Download Gastrointestinal Motility Disorders Jassin M. Jouria, MD Dr. Jassin M

Gastrointestinal
Motility Disorders
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor,
professor of academic medicine, and medical
author. He graduated from Ross University
School of Medicine and has completed his
clinical clerkship training in various teaching
hospitals throughout New York, including King’s
County Hospital Center and Brookdale Medical
Center, among others. Dr. Jouria has passed all
USMLE medical board exams, and has served
as a test prep tutor and instructor for Kaplan.
He has developed several medical courses and
curricula
for
a
variety
of
educational
institutions. Dr. Jouria has also served on
multiple levels in the academic field including
faculty member and Department Chair. Dr.
Jouria continues to serve as a Subject Matter Expert for several continuing education
organizations covering multiple basic medical sciences. He has also developed several
continuing medical education courses covering various topics in clinical medicine. Recently,
Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy &
Physiology.
Abstract
The muscles of the gastrointestinal (GI) tract perform an important job. The
GI tract peristalsis, or contractions, mix the contents of the stomach and
propel contents throughout the entire GI tract until they exit as waste. When
these muscles underperform or fail to perform, it can create serious and
painful consequences, diagnosed as GI motility disorders. Although these
disorders are rarely fatal, they can cause physical and emotional effects that
negatively impact a patient's quality of life. However, there are many
options for treatment of GI motility disorders available to healthcare
professionals. Treatment is discussed in context of the current research and
trends to develop new criteria to diagnose and clinically manage care.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 7 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacology content is 1 hour.
Statement of Learning Need
Clinical criteria to treat patients diagnosed with a gastrointestinal motility
disorder have developed options for primary and acute care clinicians
involved in managing treatment. Research in the area of
neurogastroenterolgy is focused on primary care to access new criteria to
diagnose and guidelines to treat.
Course Purpose
To provide health clinicians with knowledge of gastrointestinal motility
disorders diagnosis, treatment and interventions to support improved quality
of life.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. Ninety percent of absorption of nutrients occurs in the
a.
b.
c.
d.
stomach.
duodenum.
small intestine.
large intestine.
2. True or False: The small intestine is referred to as “small”
because it is the shortest segment of the GI tract.
a. True
b. False
3. The junction between the small intestines and the colon is the
a.
b.
c.
d.
ileocecal valve.
cecum.
pyloric sphincter.
duodenum.
4. When disorders of motility occur in the small intestine, the
affected patient may suffer from
a.
b.
c.
d.
malnutrition.
fluid and electrolyte imbalances.
overgrowth of intestinal bacteria.
All of the above
5. True or False: An opioid analgesic, a drug used to manage
moderate-to-severe pain, may cause side effects, such as nausea,
vomiting, and constipation.
a. True
b. False
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Introduction
The gastrointestinal (GI) tract serves a multitude of important functions to
keep the body healthy and active. Much of the work of the GI tract goes on
behind the scenes within the body and is beyond physical or voluntary
control. Gastrointestinal motility describes the process of food, fluids, and
other secretions moving through the GI tract. The intestinal tract normally
carries out a certain number of contractions that advance food and liquids
through the gastrointestinal system as part of digestion and absorption of
nutrients. When disorders of motility occur, the GI tract is said to have some
sort of abnormal amount of motility; it may be working too fast, pushing
food and fluids through at an abnormal rate, resulting in dumping syndrome
or diarrhea. Alternatively, GI motility may be sluggish and working at a rate
much slower than normal or, in the case of aperistalsis, not at all.
The muscles that move and transition food and waste through the GI tract
are involuntary and cannot be physically controlled. The work of the GI
musculature continues at a set pace that makes up part of a complex system
of digestion, absorption of nutrients, and excretion of waste. If the pace of
GI motility is abnormally fast or slow, the affected person will experience
symptoms that can cause discomfort and that could lead to illness. Whether
GI motility problems occur as a result of chronic disease, damage to the
intestinal tract, or short-term illness, the affected patient typically suffers
the effects when normally routine motility and transfer of food goes awry.
The Gastrointestinal Tract
A pathway that extends throughout the body from the upper portion in the
face and head to its terminal location below the pelvis, the gastrointestinal
tract, is between 23 and 26 feet long, beginning with the mouth and ending
with the anus. Instead of being one complete organ, the GI tract consists of
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a number of different organs throughout the length of the system. Together
these organs are designed to carry out the processes of digestion but each
organ has its specific purpose and function.
The various organs include those of the upper GI tract, which consists of the
structures of the mouth and throat, the esophagus, the stomach, and the
duodenum of the small intestine. The lower GI tract is comprised of most of
the small intestine and the colon, including the distal portions of the large
intestine containing the sigmoid colon, the rectum, and the anus. Accessory
organs of the gastrointestinal tract are those that are not technically
considered gastrointestinal organs; however, they do play important roles in
the process of digestion and in supporting the work of the GI tract.
Accessory organs include the tongue, salivary glands, the liver, gall bladder,
and pancreas. This course will focus primarily on the main organs of the GI
tract, their functions and disorders of motility.
Esophagus
The esophagus, also referred to as the alimentary canal, is a hollow tube
found in the upper GI tract that is vertically located at approximately the
level of the chest. It is about 10 inches long and connected to the pharynx at
the back of the throat on one end and the stomach at the other end. The
esophagus runs through an opening in the diaphragm known as the
diaphragmatic hiatus before connecting with the stomach.
The process of digestion actually begins before food reaches the esophagus.
It starts in the mouth as a person chews his or her food. The enzymes in
saliva interact with food and start to break food down before it is even
swallowed. As an individual chews and prepares to swallow, ptyalin, the
main enzyme within saliva, works to break down starches and carbohydrates
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in foods. Chewing involves using the teeth to break down food until it is in
small enough pieces that it can enter the esophagus; the tongue then
pushes the food toward the back of the mouth so that it can be swallowed.
When swallowing, the food passes through the pharynx and enters the
esophagus as it travels toward the stomach. Despite being a hollow tube
that stretches from the neck to the abdomen, the esophagus does not
simply act as a chute for food to slide from the mouth to the stomach.
Instead, the esophagus contains three layers of tissue where each has a
different function: the interior layer lining or the inner lumen of the
esophagus, a mucosal layer that secretes mucus to provide lubrication for
food as it moves through the esophagus, and, the layer underneath the
mucosal layer, which contains smooth muscles that contract in sequence to
propel food along the tract. The esophageal muscles work in sequence to
control the food’s movement instead of letting it slide toward the stomach by
gravity. The muscles are arranged circumferentially around the esophagus
and also longitudinally along the length of the esophageal lumen.
Toward the top of the esophagus, near the pharynx, the muscles work
voluntarily. When swallowing, a person has more control over muscular
processes used in this area and can better manage the passage of food. As
food gets closer to the stomach at the lower end of the esophagus, the
muscles are smooth and the work of the esophageal musculature is
involuntary; the person eating food does not control the muscular
movements in this area.3 The process of the muscles moving the food
throughout the esophageal tube is known as peristalsis and it occurs
whether or not the person is eating while standing up, sitting, or lying down.
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At the base of the esophagus is the lower esophageal sphincter (LES), a
muscle that forms the connection between the esophagus and the stomach.
As food is propelled through the esophagus, the LES relaxes and opens
slightly, which allows the food to pass into the stomach. As soon as the food
enters the stomach, the LES then closes tightly again. It remains closed
when the individual is not eating or swallowing, which prevents stomach acid
and food from being regurgitated and backing up into the esophagus again.
The main function of the esophagus is to transport the food between the
mouth and the stomach. There is very little digestion that occurs within the
esophageal lumen; whatever was first broken down in the mouth and
partially digested is transferred to the stomach to further the digestive
process. Alternatively, some foods are not broken down for digestion until
they reach the stomach. The esophagus therefore plays a very important
role in transferring food from one area to the next so that the body can
digest food, absorb nutrients, and gain energy.
Stomach
The stomach is a curved, hollow organ at the base of the esophagus, and it
consists of four different sections: the cardia, fundus, body, and pylorus.
Food enters the stomach after passing through the esophagus and the lower
esophageal sphincter where it is then partially digested as well as broken
down into smaller pieces so that it can continue to move along the
gastrointestinal tract. The stomach is able to expand and contract,
depending on the volume of food eaten.
