The Pennington Lecture

Chronic idiopathic intestinal pseudo-obstruction: the need for a multidisciplinary approach to management

D. B. A. Silk^a1 c1

^a1 Department of Gastroenterology and Nutrition, Central Middlesex Hospital and Division of Surgery, Anaesthetics and Intensive Care, Imperial College, London, UK

Abstract

At the outset of the research programme into irritable bowel syndrome (IBS) it was perceived that there was a need to develop a symptom-based classification for the patients. Four groups of patients were identified, those with spastic colon syndrome, diarrhoea-predominant spastic colon syndrome, functional diarrhoea and midgut dysmotility. While working with outpatients with IBS it was noted how some of them had suffered symptoms for many years; specifically, a group of patients satisfying the criteria for midgut dysmotility had also suffered from particularly severe and intractable intestinal symptoms. These patients underwent 24 h ambulatory studies of small intestinal motility and the majority were found to have manometric features of chronic idiopathic intestinal pseudo-obstruction (CIIP). To characterise the cause, laparoscopic full-thickness small intestine and colonic biopsies have been obtained in forty-five of the latter group of patients. Of these patients 58% have been found to have complete or partial deficiency of α-actin epitope staining in the inner circular layer of small intestinal smooth muscle. This deficiency is believed to represent an important biomarker rather than the cause of CIIP, since α-actin epitope deficiency has been observed in association with enteric neuropathy and myopathies. In relation to the management of CIIP patients, a multidisciplinary model is proposed incorporating management of co-morbid psychological and psychiatric pathology, abdominal and musculoskeletal pain, fatigue, urological symptoms and nutrition. A six-stage nutritional management plan for these patients is presented.

Key Words:

• Chronic idiopathic intestinal pseudo-obstruction;
• Irritable bowel syndrome;
• Symptom-based classification;
• Multidisciplinary management model;
• Nutritional management plan

Correspondence:

^c1 Corresponding author: Professor David Silk, fax +1 20 8453 2538.