Chronic Intestinal Pseudo Obstruction (CIPO) and Gastroparesis in Adults

Chronic Intestinal Pseudo-Obstruction (CIPO) is a rare condition that can affect all segments of the gastrointestinal tract and is characterized by failure of the movement of intestinal contents due to the inability to generate suitable motor patterns, either due to deficit in the neuropathic (nerve) or myopathic (muscle) forces.

Commonly, in adults, it is secondary to a neuromuscular diseases such as scleroderma, systemic sclerosis, bronchial carcinoma, or amyloidosis. In other cases, it may be a primary disease which selectively effects the smooth muscle or enteric nerve plexuses in which it may be a degenerative or inflammatory process.

Rarely, pseudo-obstruction arises acutely in a condition known as Ogilvie’s syndrome, and is concurrent with non-gastrointestinal disorders such as myocardial infarction, infection, or non-operative trauma. This syndrome is characterized by acute colonic dilation, pain, and abdominal distention.

Signs and Symptoms:

• Abdominal pain

• Distention

• Nausea and/or vomiting

• Constipation

• Early satiety (fullness)

Diagnosis:

• Manometry: The gold standard for diagnosis as it measures the contractions of the intestinal tract and can help to localize the functioning areas of the gastrointestinal tract. Manometry can help evaluate functional areas prior to any surgical intervention or creation of a stoma.

• Gastric emptying studies: Direct, noninvasive measurements of liquid or solid gastric emptying to assess the function of the stomach.

• Full thickness biopsy: Full thickness biopsies are useful in the diagnosis of autoimmune or mitochondrial etiology for chronic intestinal pseudo obstruction and can get a better understanding of abnormalities of the enteric nervous system.

Treatment:

• Nutritional Support: The majority of patients will require nutritional support, often requiring total parenteral nutrition (TPN).

• Prokinetics, such as erythromycin, octreotide, or tegaserod may be recommended.

• Antibiotics may be used to treat small intestinal bacterial overgrowth.

• Surgical: A decompressing gastrostomy or jejunostomy is reported to be beneficial intervention in patients with chronic intestinal pseudo obstruction.

• Small Bowel Transplant: May be indicated in patients who have TPN dependency and have TPN failure. Important to evaluate the presence or absence of gastric or colonic dysfunction, so the decision can be made whether to proceed with isolated or multivisceral transplant.

Gastroparesis

The literal translation of gastroparesis is "stomach paralysis." It is a condition in which the motility of the stomach is either abnormal or absent and results in delayed stomach emptying.

Symptoms:

• Nausea and vomiting

• Bloating

• Getting full quickly

• Heartburn

• Upper abdominal pain

Diagnosis: 

• Gastric emptying study: A nuclear medicine test in which you ingest some type of food (usually an egg sandwich) which contains a radioactive tracer to monitor how long it takes for food to leave your stomach. A delay in emptying indicates gastroparesis.

• Gastroduodenal manometry: This test uses a specialized tube to measure the contractions of you stomach and upper portion of your small intestine, the duodenum. Usually the test will run in a fasted state and then while you are eating to monitor stomach contractions.

• Upper endoscopy: This is when a small tube with a pin-point camera at the end is advanced down your throat and into your stomach. While this cannot diagnose gastroparesis, it can help rule out other possible causes of upper abdominal pain and other symptoms you may be having, such as a gastric ulcer.

• SmartPill®: This is a capsule that can measure temperature, pH, and pressure changes as it travels through your digestive tract. It can monitor the rate at which things are moving through your system.

Treatment:

• Diet modification: Working with a nutritionist is important for individual's with gastroparesis.

• Medications: The purpose of medication is to help increase stomach emptying, however, the medications that do exist often have unwanted side effect profiles. Speak with your team about options.

• Surgical options- Gastric pacemaker: Uses electrical stimulation to enhance gastrointestinal contractile activity. The pacemaker is surgically implanted under the skin and is connected to electrodes placed on the stomach wall.