The stomach is lined with millions of gastric glands that are made up of
various types of cells that secrete different substances, such as hydrochloric
acid, digestive enzymes, intrinsic factor, and certain hormones. After food
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passes through the esophagus, it enters the gastric cardia, which is the first
portion of the stomach. Gastric juices are created in the cardia of the
stomach; these juices contain mucus, hydrochloric acid, and enzymes that
work to break down the food as it enters the stomach. Hydrochloric acid,
while often well known as a component of gastric juice, is only one product
excreted in the stomach that contributes to the breakdown of food during
digestion. Hydrochloric acid has a pH between 1 and 2, which facilitates food
breakdown and kills most types of bacteria that may be present in food.
The fundus is the next portion of the stomach after the cardia. Food is
temporarily stored in the fundus, and this is the point where food is churned
and broken down when it is mixed with enzymes. The chief cells of the
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stomach secrete pepsinogen, which converts to form pepsin, an enzyme
needed for protein digestion. The parietal cells lining the stomach secrete
gastrin, a hormone that stimulates production of gastric juice and all of its
components. Intrinsic factor is a type of protein that allows the body to take
in vitamin B12 by combining with the nutrient so that it can be absorbed in
the small intestine.
Food digestion continues in the body of the stomach, which is the largest
portion. Digestion occurs as the stomach secretes gastric juices to break
down food particles. In addition to secretion of gastrin, which stimulates
production of gastric juices, there are other factors that may increase or
decrease the rate of digestion because of how much gastric juice is released.
For example, as food enters the stomach, the walls of the stomach stretch,
stimulating certain receptors that promote the release of gastric juice.
Release of gastric juice may also occur when a person smells or sees food;
this process is known as the cephalic phase of digestion.
The body of the stomach is where most of the enzymatic breakdown of food
occurs and it is considered the primary area of digestion. Like the
esophagus, the stomach is lined with several layers, one of which contains
muscles that contract in different directions to move the food around and to
churn it within the stomach cavity. After spending time in the body of the
stomach, food reaches the antrum, which is the last portion of the stomach
before the small intestine. Similar to the esophagus, the stomach also has
peristaltic waves that propel food toward the small intestine. The word
antrum actually means ‘cave’ and it is in this location that food is slowly
released into the duodenum in small amounts to avoid dumping it into the
next section all at once.4
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The length of time that food remains within the stomach varies between 30
minutes to several hours, depending on how much food was eaten and the
composition of the meal, but the average amount of time food spends in the
stomach is four hours.4 As food is broken down and partially digested, it
turns into a semifluid mass known as chyme as it travels through the rest of
the GI tract. The sphincter separating the stomach from the small intestine
is known as the pyloric sphincter. Large food particles cannot pass through
the pyloric sphincter, so if food is not broken down well enough as it
approaches the small intestine, it is churned back within the body of the
stomach to break it down further. As with the LES, the pyloric sphincter is
also a muscle that opens to allow small amounts of chyme to enter the small
intestine at a time and then closes tightly again to keep stomach contents
within the pouch.
As part of the GI tract, the stomach plays an important role in digestion and
motility of food. The stomach can develop its own issues of motility that are
separate from other sections of the GI tract; when this organ develops
motility problems, the affected patient may suffer from a number of
symptoms, depending on whether food is being moved too quickly, too
slowly, or is being regurgitated in the wrong direction. Any of these
symptoms can wreak havoc on other parts of the body, so regulation of
stomach motility is essential for normal GI function.
Small Intestine
Although it is referred to as “small,” the small intestine is actually the
longest segment of the GI tract. Its description as being small refers to its
diameter, which is less than that of the nearby colon. The small intestine is
connected to the base of the stomach; and, the muscular sphincter between
the two structures is known as the pyloric sphincter, which is responsible for
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controlling the rate of chyme, or partially digested food, entering the small
intestine from the stomach. The small intestine makes up approximately
two-thirds of the total length of the GI tract, but it remains within a compact
cavity by winding around in loops and coils within the area.
The small intestine consists of three main segments, each of which has its
own purposes and activities as part of digestion. The first section is the
duodenum, which is proximal to the stomach and first receives chyme as it
enters the small intestine. The duodenum is where much of digestion occurs
that finishes what was started in the stomach. Accessory digestive organs,
including the pancreas and gall bladder secrete substances into the
duodenum to aid in digestion. Following this segment is the middle portion
of the small intestine, called the jejunum, which has various folds within its
interior layer. These folds increase the overall surface area of this portion of
the small intestine; consequently, the jejunum is the section of the small
intestine where much of the absorption of nutrients takes place. The distal
section of the small intestine is the ileum, the end of which connects to the
large intestine at the ileocecal valve. This valve is actually another sphincter
found along the GI tract that controls the amount of partially digested food
as it enters the colon.
The small intestine moves chyme throughout its tract by two different
actions: intestinal peristalsis and segmentation. The presence of chyme
within the small intestine stimulates peristalsis, which is the movement of
the smooth muscles to propel the food forward as it moves along the tract.
Segmentation refers to intestinal contractions that create small waves that
churn the chyme as it moves through peristalsis.
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Digestion occurs within the stomach of
the GI tract. The stomach begins
absorption of nutrients, and, the small
intestine completes the process of food
digestion and absorbs many nutrients
as the chyme passes through it. The
pancreas and gall bladder, both located
next to the small intestine, secrete
digestive enzymes, including amylase
and lipase into the duodenum to
stimulate further digestion of food.
Once food enters the duodenum, this
action stimulates other areas to
secrete other substances as well, such
as bile from the liver, which work
together to facilitate food digestion and the breakdown of fats, starches, and
other substances in the chyme. The rate of motility of the small intestine is
regulated by secretion of hormones and neuroregulators found within
intestinal secretions.
Chyme travels through the small intestine during an average time of 3 to 6
hours. Absorption occurs because of the microscopic projections on the
surface of the small intestine; these projections, known as villi, are located
on the mucosal surface and are where absorption takes place. Ninety
percent of absorption occurs in the small intestine along its full length. Water
enters and is reabsorbed in the small intestine as well. Each villous is
connected to a tiny capillary network that allows for absorption of nutrients
such as carbohydrates, vitamins, and fatty acids directly into the
bloodstream.
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Absorption begins in the jejunum of the small intestine as nutrients pass
from the villi and are diffused through the intestinal wall into the capillary
network. Absorption continues in the ileum of the small intestine, with
specific nutrients being absorbed in certain locations throughout; for
instance, sodium and chloride are absorbed in the jejunum, while vitamin
B12 and bile salts are absorbed in the ileum.1 Most of the nutrients are
absorbed in the small intestine. The remaining substances move into the
colon. The substances first move into an area known as the terminal ileum,
which is the very end of the small intestine, and then pass through the
ileocecal valve. What is left is indigestible and will travel through the colon
where a certain amount of fluid is absorbed before the matter finally exits
the body.
The extraordinary length of the small intestine means that food and chyme
spends a significant amount of time moving through this organ of the
digestive tract. When the small intestine develops a motility disorder, food
can move through this organ much more quickly and may spend very little
time in the small intestine. Because the small intestine is responsible for
much of the absorption that takes place in the GI tract, when motility
disorders occur, the affected patient may then suffer consequences
associated with malabsorption, including malnutrition, fluid and electrolyte
imbalances, and overgrowth of intestinal bacteria.
Colon
Also referred to as the large intestine, the colon is shorter than the small
intestine but its diameter is much larger in size. The colon is divided into
three areas, based on its position in the abdominal cavity. The ascending
colon is connected to the small intestine at the ileocecal valve and is located
on the right side of the body; undigested material travels through this
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portion of the colon first. The large intestine turns and then becomes the
transverse colon, which extends from the right to the left side of the
abdomen. At this point, the intestine turns again to become the descending
colon that travels down the left side of the body. The terminal portion of the
descending colon is the sigmoid colon, the S-shaped final portion that
connects to the rectum, and finally, the anus.
The end of the small intestine and the
junction between the small and large
intestines contains the ileocecal valve,
which connects the small intestine to
the colon. Each wave of peristalsis of
the small intestine opens the ileocecal
valve briefly to allow a small amount of
material to pass into the colon. Near
the ileocecal valve is the cecum, which
is a pouch that absorbs some fluid and
salts from undigested food. Next to the
cecum is the appendix, a finger-like
projection that may serve as a reservoir for beneficial bacteria in the gut.
Undigested materials enter the colon from the small intestine and travel
through its segments over the course of several hours; the average amount
of time that these materials stay in the colon is approximately 24 hours.4
The colon has a segmented appearance and contains layers of tissue that
are similar to the small intestine; however, the interior layer of tissue in the
large intestine does not contain villi needed for nutrient absorption. The
mass of material is moved through the colon in peristaltic waves that occur
on an intermittent basis, typically from stimulation by secreted hormones
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that are released after another meal is eaten. In other words, food from the
last meal may move through the digestive tract and, once it reaches the
large intestine, it is further stimulated to move through this organ when the
person eats the next meal.
