Recent advances in the treatment of gastrointestinal motility disorders in children

ABSTRACT

Introduction

Pediatric gastrointestinal motility disorders represent some of the most challenging clinical conditions with largely undefined pathogenetic pathways and therefore limited therapeutic options. Herein, we provide an overview of the recent advances in treatment options for these disorders and their clinical impact.

Areas covered

PubMed and Medline databases were searched for relevant articles related to the treatment of achalasia, esophageal atresia, gastroparesis, PIPO and constipation published between 2017 and 2022. In this article, we review and summarize recent advances in management of gastrointestinal motility disorders in children with a particular focus on emerging therapies as well as novel diagnostic modalities that help guide their application or develop new, more targeted treatments.

Expert opinion

Gastrointestinal motility disorders represent one of the most challenging conundrums in pediatric age and despite significant advances in investigative tools, the palette of treatment options remain limited. Overall, while pharmacological options have failed to bring a curative solution, recent advances in minimal invasive therapeutic and diagnostic techniques have emerged as potential keys to symptom and quality of life improvement, such as ENDOFLIP, POEM, cine-MRI, fecal microbiota transplantation.

KEYWORDS:

• Achalasia
• PIPO
• gastroparesis
• constipation
• advances
• ENDOFLIP
• GLASS score
• cine-MRI

Article highlights

• Although with limited data in children, combined HREM and ENDOFLIP with therapeutic procedures for achalasia, esophageal atresia and gastroparesis are emerging as novel tools for individualized treatment.

• New diagnostic methods are available for diagnosis of PIPO and constipation in-depth analysis of contractile activity and the novel ADM (GLASS) score, respectively cine-MRI.

• Achalasia: To date there are no clinical randomized control trails on the management of children with achalasia. POEM is considered a surgical alternative of treatment, however the available limited data in children show that while it may be more successful, the complication rate can be higher. Surgical procedures combined intraoperative HREM or ENDOFLIP are emerging as an individualized treatment option for adults with achalasia but experience in children is still very limited.

• Esophageal atresia: In children with OA, fundoplication is generally associated with a poor outcome and should be considered judiciously for individualized cases. ENDOFLIP is emerging as a potential useful tool for monitoring the functionality of the esophagus post OA repair. Intralesional steroid injections seem to reduce the diameter of the stricture and the likelihood for further dilatations although the effect appears limited to the first three injections.

• Gastroparesis: Prucalopride is effective in improving symptoms, such nausea, reflux, and feeding difficulties in children with refractory upper GI symptoms. Patients with pyloric dysfunction are likely to respond to Botulinum toxin injections and there may be a role for the use of ENDOFLIP before and after the injection. Gastric electrical stimulation decreases overall symptoms, medication use and feeding tolerance in children with gastroparesis.

• PIPO: Using in-depth analysis of contractile activity and the novel ADM (GLASS) score, may allow improved diagnosis and classification of PIPO together with better correlation with histological findings from full-thickness small intestinal biopsies. Small bowel scintigraphy may be able to separate myopathic from neuropathic PIPO. Although there are no curative drugs able to restore GI motility function in PIPO, pyridostigmine and prucalopride appear to enhance the propulsive intestinal motility.

• Constipation: Cinematic magnetic resonance imaging (cine-MRI) is a novel tool that could be performed in combination with manometry in children with constipation. Trans-anal irrigation device showed a significant symptom improvement, particularly in patients with refractory constipation. Faecal microbiota transplantation via alteration of gut microbial composition could affect colonic transit time both in humans and animal models.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.