the diagnosis of intestinal motility disorders, but it should never be administered to patients with symptoms of pseudo-obstruction because it may cause irreversible blockage of intestinal transit. It may show a delay in transit time in persons with constipation, or the results may be normal in patients with IBS.
• Reserve CT scan and nuclear magnetic resonance examinations for patients with possible intestinal malignancy; these tests are expensive.
• Defecography offers some information about the kinetics of rectal emptying. Currently, scintigraphic study of the small bowel or colonic transit time is preferred. Radionuclide gastric emptying tests are also performed when needed. Scintigraphic study of intestinal transit time, accomplished by the oral administration of radiolabeled foods, allows study of gastric emptying and intestinal progression of the meal. It is not helpful in the diagnosis of patients with possible intestinal cancer.
• Again, the emphasis on tests is to rule out an organic cause of the patient's symptoms (eg, myxedema, dynamic bowel obstruction, malignancy), which are imminently treatable conditions.

Other Tests

• Rectal manometry, a procedure to measure intestinal pressure due to the muscles of the pelvic floor, may provide some important information in patients with intestinal motility disorders, especially in those with fecal incontinence. Esophageal or gastroduodenal manometry or a cystometrogram may be performed as indicated.
• Electromyography of the pelvic floor yields information about nervous conduction and muscle function, but it is not very accurate. Such information makes possible the differentiation of functional and organic disorders of defecation.

Procedures

• Endoscopy usually provides information about morphologic and functional patterns of the digestive tube.
• • Perform endoscopic studies of the upper and lower digestive tracts in any patient with an intestinal motility disorder because, in most of these patients, dysmotility has been described in the whole digestive tract. A rectal mucosal or full-thickness biopsy may be useful in helping to diagnose amyloidosis or pathologic abnormalities of the muscularis propria or the nerve plexus (myopathies and neuropathies).
  • Echoendoscopy may provide additional information about the muscular layer of the GI tract.
• Always perform a digital rectal examination in any patient with intestinal motility disorders to detect the presence of a mass (eg, fecal, tumoral, foreign bodies) or blood in the rectum.
• Diagnostic laparoscopy or laparotomy, with full-thickness biopsy or resection, and immunohistochemistry can be performed to assess for c-kit–positive cells.
• • A full-thickness biopsy sample of the small intestine can be obtained via laparoscopy, with or without placement of a feeding jejunostomy tube. Full-thickness biopsy specimens should be examined for muscle disease, inflammatory infiltrates of the myenteric plexus, neuronal intranuclear and intracytoplasmic inclusions, neuronal destruction, and absent or deficient c-kit immunoreactivity.
  • If laparotomy is performed, specimens should be taken from 2 sites, with tissue obtained from dilated and nondilated segments of intestine and processed for conventional light microscopy and immunohistochemistry.

Histologic Findings

Because of their functional origin, no specific histologic pattern has been associated with primitive intestinal motility disorders. Some sort of molecular damage in muscle fibers of the digestive tube is thought to occur, or intrinsic innervation (enteric nervous system) may cause motor incoordination due to alterations of migrating myoelectric complexes. C-kit immunoreactivity is used to assess the volume of interstitial cells of Cajal. Literature suggests that a decrease in the volume of interstitial cells of Cajal is associated with slow transit of the bowel.

TREATMENT

Section 6 of 11  

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Medical Care

Because several different drugs can cause intestinal motility disorders, avoiding them, if possible, may resolve the condition. In patients with primitive (idiopathic) intestinal motility disorders, the administration of some drugs may be useful to control symptoms (see Medication). Broad-spectrum antibiotics are not discussed in detail but may be needed to treat stagnant loop syndrome with bacterial colonization. A 7-day course of antibiotics (eg, tetracycline, doxycycline, ampicillin, quinolones, metronidazole) may lead to remission of the diarrhea.

Surgical Care

Surgery is not usually performed to treat patients with primitive intestinal motility disorders. An exception is in the treatment of idiopathic constipation not responsive to medical therapies and intestinal pseudo-obstruction. Surgery for these patients is always palliative. Only patients who are incapacitated by their symptoms or those who have adversely affected nutrition undergo surgery. Before deciding on a particular operation, determining which symptoms are being palliated and from which area of the intestine these symptoms emanate is extremely important. Surgery is always indicated if the patient has complications such as perforation of the bowel or peritonitis.