The remainder of material that enters the colon is further broken down, as it
becomes waste products that will eventually be evacuated from the body as
stool. This process occurs in the colon through intestinal secretions and the
work of bacteria, which are always present within the large intestine. The
intestinal secretions lubricate the fecal mass as it moves through the colon;
and, the bacteria break down any other nutrients that are present at this
point. The mass moves through the colon much more slowly when compared
to the small intestine. During transit, extra water and electrolytes are
absorbed so that the material eventually forms the fecal mass that becomes
stool.
When the fecal mass reaches the rectum, it distends to contain the stool.
This fecal matter is mostly fluid with some solid material. It contains
indigestible particles of food and bacteria. As the stool stretches the rectum,
it stimulates the autonomic nervous system that controls the internal
sphincter near the anus. The anal opening contains both an internal and an
external sphincter to control passage of stool out of the body. Normally, the
external sphincter stays contracted and closed until the point when
defecation occurs, and it then relaxes to allow stool to pass. The work of the
colon is largely involuntary until stool reaches the rectum and the anus; at
this point, some control of the external anal sphincter is voluntary, allowing
the individual to control defecation.
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A significant portion of the colon’s purpose is to absorb fluid and prepare
waste for evacuation, which is healthy and necessary to rid the body of
waste products and those materials that cannot be used by the body. This
last portion of the GI tract is necessary to complete the digestive process, to
eliminate stool and materials that the body does not need, to regulate fluid
and electrolyte levels, and to maintain overall health of the body.
Etiology Of Gastrointestinal Motility Disorders
There are multiple factors that contribute to motility disorders. Because
dysmotility may be manifested in different ways, for instance, as delayed
motility that results in too slow of transit or increased motility that prevents
proper nutrient absorption, there are also various causes of dysmotility.
Some factors may be related to patient health, such as, a decline in overall
health as a result of aging or chronic disease, which can affect the
gastrointestinal system and its rate of motility. Alternatively, there are some
elements in the environment that also affect gastrointestinal function, such
as with drug use. Understanding the potential etiologies of motility problems
may better assist healthcare providers with diagnosing these conditions
when patients present for care.
Degenerative Disorders
The motility of food and materials through the digestive tract is a complex
process that involves stimulation of the muscles and tissues of the
esophagus, stomach, and intestines to propel food through the tract using
peristalsis. Factors such as hormones, enzymes, blood flow, nerve activity,
and intestinal secretions all impact the rate of food transit and digested
materials. Because degenerative disorders can affect many of these factors,
people who suffer from these illnesses may be more likely to develop
disorders of motility within the gastrointestinal tract.
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Chronic Intestinal Pseudo-Obstruction
Chronic intestinal pseudo-obstruction (CIP) develops as a disorder that
results in poor intestinal motility. The patient may suffer from signs or
symptoms that would occur with an intestinal obstruction but there is
actually no evidence of any sort of blockage or barrier upon exam. The
condition may develop because of various factors, including surgical trauma
or chronic disease, as well as various nerve and muscle disorders, including
scleroderma, Parkinson’s disease, and lupus.
A person who develops CIP will often suffer from symptoms characteristic of
intestinal obstruction, including abdominal distention and pain, nausea and
vomiting, and either constipation or diarrhea. The patient actually presents
with symptoms that lead the healthcare provider to believe, upon initial
assessment, that some sort of intestinal obstruction is present. However,
after diagnostic testing, the patient is then found to have no lesions or
occlusions in the intestinal tract that would cause the symptoms.57,85
Diagnosis of CIP requires a physical
exam and diagnostic testing, which
typically involves imaging studies. The
patient most often needs an abdominal
X-ray, a CT scan of the abdomen, or
even endoscopy to verify what is
causing the symptoms or to rule out
any other cause, such as an actual
intestinal obstruction. Chronic intestinal
pseudo-obstruction affects GI motility
because the condition affects intestinal
peristalsis, including causing delayed
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gastric emptying or rapid transit of digestive substances.
Management of CIP is usually not curative and the best approach is to treat
the patient’s symptoms and to prevent complications, such as malnutrition
or dehydration that may develop from the condition. The patient often needs
nutritional guidance and to be counseled about food intake, as weight loss is
common. In some cases, the symptoms are so severe that the patient
requires a feeding tube to ensure that he or she is getting enough nutrients.
A feeding tube can ensure that the patient continues to gain nutrition
because CIP tends to affect how the food moves through the intestinal tract
but does not necessarily cause changes in the intestinal lining that would
otherwise affect nutrient absorption.
The medications required as part of management of CIP are also prescribed
to control symptoms and to reduce complications. If the patient primarily
suffers from delayed gastric emptying and constipation, then drugs such as
stool softeners, laxatives, and antiemetics may be necessary. Alternatively,
if the condition leads to frequent diarrhea, then antidiarrheal medications
would be required. If the CIP is caused by an infection, the provider can
prescribe antimicrobial drugs to contain the infection and to control
symptoms.
Ideally, CIP is managed by controlling the condition that is causing it;
however, when it develops because of chronic disease that has no cure, such
as lupus or scleroderma, CIP management becomes symptomatic only. The
patient may then continue to take medications and undergo treatments to
control his or her chronic illness while simultaneously managing GI
dysmotility. If symptoms are severe or are unresponsive to medication, the
patient may need surgical treatment. Treatments involved also prevent
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complications and may include decompression of the gas that has
accumulated in the intestinal tract, removal of excess stool and waste in the
large intestine, or surgically manipulating intestinal sphincters to improve
muscular control.
Swallowing and Esophageal Disorders
Gastrointestinal motility problems may develop within various segments of
the GI tract. When motility issues occur in the upper gastrointestinal tract
and affect a person’s ability to swallow or transport food to the stomach, the
person is at risk of complications such as dehydration, malnutrition, and
electrolyte imbalance because he or she may have greater difficulties with
getting enough to eat and drink. Motility problems in this portion of the GI
tract are typically classified as swallowing problems or esophageal motility
disorders.
Dysphagia describes difficulty with swallowing; when a person develops
dysphagia, he or she has trouble transitioning food from the back of the
mouth and into the esophagus. Dysphagia can develop as a consequence of
a number of conditions, including physical disabilities, stroke, and
carcinoma, and, it may also develop because of difficulties related to certain
types of degenerative disorders. The problem not only causes issues with GI
motility and food transport, it can lead to other complications, such as
malnutrition, dehydration, and aspiration if food or liquid accidentally enters
the lungs instead of the esophagus.
Degenerative disorders can cause swallowing problems when the nerves that
impact a person’s ability to coordinate swallowing become damaged or
injured as a result of the disease process. Many degenerative conditions
cause loss of neurons in the brain and spinal cord, which further affect
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movement and coordination in the GI tract. Degenerative diseases are
typically progressive and are often incurable, with treatment focusing on
management of symptoms and maintaining quality of life. Examples of
degenerative diseases that affect neurological function and swallowing
include such conditions as Huntington’s disease, dementia, or CreutzfeldtJakob disease.
Dysphagia causes motility problems in that an affected person is unable to
adequately coordinate how to transition food from the mouth into the
esophagus so that it can travel to the stomach. The process of swallowing
requires sequencing of various muscles, including those of the face, neck,
mouth, and esophagus; it also requires recognition of the sensations needed
to move the muscles to pass the food along, enough muscle strength to
coordinate movement of the food, and intact reflexes in the pharynx and the
larynx.7 When considering that swallowing is something that most people do
multiple times per day, and that it is a mostly voluntary action, the act of
swallowing is surprisingly complex.
Degenerative changes can also further complicate dysphagia with advancing
age and with other factors that affect cognitive ability, including reduced
cognition because of a decline in the number of neurons in the brain, poor
dentition, decreased salivary production, poor oral hygiene, and decreased
mobility. Strategies to increase quality of life can help to maintain an
affected person’s ability to swallow, despite progression of the disease. This
may involve thickening liquids to make them easier to swallow or choosing
soft and moist foods that are not sticky or hard, making them easier to pass
and less likely to be aspirated.
