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ABSTRACT
Introduction
Chronic intestinal pseudoobstruction (CIPO) is a rare, heterogenous, and severe form of gastrointestinal dysmotility.
Areas covered
Pertinent literature on pediatric and adult CIPO management has been assessed via PubMed, Scopus, and EMBASE from inception to June 2022. Prokinetics, aimed at restoring intestinal propulsion (e.g. orthopramides and substituted benzamides, acetyl cholinesterase inhibitors, serotonergic agents, and others), have been poorly tested and the available data showed only partial efficacy. Moreover, some prokinetic agents (e.g. orthopramides and substituted benzamides) can cause major side effects. CIPO-related small intestinal bacterial overgrowth requires treatment preferably via poorly absorbable antibiotics to avoid bacterial resistance. Apart from opioids, which worsen gut motility, analgesics should be considered to manage visceral pain, which might dominate the clinical manifestations. Nutritional support, via modified oral feeding, enteral, or parenteral nutrition, is key to halting CIPO-related malnutrition.
Expert opinion
There have been significant roadblocks preventing the development of CIPO treatment. Nonetheless, the considerable advancement in neurogastroenterology and pharmacological agents cast hopes to test the actual efficacy of new prokinetics via well-designed clinical trials. Adequate dietary strategies and supplementation remain of crucial importance. Taken together, novel pharmacological and nutritional options are expected to provide adequate treatments forthese patients.
Article highlights
The pharmacological and nutritional treatments of pediatric and adult chronic intestinal pseudo-obstruction (PIPO/CIPO, respectively) remain challenging.
Prokinetics, e.g. orthopramides and substituted benzamides, acetyl cholinesterase inhibitors, and serotonergic agents, yielded only partial results in improving intestinal propulsion and controlling dysmotility-related symptoms.
Abdominal pain and distension (along with bloating) are usually severe symptoms/signs in PIPO/CIPO patients and require pharmacological (avoiding opioids)/non-pharmacological (endoscopic decompressive measures) anti-nociceptive strategies.
Small intestinal bacterial overgrowth (SIBO) should be managed by using poorly absorbable antibiotics and prokinetic drugs. In line with this, in patients with mild forms of PIPO/CIPO dietary indications should be advised (i.e. low-sugar, -fibre and -fat diet).
Each patient should be evaluated by a multi-disciplinary team (including nutritionists and dieticians) to establish an individualized step-wise dietary/nutritional strategy (from oral to enteral/parenteral nutrition).
Significant changes are awaited in the treatment strategies hopefully improving quality and life expectations of PIPO/CIPO patients.
Abbreviations
| ACIs | = | acetyl cholinesterase inhibitors |
| ACPO | = | acute colonic pseudo-obstruction |
| ANNA | = | anti-nuclear neuronal antibodies |
| CIPO | = | chronic intestinal pseudo-obstruction |
| EMA | = | European Medicines Agency |
| FDA | = | Food and Drug Administration |
| FMT | = | fecal microbiota transplantation |
| FODMAP | = | fermentable oligosaccharide, disaccharide, and monosaccharide and polyols |
| GI | = | gastrointestinal |
| hERG | = | human ether-à-go-go |
| 5-HT | = | 5-hydroxytryptamine |
| IBS | = | irritable bowel syndrome |
| ICC | = | interstitial cells of Cajal |
| IFALD | = | intestinal failure associated liver disease |
| MMC | = | motor migrating complex |
| NSAID | = | non-steroidal anti-inflammatory drug |
| PEG-J | = | percutaneous endoscopic gastro-jejunostomy |
| PIPO | = | pediatric intestinal pseudo-obstruction |
| PN | = | parenteral nutrition |
| SIBO | = | small intestinal bacterial overgrowth |
| TCA | = | tricyclic antidepressant |
Declaration of interest
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.
Data availability statement
There is no data set available for this paper.
Authors’ contribution
Conceptualization: GDN, LZ, GB, VS, RDG. Methodology: GDN, LZ, MG, AM, PP. Project administration: GDN, LZ, VS, RDG. Supervision: GDN, LZ, MG, AM, PP, GB, VS, RDG. Writing the original draft: GDN, LZ, AM, PP. Writing/review & editing: MG, GB, VS, RDG. All authors have seen and approved the manuscript and its contents.