• In patients with acute intestinal pseudo-obstruction, endoscopic decompression is suitable and may resolve the problem. When indicated, always attempt endoscopic decompression prior to any open surgical intervention. Some patients may benefit from laparoscopy and lysis of adhesions. Surgical procedures such as feeding jejunostomies, decompressive gastrostomy, or ileostomy also may be necessary.
• Small intestine transplantation is still in the experimental stages, but steady progress has been made and improved survival has been noted in the last 5 years.
• Patients with chronic intestinal motility disorders may have symptom relief from total colectomy associated with near-total proctectomy. This surgical procedure is successful in nearly 90% of patients. Some surgeons prefer to perform a total proctocolectomy with ileoanal anastomosis on a J-pouch.
• • This procedure may be necessary in patients who have a megacolon and severe abdominal distention. However, even with this procedure, some patients continue to have severe symptoms from coexistent small intestinal disease. In addition, colectomy may exacerbate diarrhea. Thus, undertake palliative surgery only after careful consideration. Avoid unnecessary surgery at all costs.
  • Once any abdominal procedure is performed, excluding mechanical obstruction caused by adhesions may be difficult if the patient returns with symptoms of intestinal obstruction. On the other hand, surgery may be quite necessary for acute problems, such as intestinal volvulus, perforation, or herniation, all of which can occur in patients with pseudo-obstruction.
• Extensive, sometimes radical, small bowel resection may be necessary in rare patients with unrelenting intestinal obstruction and massive intestinal fluid secretion that make it impossible to keep up with fluid losses or to control severe obstructive symptoms. Some patients continue to have abdominal pain or such copious intestinal secretion that vomiting and fluid and electrolyte losses remain substantial. These patients may require a decompressive gastrostomy or an extended small bowel resection to remove the abnormal intestine. In such cases, the patient is invariably on home parenteral nutrition.
• If the patient is unable to maintain adequate nutritional intake or continues to have severe symptoms despite palliative treatment, long-term home parenteral nutrition may be necessary. Many patients on home parenteral nutrition seem to do well, although some develop sepsis and thrombotic complications of the central intravenous catheter, depression, prolonged suffering, and analgesic dependence. Support groups, such as the American Association of Gastrointestinal Motility Disorders and the American Pseudo-Obstruction and Hirschsprung Society, provide advice, information, educational meetings, and psychological support to patients and their families.

Consultations

Counseling with a neuropsychologist, evaluation by an endocrinologist, and research of toxins and drugs in the blood may be helpful for diagnosis.

Diet

Changes in dietary habits alone can help cure motility disorders. Correct fiber intake is useful in patients with either constipation or stool leakage. Fiber and water must be abundant in the diet of patients with constipation. Patients should avoid fermentable foods. Patients should take small frequent meals (6-8 times/d), avoid foods high in fat or lactose, and avoid residue- and gas-producing foods. Pureed foods (via a blender or other means) may be tolerated by some individuals. Patients can receive supplementation with liquid formulations, vitamins, and minerals (eg, vitamin B-12, iron, calcium, folic acid, water-soluble vitamins, vitamin A, vitamin D, vitamin E, vitamin K, trace elements) as needed to meet the requirements. Consultation with a dietitian helps provide the patient with a number of options.

Activity

Mild physical exercise is not contraindicated and may be very useful for symptom relief in patients with IBS or constipation.

MEDICATION

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The most useful drugs in the treatment of intestinal motility disorders are neostigmine, bethanechol, metoclopramide, cisapride, and loperamide.

Drug Category: Parasympathomimetics

Excessive parasympathetic suppression appears to be involved in the genesis of intestinal pseudo-obstruction. These agents may allow early resolution of pseudo-obstruction and obviate surgery.

Drug Category: Prokinetic agents

Are promotility agents, proposed for use with severe constipation-predominant symptoms.

Tegaserod marketing was temporarily withdrawn from the US market in March 2007; however, as of July 27, 2007, restricted use of tegaserod is now permitted via a treatment investigational new drug (IND) protocol. The treatment IND protocol will allow tegaserod treatment of irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Its use is further restricted to those in critical need who have no known or preexisting heart disease.
 
Earlier in 2007, tegaserod marketing was suspended because of a meta-analysis of safety data pooled from 29 clinical trials that involved more than 18,000 patients. The results showed an excess number of serious cardiovascular adverse events, including angina, myocardial infarction, and stroke, in those taking tegaserod compared with placebo. In each study, patients were assigned at random to either tegaserod or placebo. Tegaserod was taken by 11,614 patients, and placebo was taken by 7,031 patients. The average age of patients in these studies was 43 years, and most patients (ie, 88%) were women. Serious and life-threatening cardiovascular adverse effects occurred in 13 patients (0.1%) treated with tegaserod; among these, 4 patients had a heart attack (1 died), 6 had unstable angina, and 3 had a stroke. Among the patients taking placebo, only 1 (0.01%) had symptoms suggesting the beginning of a stroke that went away without complication. 
 
For more information, see the FDA MedWatch Product Safety Alert.

Drug Category: Antidiarrheals

Agents that inhibit peristalsis and slow intestinal motility.

Drug Category: Antibiotics

Erythromycin is a prokinetic agent for the stomach. It is indicated in patients with gastroparesis.