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According to Walse in the Journal of Gastroenterology and Hepatology, the
mode of dysphagia can vary depending on the type of degenerative
condition present. For instance, a person with Alzheimer’s disease may have
difficulty with sensing that food is in the back of the mouth to be swallowed,
while a person with vascular dementia may have difficulty with chewing.7
Because dysphagia is so complex of a process, each patient who suffers from
a medical condition that affects swallowing may have differences in abilities
to contend with when compared to another patient who is also classified as
having dysphagia.
Interventions for people who struggle with dysphagia are centered on
preventing complications associated with the condition and improving overall
wellbeing. Eating is such a social activity that a person’s inability to swallow
normally may further impair the person’s ability to enjoy a meal and to eat
with others. This potentially leads to social isolation and feelings of
loneliness. It is therefore important to consider that dysphagia can deeply
impact quality of life for the affected patient, and improving the ability to
swallow may then increase quality of life for those involved.
The healthcare provider who works with a patient with dysphagia may
provide some interventions that would facilitate easier swallowing. As
mentioned, this may involve thickening liquids and otherwise modifying food
textures and consistencies. The provider may also help the patient to
straighten or move the neck or posture to make swallowing easier and to
reduce the risk of obstruction. Some forms of rehabilitation utilize adaptive
utensils and other methods that make eating easier for the patient.
Further interventions are aimed at preventing aspiration pneumonia, a
potentially serious complication that can develop when the patient aspirates
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food into the lung tissue because he does not have control over food and
liquids while swallowing. Silent aspiration occurs when the person swallows
incorrectly and the food or liquid enters the lungs but there is no physical
response from the individual, such as with coughing or choking. Silent
aspiration can be one of the more dangerous complications of dysphagia
because it can be difficult to detect and control, and yet can lead to
pneumonia and breathing difficulties.
Pharmacological and surgical interventions can be helpful for some people
who have difficulties with swallowing, but in most cases, they are not terribly
effective and only help with some of the symptoms.7 For instance, if drooling
is a problem, drug administration may help to control the amount of saliva
production. In many cases, palliative care is often the only management
strategy after attempts at helping the patient to achieve normal swallowing
have been exhausted. Administration of enteral feedings through a feeding
tube may be necessary for some patients who are no longer able to swallow
and who are at risk of malnutrition and dehydration from an inability to pass
food and liquids from the mouth to the esophagus. Caregivers who
determine when and what type of enteral feedings are needed must consider
numerous factors related to the patient’s health, age, living situation, and
prognosis, as changing to this form of feeding may involve a certain amount
of ethical decision making on the part of the healthcare provider. However, it
can continue to provide nutrients and fluid to a patient who is otherwise
unable to adequately swallow.
Achalasia describes a condition that affects how food is transitioned between
the mouth and the stomach. Achalasia develops after damage to the nerves
of the esophagus, causing aperistalsis, in which the esophagus is unable to
propel food and liquids because it lacks the muscular action. The condition
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also causes weakening and incomplete closing of the lower esophageal
sphincter, leading to acid reflux and difficulty swallowing. Over time, the
patient with achalasia develops greater difficulties with eating and drinking,
and may suffer from severe gastroesophageal reflux, all of which could
potentially lead to weight loss and malnutrition.
The exact reason why achalasia develops in some people is not entirely
clear, but there are some theories. One common opinion is that the nerves
that control the esophagus become damaged because of an autoimmune
disorder, in which the body attacks its own nerve cells, rendering them
useless for maintaining normal motility in the esophagus.6 The nerve cells
within the muscles of the esophagus slowly degenerate until they are almost
non-functional. Achalasia typically does not develop all at once; instead,
symptoms progressively worsen over time as the patient loses more ability
to drink liquids and to eat solid food. The condition may initially cause
symptoms of mild reflux that can eventually develop into severe pain any
time that the individual tries to eat.
Unfortunately, achalasia is a progressive condition in that the nerve cells
continue to degenerate and the condition continues to worsen. Achalasia can
be managed, though, and depending on the type of treatment, the affected
patient may go for months to years without further symptoms. Treatment
with medication includes administration of botulinum toxin injection into the
LES, which paralyzes the sphincter and allows for food to pass into the
stomach. Surgical myomectomy is another option for treatment that involves
cutting the muscles around the LES, which allows for food to pass into the
stomach.
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Stomach and Small Intestine Disorders
Some disorders affect the body’s ability to transition food through areas of
the GI tract; food may have reached a certain point within the
gastrointestinal system but because of some degenerative conditions, the
patient’s body may have enough motility difficulties that it has problems
with further movement. Disorders that affect the nerves of the stomach and
small intestine can cause delayed gastric emptying, dumping syndrome, or
difficulties with absorbing food properly.
Polymyositis degenerative disorder is a relatively rare condition that causes
inflammation of connective tissues. It is characterized by muscle
inflammation, weakness, and elevated serum muscle enzymes, as well as
patient fatigue, shortness of breath, and dysphagia or speaking difficulties.8,9
The exact cause of the condition remains unknown, but it is thought that the
muscle inflammation develops as an autoimmune condition. Most people
with the condition develop pain and inflammation in the muscles of the
upper body, including the neck, shoulders, upper back, and upper
extremities, however, GI symptoms and motility problems are also common
with this condition.
Polymyositis has been known to be responsible for a number of GI conditions
that affect anything from swallowing to lower esophageal sphincter tone.
One condition that may be more likely to develop with polymyositis is
delayed gastric emptying, also called gastroparesis, which occurs when food
moves too slowly from the stomach and into the small intestine. The
condition can often cause gastroesophageal reflux, abdominal pain and
bloating, and anorexia in affected individuals and can lead to an increase of
bacterial proliferation within the stomach and painful lumps of undigested
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food in the stomach that are difficult to break down and pass into the small
intestine.
Patients with polymyositis have also developed GI symptoms of diarrhea or
constipation, colonic dilatation, GI bleeding, and pseudodiverticula, which
occur as small projections of the mucosal layer of the intestine into the
muscular wall. All of these symptoms can cause significant discomfort for the
affected patient, potentially resulting in malnutrition and anorexia if the
patient is unable to eat or digest food properly and if the patient struggles
with painful symptoms when eating. Treatment involves administration of
corticosteroids to reduce inflammation and symptom management to control
gastrointestinal motility problems, such as through modifying food textures
to facilitate easier chewing and swallowing, increasing fluid intake, and
eating smaller but more frequent meals.
Another type of disorder that causes too rapid intestinal motility from the
stomach to the small intestine is known as dumping syndrome. The
condition often develops following certain surgical procedures when the
muscles and nerves have been damaged or changed and no longer work
correctly to control gastric motility. Dumping syndrome is said to affect up to
50 percent of patients who have undergone gastric surgery.66 It occurs when
food moves too quickly out of the stomach and into the duodenum of the
small intestine. The condition is actually a collection of symptoms that
develop with the increased movement of food through the intestine; it is
classified as being early phase or late-phase dumping syndrome according to
the timing of symptoms.
Early phase dumping syndrome occurs within 30 to 60 minutes after a meal.
The affected patient may develop abdominal pain and cramping and may
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start to sweat or feel flushed and lightheaded. Other symptoms include a
distinct feeling of fullness in the abdomen, nausea, vomiting, diarrhea, and a
rapid heart rate. Up to three hours after a meal, late dumping syndrome
may develop, which causes symptoms of flushing, sweating, fatigue, tremor,
dizziness, tachycardia, and mental confusion.67
Dumping syndrome is said to develop because of changes in the size of the
intestinal tract during digestion, the release of certain hormones after eating
that can affect blood pressure, rapid swings in blood glucose levels after
eating, and increased fluid absorption from the bloodstream and into the
small intestine.66 When a patient has bariatric surgery, such as with gastric
bypass, the patient may also develop dumping syndrome because the
procedure may affect innervation of the stomach muscles. If the nerves
controlling the muscles are cut during surgery or are otherwise damaged,
the patient may then lose control over stomach contractions, leading to
dumping syndrome.
Dumping syndrome is best managed with changes in dietary practices,
including avoiding anything that would overstimulate the muscles of the
stomach and cause it to contract too quickly. For instance, the patient
should be advised to slow down while eating and to eat small meals,
chewing every bit thoroughly before swallowing. A patient may also be
instructed to avoid drinking large volumes of liquid before, during, or after
meals, and may need to increase fiber intake while decreasing intake of
sugar, alcohol, and caffeine.
For some patients, dumping syndrome is only managed through medications
or surgery if it does not respond to lifestyle changes. Antidiarrheal
medications can help to control some of the abdominal pain, flatulence, and
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diarrhea that often develop because of dumping syndrome. In severe cases,
surgery to alter the muscles of the pyloric sphincter can best manage
dumping syndrome in order to control the rate at which food passes between
the stomach and the small intestine.
Muscular dystrophy is another type of degenerative disease that may cause
GI motility problems throughout the entire GI tract; however, many
symptoms of motility disorders can be concentrated within the stomach or
small intestine regions with this disorder. Muscular dystrophy is actually a
group of more than 30 degenerative diseases that involve breakdown of
muscle tissue, affecting movement and coordination. Muscular dystrophy has
no treatment, and management is focused on physical therapy and use of
assistive devices to maintain quality of life and to offset some of the muscle
weakness experienced by the patient.
In addition to the symptoms affecting
various skeletal muscles of affected
patients, muscular dystrophy can also
cause gastrointestinal changes that affect
motility; the most frequently cited
symptoms include dysphagia, dyspepsia,
gastroesophageal reflux, and vomiting.10
Other symptoms may also include
constipation or diarrhea, early satiety,
delayed gastric emptying, abdominal pain,
and bloating. The extent of symptoms
experienced by the patient is typically not
correlated with the extent of the disease,
as muscular dystrophy affects skeletal muscles and not necessarily the
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smooth muscles of the GI tract. Still, those who have more advanced forms
of muscular dystrophy have been shown to also struggle with more severe
gastrointestinal symptoms, suggesting that motility problems seem to
worsen over time.
The progressive muscle weakness that develops from muscular dystrophy is
related to skeletal muscles; those that are used for physical movement and
functioning and are voluntarily controlled. While some of the gastrointestinal
tract utilizes the work of voluntary muscles, much of the peristalsis and
transit of food and chyme is done through involuntary control of the smooth
muscles lining the GI tract. Experts are not sure why patients with muscular
dystrophy then develop gastrointestinal disturbances, but many believe that
it is due to an alteration in gastrointestinal secretions and changes in nerve
function associated with the disease.10
Because of the potential for altered nutrition due to gastrointestinal motility
problems in patients with muscular dystrophy, healthcare providers often
include interventions designed to improve motility, increase appetite, and
assist the patient with eating and digesting food properly, despite the
condition. This may mean administering medications that increase bowel
motility and to treat diarrhea, and dietary modifications to facilitate easier
chewing and swallowing. As with some other progressive degenerative
diseases that affect gastrointestinal motility, tube feedings may be
necessary to maintain adequate nutrition once the patient’s condition has
advanced.
Disorders of the Large Intestine
Although degenerative disorders can affect motility at any point along the
digestive tract, the areas of concern are most often within the colon and the
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rectum. In the large intestine, extra water is absorbed and stool is stored
until the individual can evacuate stool voluntarily. When a degenerative
disease develops, it can impact a person’s ability to control stool evacuation
or to sense the need to defecate. Consequently, patients diagnosed with
degenerative disorders often suffer from motility problems, including
constipation, fecal incontinence, or fecal impaction.
Degenerative neurological disease can affect nervous pathways leading to
the large intestine, causing potential complications for a patient diagnosed
with this type of disease. Degenerative conditions such as multiple sclerosis,
Parkinson’s disease, and spinal cord lesions have all been shown to impact
nervous system pathways to the large intestine, leading to dysregulation of
intestinal smooth muscle and difficulties with peristalsis and transit.5
The greater risk of complications tends to occur with further progression of
the degenerative disease. In other words, the more advanced the stage of
the neurodegenerative disorder, the more likely the patient will be affected
with gastrointestinal motility problems. A report by Wald of the International
Foundation for Functional Gastrointestinal Disorders stated that among
patients with multiple sclerosis (MS) analyzed in a large research study,
about two-thirds struggled with constipation or fecal incontinence, and, most
were considered to have moderate or severe disability associated with MS.5
It should be noted that patients who are considered to have even mild forms
of some degenerative disease may still suffer from intestinal motility
problems.
Degenerative diseases may also contribute to muscle weakness that impact
the body’s abilities to control sphincter muscle tone. Patients who have
diabetes mellitus may experience muscle weakness and may have an
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inability to control the external anal sphincter muscle that normally tightens
and relaxes to control defecation. When the patient is unable to control the
external anal sphincter because of muscle weakness, he or she is at higher
risk of fecal incontinence because of an inability to control stool and
defecation. Patients who suffer from some neurodegenerative disorders may
be more likely to struggle with constipation from decreased motility rather
than diarrhea. If there is a risk of fecal incontinence because of muscle
weakness and poor anal sphincter control, the healthcare provider should
carefully consider management of constipation as aggressive treatment
could not only reverse the condition, but could also cause diarrhea that
would be difficult to control with muscle weakness.5
Hirschsprung’s disease, also called congenital intestinal aganglionosis, occurs
as a type of birth defect in which a person is missing some of the nerve cells
that control the GI tract. It typically affects the large intestine. Normally, the
nerve ganglia develop between muscle layers that line the colon; and, these
nerve bundles are usually present throughout the length of the large
intestine. With Hirschsprung’s disease, nerve growth is incomplete and, in
some areas, nerve bundles fail to form at all, which results in aganglionosis.
The length of aganglionosis may vary between individuals; some people are
born with aganglia only in the sigmoid colon and the rectum, while others
may have absent nerve bundles extending to proximal portions of the large
intestine. Approximately 80 percent of patients have aganglionosis within
the recto-sigmoid portion of the colon.11 This affected area is also classified
as short-segment disease.
Because Hirschsprung’s disease is a congenital condition, symptoms start to
appear during infancy. Symptoms are typically manifested as an inability to
pass stool in a normal manner, including difficulties with passing first
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meconium after birth among some infants. Other symptoms include frequent
emesis, chronic constipation, and abdominal pain and distention. As the
person grows, he or she may suffer from long-term problems with
constipation, flatulence, and fatigue.
Unfortunately, patients with Hirschsprung’s disease are at risk of intestinal
infection because of poor motility. Stool tends to back up within the colon,
causing intestinal distention and the potential for bacterial growth, which can
lead to enterocolitis. The backup of stool in the colon also causes intestinal
obstruction so that the patient has difficulties with passing stool at all. The
intestinal walls could become overly distended thereby increasing the risk of
intestinal perforation.
The most common type of treatment for Hirschsprung’s disease is surgical
resection of the affected areas of the colon where aganglionosis is present.
For patients who have short-segment disease, this may mean removal of the
diseased portion and placement of a colostomy. If longer sections of the
bowel are affected, the patient may need an ileostomy to pass stool after a
significant section of the bowel has been removed. Other interventions that
are often necessary involve monitoring food intake, including high-fiber
foods, to reduce the risk of constipation, increasing fluid intake and physical
activity, and possible administration of laxative medications to stimulate gut
peristalsis.
Endocrine Disorders
Endocrine disorders develop from dysfunction of the endocrine glands that
result in either over- or underproduction of hormones. Endocrine dysfunction
can lead to long-term problems and symptoms that affect the entire body,
including the gastrointestinal tract. Gastrointestinal motility disorders may
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develop in some patients with endocrine dysfunction, even if the endocrine
disorder seems otherwise unrelated to the GI condition.
Diabetic Gastroparesis
Defined as delayed gastric emptying, gastroparesis occurs when a person’s
ability to transport food from the stomach to the small intestine slows down,
despite a lack of obstruction. The condition is more often associated with
diabetic patients, although it can develop among those who do not have
diabetes. Gastroparesis more commonly occurs among diabetic patients
because uncontrolled blood glucose levels can damage the vagus nerve,
which controls the rate of stomach emptying. As a result, food tends to stay
in the stomach longer and is slower to transition to the small intestine for
further digestion and absorption.
Gastroparesis can lead to multiple uncomfortable symptoms related to
delayed gastric emptying. The most common symptom typically includes
nausea, vomiting, abdominal bloating, early satiety, and epigastric fullness.
The patient is more likely to suffer from poor quality of life because of
symptoms and may eventually develop malnutrition and weight loss when
food cannot be transitioned normally in the GI tract. Furthermore, some
patients with gastroparesis are unable to absorb oral medications in a
normal manner, making this route of medication administration ineffective;
these groups of people may then need to utilize other methods of drug
administration to control symptoms. The vomiting and anorexia associated
with gastroparesis can also significantly impact the diabetic patient’s blood
glucose levels.
Diabetes mellitus is an endocrine disorder that impacts how the body uses
glucose for energy. It is a complex disease that is divided into types 1 and 2.