FOLLOW-UP

Section 8 of 11  

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In/Out Patient Meds

• Psychological counseling may be helpful.

Deterrence/Prevention

• A healthy lifestyle is the best prevention for intestinal motility disorders.
• A diet rich in fiber, especially insoluble fibers, cannot prevent colon cancer, but it may prevent constipation and impaction, its more severe complication. In addition, because insoluble fibers create a mass effect in the stomach, they may be helpful in weight control, preventing diseases related to obesity (eg, cardiovascular accidents, endocrine disturbances).
• Limit prescriptions of laxatives, diuretics, benzodiazepines, and anticholinergic drugs. They may interfere with GI motility; administer only if useful for patients and for a limited time only.
• Schedule any patients older than 50 years for colonoscopy, even if nonsymptomatic.
• Accurately evaluate patients with a history of abdominal surgery who have recurrent bowel habit disorders to detect eventual adhesions. The same consideration is valid for patients with a history of radiotherapy of the abdomen or pelvis.

Complications

• Complications of intestinal motility disorders vary greatly depending on the type of disorder considered.
• Intestinal pseudo-obstruction is often associated with a high mortality rate (15-30%), in most cases due to delayed diagnosis.
• Constipation may have a severe complication, impaction. If this condition is not recognized early, the patient may die.
• • Impaction is the collection of dry and hardened feces in the rectum or colon.
  • Symptoms may be similar to constipation or may be unrelated to the GI system.
  • If abdominal distention occurs, movements of the diaphragm are compromised and cause insufficient aeration with subsequent hypoxia and left ventricular dysfunction. In addition, hypoxia can precipitate angina or tachycardia.
  • When a vasovagal response begins, the patient may have hypotension.
  • Patients with impaction may experience vomiting, diarrhea, and resultant dehydration. They may present in an acutely confused and disoriented state, with tachycardia, fever, and altered blood pressure.
• IBS does not usually have complications.
• Fecal incontinence may cause psychological problems in affected patients.

Prognosis

• Intestinal motility disorders that are primitive or not secondary to malignancy or debilitating pathology have a good prognosis.
• According to many reports, the prognosis is excellent for patients with IBS, noncomplicated primitive constipation, and mild fecal incontinence.
• The prognosis is worse for patients with intestinal pseudo-obstruction, which has a high mortality rate.

Patient Education

• Educate patients with intestinal motility disorders to cope with their condition and to avoid any situation or substance that may cause the symptoms to worsen.

MISCELLANEOUS

Section 9 of 11  

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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to make the correct diagnosis, especially in patients with IBS, because several cancers of the digestive tract mimic this condition, even in late stages

Special Concerns

• During pregnancy, intestinal motility disorders may worsen, due to uterine compression of intestinal loops.
• Gastric preprandial dysrhythmia may lead to impaired gastric emptying, than contributing to irregular drugs absorption from the small intestine and concurring to disabling response fluctuations of the therapy.

MULTIMEDIA

Section 10 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
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Media file 1:  Dilated cecum (16 cm) and colon in patient with pseudocolonic obstruction.
	View Full Size Image
Media type:  X-RAY

REFERENCES

Section 11 of 11

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1. Sigurdsson L, Reyes J, Kocoshis SA, et al. Intestinal transplantation in children with chronic intestinal pseudo- obstruction. Gut. Oct 1999;45(4):570-4. [Medline].
2. Knowles CH, Martin JE. Slow transit constipation: a model of human gut dysmotility. Review of possible aetiologies. Neurogastroenterol Motil. Apr 2000;12(2):181-96. [Medline].
3. Benninga MA, Voskuijl WP, Akkerhuis GW, Taminiau JA, Büller HA. Colonic transit times and behaviour profiles in children with defecation disorders. Arch Dis Child. Jan 2004;89(1):13-6. [Medline]. [Full Text].
4. Candelli M, Nista EC, Zocco MA, Gasbarrini A. Idiopathic chronic constipation: pathophysiology, diagnosis and treatment. Hepatogastroenterology. Jul-Aug 2001;48(40):1050-7. [Medline].
5. Cleveland Clinical Foundation, Center for Gastrointestinal Motility Disorders. Intestinal motility disorders. Available at: http://www.ccf.org/gastro/motility/default.htm. Cleveland, Ohio: Cleveland Clinic;. 1999. [Full Text].
6. De Giorgio R, Sarnelli G, Corinaldesi R, Stanghellini V. Advances in our understanding of the pathology of chronic intestinal pseudo-obstruction. Gut. Nov 2004;53(11):1549-52. [Medline].
7. Farthing MJ. Treatment options in irritable bowel syndrome. Best Pract Res Clin Gastroenterol. Aug 2004;18(4):773-86. [Medline].
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Article Last Updated: Oct 12, 2007