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Type 1 diabetes develops when the pancreas, the main organ responsible for
secreting insulin to get glucose into the cells for energy, is damaged or
otherwise unable to secrete enough of the insulin hormone to control how
much glucose enters the bloodstream. Type 2 diabetes tends to develop
because of insulin resistance, in which the cells are unaffected by insulin and
thereby become unable to take on enough glucose for energy. Without
treatment, both types of diabetes result in elevated levels of glucose in the
bloodstream, which can be damaging to blood vessels and to the nerves that
serve various organs throughout the body. For this reason, diabetes has
been known to cause many different types of health conditions, such as
circulatory and peripheral vascular disease, as well as blindness.
Diabetes is also closely linked to gastrointestinal motility problems. As food
is absorbed in the digestive tract, it is transformed into glucose so that the
body can use it for energy; however, when there are GI motility problems
that affect absorption, the body may be unable to take up enough nutrients
to provide glucose for energy. Alternatively, too much glucose in the
bloodstream that circulates without being used for energy damages parts of
the GI system, including the nerves that serve the intestinal tract, which
may lead to severe GI motility disturbances.
Between 5 and 12 percent of patients with diabetes report symptoms of
gastroparesis.12 Gastroparesis is not necessarily a condition that develops
early on after a diabetes diagnosis, instead, it is more likely to occur later in
the course of the disease, after the patient has had diabetes for several
years and may more likely suffer from concurrent conditions that have also
developed as a result of diabetes, including nephropathy, neuropathy, or
retinopathy.
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Normally, the stomach uses muscular contractions to churn and propel food
within it, and the stomach’s peristaltic waves then move the food,
coordinated with the opening and closing of the pyloric sphincter (between
the stomach and duodenal (small intestine) bulb, to push it into the first
portion of the small intestine. Once damage has occurred to the vagus nerve
that controls this process, there is no cure for the condition. The patient is at
risk of several complications, including malnutrition and dehydration when
food and liquids cannot be processed normally. A bezoar may develop, which
is a hard mass of undigested food that sits in the stomach and cannot be
passed into the small intestine. The patient typically develops nausea and
may vomit when a bezoar is present; and, it can eventually be dangerous for
the patient if it blocks the pyloric sphincter and prevents other food from
passing into the small intestine.
Management of gastroparesis involves controlling the underlying condition
and taking steps to improve the rate of gastric emptying. For the patient
with diabetes, the damage to the vagus nerve that causes gastroparesis is
typically irreversible, even with later blood glucose management. However,
it is still important to help the patient to control blood glucose levels to
better prevent other complications of the condition and to inhibit the
potential for gastroparesis symptoms to affect blood glucose levels.
Gastroparesis is also managed through dietary changes that help the patient
to eat foods that are easier to digest. The patient may need to chew food
very thoroughly so that bites are very small and easier to pass through the
stomach. Other dietary interventions often include increasing fluid intake
and avoiding certain foods; those foods that are very fibrous or that contain
hard particles, such as nuts and seeds, may be more difficult to digest and
can complicate symptoms of gastroparesis. Some medications may stimulate
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stomach contractions to help with the passage of food. Metoclopramide
(Reglan®) may be given to improve the rate of gastric emptying; and,
erythromycin is another drug that has been shown to be successful.
Erythromycin stimulates the smooth muscles in the stomach and the
duodenum of the small intestine to increase gastric motility.12
Electrical stimulation may also be used as part of treatment for
gastroparesis. The process uses a permanent implanted device, inserted
surgically, that stimulates the lower gastric nerves of the stomach, which
helps the stomach to contract. The most common device is called Enterra™
and it is used when the clinician laparoscopically inserts the electrodes into
the patient’s stomach to deliver the electrical current. A study published in
the Journal of Minimal Access Surgery demonstrated that a permanently
implanted device such as Enterra to deliver electrical stimulation improved
symptoms in 70 percent of patients with severe gastroparesis who had
participated in the study.13 Once implanted, the Enterra device stays in place
for the long-term and provides permanent stimulation to control
gastroparesis and prevent it from worsening; and, it is typically reserved for
patients with delayed gastric emptying who have not otherwise responded to
other therapies.
Because there is no cure for diabetes, the patient who is diagnosed must be
educated about the damaging effects of the disease and the need for control
of blood glucose levels to prevent complications. Gastroparesis that develops
as a result of diabetes is also a permanent condition that will require lifelong
management once it occurs. If possible, it is better to prevent the condition
from developing instead of trying to manage it after it has already occurred.
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Thyroid Disorders
Over-activity or underactivity of certain glands causes endocrine problems
and potentially debilitating symptoms that can lead to gastrointestinal
issues. The thyroid gland, which releases hormones that regulate body
metabolism, temperature, and heart rate, may not function properly if there
are complications associated with the gland itself or with the portion of the
brain that stimulates its release of hormones. Hyperthyroidism develops
when the thyroid is overactive and produces too many hormones; it
normally results in a rapid heart rate, increased appetite, shakiness, and
anxiety, but it can also lead to motility problems.
A commonly seen gastrointestinal motility disorder associated with
hyperthyroidism is diarrhea, as the transit times in the intestine are
increased due to the effects of the hormones. Diarrhea may also be more
likely to develop in hyperthyroid patients when there are abnormal rates of
intestinal secretions, whether because they are secreted in too high of
quantities or if there are not enough.9 Patients with hyperthyroidism may
suffer from other gastrointestinal symptoms as well, including steatorrhea,
which describes increased amounts of fat within the stool, epigastric pain,
abdominal fullness, and dyspepsia.
In contrast to hyperthyroidism, low levels of thyroid hormone result in
hypothyroidism, which has also been shown to cause gastrointestinal
motility disorders. Hypothyroidism is associated with slowing of many
metabolic processes, and affected patients often struggle with symptoms of
weight gain, fatigue, muscle and joint pain, depression, and increased
sensitivity to cold. One of the most common GI complaints among patients
with hypothyroidism is constipation, as colonic motility slows with a decrease
in thyroid hormone production. Hypothyroidism is also responsible for a
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number of other GI symptoms, which may include delayed gastric emptying
and bezoar formation, reflux esophagitis, and abdominal distention.
The gastrointestinal changes that develop as a result of hypothyroidism
often occur because the bowel wall becomes thickened and sometimes
dilated. There may also be cellular changes that occur in the bowel mucosa,
including an increase in mucopolysaccharides, which can affect metabolism.
This may relate to an explanation of why the patient with hypothyroidism is
more likely to have slower gut motility and constipation.
Treatment of gastrointestinal motility problems in relation to hyper- or
hypothyroidism involves controlling these underlying conditions. The initial
goal is to achieve normal levels of thyroid hormone, typically through
medications or procedures, in order to regulate metabolic processes within
the body and to diminish symptoms. Hyperthyroidism is often controlled
through radioactive iodine, which damages some of the thyroid cells so that
they stop overproducing thyroid hormones, or surgery to remove part of the
thyroid gland. Alternatively, hypothyroidism is most often controlled through
prescription synthetic thyroid hormone replacement to bring hormone levels
back to within normal limits. Often, prescription medication is administered
lifelong, as discontinuing the drugs will usually cause the body to revert back
to a state of hypothyroidism and continued problems with low hormone
levels.
Patients who suffer from thyroid abnormalities may not initially develop
gastrointestinal motility problems. These difficulties may occur later in the
course of thyroid disease, particularly when there is poor control over
thyroid hormone secretion and poor management of thyroid disease. It is
therefore important to be aware of the gastrointestinal effects that can
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develop as a result of abnormal thyroid production so that when symptoms
of motility problems do develop, the healthcare provider and the patient can
be prepared for a possible diagnosis and for treatment of the condition.
Adrenal Gland Disorders
The adrenal glands are another set
of endocrine glands that can cause
various health problems when they
are not functioning appropriately.
The adrenal glands sit on top of the
kidneys in the lower back and are
responsible for secreting hormones
that help the body respond to stress.
There are various types of adrenal
gland disorders, most of which
produce varying symptoms, and
gastrointestinal motility problems
may be included in some of these symptoms. Some of the more common
types of adrenal disorders include Cushing’s syndrome, pituitary tumors,
pheochromocytoma, and Addison’s disease.
Patients with Addison’s disease tend to develop gastrointestinal symptoms
related to nausea, vomiting, and anorexia; the symptoms seem to worsen as
the condition progresses. Addison’s disease is most often caused by an
autoimmune disorder in which the body attacks its own tissues and causes
the adrenal glands to work inappropriately. Eventually, the damage from the
autoimmune system destroys the adrenal cortex, which is the outer
protective covering to the adrenal glands. The patient is no longer able to
secrete sufficient amounts of cortisol and aldosterone needed to regulate
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various body functions, including weight control, the ability to fight infection,
and control of heart rate and blood pressure. For this reason, Addison’s
disease is also known as hypocortisolism.
Addison’s disease is difficult to diagnose because many of the symptoms,
whether they are gastrointestinal in nature or not, are non-specific and could
be attributed to any number of medical conditions. General symptoms of
Addison’s disease include hyperpigmentation of the skin and mucous
membranes, weakness, fatigue, poor appetite, and weight loss, as well as
joint pain, a heightened sense of smell, hypoglycemia, myalgia, and muscle
paralysis. Addison’s disease typically develops as a result of autoimmune
adrenocortical insufficiency; and, because over 80 percent of cases are
related to autoimmune adrenal damage, Addison’s may be seen in
association with some other types of autoimmune diseases that affect the GI
tract, including celiac disease, type 1 diabetes, Hashimoto thyroiditis,
pernicious anemia, and biliary cirrhosis.14
Management of Addison’s disease improves the likelihood of controlling GI
motility problems that develop as a result of the condition. Treatment
involves correcting the levels of hormones through hormone replacement
therapy; this includes administration of corticosteroids and androgen
replacement therapy, if necessary. Treatment with corticosteroids may
resolve some of the GI symptoms as well as many of the other symptoms of
the condition. Symptoms develop due to hormonal imbalance; the hormones
secreted by the adrenal glands are involved with regulation of the body’s
inflammatory responses, proper balance of electrolytes, and sexual
development. With hormone replacement and medications, the affected
patient may find relief from many symptoms where hormone imbalance is
the root cause. For example, a patient with an imbalance in sodium levels in
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the body may struggle with symptoms of diarrhea and dyspepsia. By
replacing mineralocorticoid levels that would otherwise be out of balance
with Addison’s disease, the body would be more likely to regulate sodium
and potassium levels, potentially diminishing the risk of diarrhea from the
condition.
Another endocrine condition that affects the adrenal glands and that is
sometimes confused with Addison’s disease is Cushing syndrome. Cushing
syndrome, also called hypercortisolism, develops when the adrenal glands
create too much cortisol; one of the most common causes of this condition is
when an individual takes in too many steroid medications, however, it can
also develop from such conditions as adrenal tumors or excess production of
adrenocorticotropin hormone (ACTH), which normally stimulates the adrenal
glands to produce cortisol.15
Excess cortisol production can have a number of effects on the
gastrointestinal system. Cortisol is sometimes referred to as the “stress
hormone” in that the body may produce greater amounts in response to
stress. Cortisol can also impact an individual’s nutritional status, as it
normally regulates energy by selecting the correct amount of carbohydrates,
fats, or proteins to meet the physiological needs of the body.16 Elevated
levels of cortisol, as seen with Cushing syndrome, can lead to elevated blood
glucose levels, weight gain, increased appetite, and cravings for high-calorie
foods. Elevated cortisol levels also affect the sympathetic nervous system,
which can affect GI function and can cause uncomfortable symptoms in the
patient with Cushing syndrome. When the person eats a meal, his or her GI
system responds poorly due to elevated cortisol levels and is more likely to
lead to suffering from problems with digestion, nausea, vomiting,
indigestion, and mucosal inflammation.
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Control of gastrointestinal motility symptoms associated with Cushing
syndrome is achieved by managing the symptoms when they occur and by
treating the syndrome to regulate cortisol levels. The type of treatment
needed depends on the cause of Cushing syndrome; for instance, if it
develops from excess corticosteroid use, the patient should be assisted to
decrease or eliminate use of this drug to avoid further deleterious effects.
Nursing interventions are focused on helping the patient to perform self-care
measures, keeping the patient safe when symptoms develop, and helping
the patient to control stress levels.
Irritable Bowel Syndrome
One of the more common functional gastrointestinal motility disorders,
irritable bowel syndrome (IBS) is thought to affect up to 10 percent of the
population of the United States.17 Irritable bowel syndrome is considered a
functional gastrointestinal disorder because its symptoms develop from
abnormal functioning of the GI tract. Diagnosis of IBS can be difficult and
clinicians are sometimes perplexed by its expression and manifestations, as
imaging studies and laboratory results tend to be completely normal in
affected patients.
A patient with IBS may suffer from severe symptoms but upon examination,
there is no sign of disease or any change in the colon. Experts have
determined that there are several factors that play a role in the development
of IBS, and control of some of these factors may help to control the negative
symptoms associated with this complex condition. Irritable bowel syndrome
has also been referred to as colitis, spastic colon, and functional bowel
disease,18 although these terms are often designated by the general public
and are not entirely accurate to the disease process that occurs with IBS.
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The exact cause of IBS is unclear, but those who develop the disorder often
have several risk factors in common, including increased levels of stress, a
low-fiber diet, recent history of infectious diarrhea, and a history of physical
or sexual abuse. The condition is seen much more often in women when
compared to men, with a 50 percent greater incidence; it is also much more
common among young- and middle-age adults, with most diagnosed cases
occurring before the age of 50 years.19
Irritable bowel syndrome can cause symptoms that predominantly involve
diarrhea or constipation, although some patients suffer from both. It is
classified according to the predominant forms of stool that occur with
symptoms, and may be considered IBS with constipation (IBS-C), IBS with
diarrhea (IBS-D), IBS mixed (IBS-M), or IBS unsubtyped (IBS-U) in which
the stool consistency does not meet the criteria for the other forms of the
condition. The affected patient may also have abdominal bloating, cramping
pain, flatulence, mucus in the stool, and the feeling of incomplete emptying
after having a bowel movement.
In addition to GI symptoms, IBS often causes other symptoms that seem
unrelated to gastrointestinal functioning, including anxiety, depression,
headache, and fatigue. The severity of symptoms may range between mild
gastrointestinal disturbances to severe enough symptoms that impact the
patient’s ability to participate in normal activities and thereby affects his or
her overall quality of life.
There are various theories as to the potential cause of IBS; experts have
proposed that IBS symptoms develop due to altered levels of serotonin in
the GI tract, increased release of inflammatory mediators, abnormal muscle
contractions in the GI tract, visceral hypersensitivity, and brain-gut
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dysfunction.18,19 Some patients with IBS may have sensitivities to
stimulation in which the muscles of the large intestine react abnormally and
either increase peristalsis to propel stool through the colon more quickly, or
to slow it down to cause constipation. Visceral hypersensitivity refers to a
situation in which the nerves of the intestinal tract are very easily stimulated
and can send pain messages to the brain in response to potentially mild
environmental triggers. When this occurs, the body may further stimulate
the involuntary muscles of the GI tract to increase peristalsis; the patient
may also be more likely to experience abdominal pain and discomfort in
response to triggers.
Brain-gut dysfunction describes a condition in which a patient may
experience gastrointestinal symptoms in response to emotions and
psychological distress. Feelings of distress may trigger further symptoms of
IBS, causing greater intensity of GI symptoms if the patient is suffering from
psychological symptoms. Unfortunately for some, there are certain
environmental triggers that are more likely to cause symptom exacerbation
in IBS. Persons with IBS have stated that they have been more likely to
experience symptoms after eating a meal containing certain foods, such as
greasy, fried, or spicy foods; and, after drinking alcohol or beverages
containing caffeine, or when experiencing distressing situations or feeling
stress because of traumatic events. Many women with IBS say that they are
more likely to experience symptoms during the days surrounding their
menstrual periods.
Irritable bowel syndrome may be diagnosed after consideration of the Rome
III Diagnostic Criteria, a set of measurements developed by research teams
of neurogastroenterolgy specialists affiliated with the Rome Foundation for
the diagnosis of functional gastrointestinal disorders. According to the Rome
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III Criteria, IBS is diagnosed when a patient has had symptoms for at least
three months with symptoms involving recurrent abdominal pain and either
improvement in pain after defecation, change in stool frequency at onset, or
change in stool appearance at onset. These symptoms must have occurred
for at least three days per month.19
Other tests are important when diagnosing IBS, as the condition could be
related to another gastrointestinal illness. Irritable bowel syndrome is not
associated with a greater risk of colon cancer, nor does it cause intestinal
bleeding. If a patient has symptoms of intestinal obstruction, bleeding, or
has a fever or significant weight loss, the patient most likely has another GI
illness that is not irritable bowel syndrome. In addition to utilizing the Rome
Criteria, the clinician may check a stool sample, perform a rectal exam, and
check a blood count. There are no specific biomarkers for IBS that would
appear in a stool or serum sample and that would specifically identify IBS
based on physical data alone. Instead, these tests are performed to rule out
other conditions that may be the cause of the patient’s symptoms. A
thorough medical history is also important to determine how long the patient
has been experiencing symptoms and whether the symptoms are triggered
by outside events.
Because it is not entirely clear what causes IBS, treatments may vary; they
are usually based on controlling symptoms and preventing patient
complications that can develop as a result of chronic IBS, including
malnutrition, chronic pain, social isolation, dehydration, and electrolyte
imbalance. Drug therapy is a common method of treatment and may include
administration of medications to relieve cramping pain and increased
peristalsis that causes diarrhea, including antidiarrheal medications, anti-gas
formulations, fiber supplements, and anticholinergic drugs that relax the
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smooth muscles of the intestines. Alternatively, a patient who struggles with
IBS-C type may need medications and diet therapy that manages and
prevents hard stools from forming, such as osmotic laxatives, stool
softeners, and bulking agents. The type of drug administered is based on the
patient’s predominant form of IBS.
There are also two different drugs that have been approved specifically for
the management of IBS. Lubiprostone (Amitiza®) is used for IBS that
involves predominant symptoms of constipation; it improves symptoms by
increasing fluid to the colon where it would otherwise be absorbed.
Increased fluid in the large intestine prevents the formation of hard stools
that are difficult to pass, as associated with constipation. Lubiprostone is
only approved for use in women. Alosetron (Lotronex®) is a second drug
that has been approved specifically for IBS treatment. This drug is more
commonly prescribed for patients who suffer from IBS with predominant
diarrhea symptoms; it works by slowing peristalsis in the large intestine by
relaxing the intestinal tract. This ultimately slows the passage of stool to
prevent diarrhea and to enhance normal stool formation and excretion.17
For some patients, it has been thought that IBS is caused by food allergies
in which the patient develops severe gastrointestinal symptoms as a type of
allergic response. When food allergies are suspected, the patient may need
to follow an elimination diet in which the potential allergen is avoided for a
certain period of time to see if symptoms abate. An elimination diet may
take quite a while for results, as the patient may need to eliminate more
than one kind of food, avoid it for several weeks to see if symptoms change,
and then reintroduce the food slowly. If there is no change, the patient then
eliminates another potential source of allergy and starts the process again.
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For many, following a healthy diet and eating small meals is enough to
control symptoms. Other lifestyle interventions that the nurse could promote
include recognizing potential triggers and avoiding them, controlling stress
and overly taxing activities, increasing activity levels, and participating in
exercise.
Antidepressants have been shown to be beneficial for patients with IBS when
they are used off label to manage symptoms. Antidepressants are helpful
among patients with IBS that is otherwise unresponsive to other medications
and lifestyle interventions. Tricyclic antidepressants (TCAs) and selective
serotonin reuptake inhibitors (SSRIs) are the most common types of
antidepressants prescribed in these situations. Because IBS has been
associated with greater levels of anxiety and depression among some
patients who develop the condition, prescription antidepressants can help to
control many psychological symptoms that develop as a result. When further
considering the brain-gut dysfunction theory, management of emotional
stressors and depression could also physically alter the body’s
gastrointestinal response to psychological factors.
Tricyclic antidepressants have also been shown to decrease transit times in
the gastrointestinal tract, which could potentially control symptoms of
diarrhea. They are also somewhat effective in relieving abdominal pain
associated with IBS. Some types of TCAs that may be prescribed include
desipramine (Norpramin®) and nortriptyline (Pamelor®). Selective
serotonin reuptake inhibitors are more likely to increase GI motility and may
be more appropriate for patients who suffer from predominant constipation.
Some types of SSRIs that are prescribed in these cases include fluoxetine
(Prozac®) and citalopram (Celexa®).19
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Patients with IBS have also been helped with controlling stress through
nonpharmacological interventions, including cognitive-behavioral therapy
(CBT) and gut-directed hypnotherapy. These interventions and others,
including stress management techniques of relaxation therapy,
aromatherapy, massage, and yoga may be included as part of treatment for
IBS. Because the symptoms of IBS have been associated with some
psychological manifestations as well, it is important to not only manage the
physical GI symptoms that develop with this condition, but to also consider
the mental health of the patient.
Fecal Incontinence
Although less common than urinary incontinence, fecal incontinence is
thought to affect up to 20 percent of older adults living in the community
and up to 50 percent of long-term care residents.26 Fecal incontinence is
described as the unintentional loss of solid or liquid stool. Involuntary loss of
gas or liquid stool is known as minor incontinence whereas loss of solid stool
is referred to as major incontinence. The condition most often occurs due to
loss of control of the anal sphincter, which is normally responsible for
tightening the sphincter and maintaining stool within the rectum until the
person is ready to defecate. Without adequate sphincter control, the
individual may have little to no control over stool evacuation. Loss of anal
sphincter control may occur due to trauma or injury to the pelvis, from
medical conditions that affect nerve function in the area, or due to chronic
GI conditions that affect stool characteristics and bowel frequency, such as
Crohn’s disease.
Furthermore, fecal incontinence could develop through other conditions that
are unrelated to damage to the anal sphincter. Instead, the affected patient
could develop difficulties with controlling sphincter tone to keep it closed in
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enough time to retain stool. Neurologic damage from some chronic
conditions causes the patient to lose the normal awareness of needing to
defecate and may lead to incontinence of stool because of decreased
sensation. Examples of conditions that may lead to this damage include
uncontrolled diabetes or multiple sclerosis.28 Alternatively, fecal impaction
that develops from constipation could also contribute to fecal incontinence in
a condition known as overflow incontinence. If the patient develops a stool
impaction in the lower GI tract, he or she may actually leak stool around the
impaction when the anal sphincter relaxes to the point that stool can escape.
Fecal incontinence may be considered either an acute or chronic condition. A
person may lose control of defecation during times of acute illness, leading
to incontinence of stool that is often diarrhea. This may or may not occur
more than once and may be settled when the illness or current condition is
resolved. For example, a patient who suffers from a viral infection affecting
the gastrointestinal tract may develop severe and explosive diarrhea and
may suddenly experience cramping that indicates that a bowel movement is
going to occur. The patient may experience fecal incontinence if he or she is
unable to get to the bathroom in time to defecate, but once the viral illness
has resolved and the patient’s stools have returned to normal, he or she
may resume a normal pattern of bowel movements without incontinence.
Alternatively, when a chronic condition develops, the patient may struggle
with fecal incontinence and involuntary loss of stool on an ongoing basis.
The patient may or may not be incontinent of feces with each bowel
movement, but may have a condition that causes incontinence of stool over
a longer period of time that is not resolved despite ongoing medical
management. The patient with chronic incontinence is also at higher risk of
complications associated with involuntary loss of stool, including skin
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irritation and breakdown from repeated contact between the feces and the
skin.
Fecal incontinence is also embarrassing for the affected patient. Uncontrolled
fecal incontinence can lead to feelings of depression and anxiety and the
patient may be more likely to suffer from social isolation if he or she is afraid
to leave the house or attend social functions because of an inability to
control defecation. Although there are statistics about how many people
suffer from fecal incontinence, the actual numbers may be higher since
many who struggle with this condition avoid talking about it and bringing it
to the attention of their healthcare provider because they are too
embarrassed. Management of fecal incontinence depends on whether the
condition is acute or chronic and on the underlying situation that leads to
loss of control. Treatment of the condition typically is through medication
and non-pharmacological measures, surgery, or biofeedback.
When diarrhea is a major cause of incontinence, medications that increase
stool bulk can reduce the risk of leaking liquid stool. Bulking agents,
including fiber supplements, such as methylcellulose or psyllium, are often
used for management of constipation but can be helpful for fecal
incontinence as well. Bulking agents prevent diarrhea and, by adding more
bulk to the stool, they may help the patient to retain formed stool within the
rectum until there is a chance to voluntarily pass it. Increasing dietary fiber
will have a similar affect. The nurse may ask patients about their diet history
and calculate daily fiber intake, counseling patients to increase fiber slowly,
day-by-day to reach a high-fiber diet. The soluble and insoluble fiber in
some foods also provides bulk for stools, potentially reducing instances of
diarrhea and fecal incontinence.
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Some medications that are given to control diarrhea may also be helpful in
cases of fecal incontinence. These are available without a prescription, but
the affected patient should consult with a healthcare provider before using
them to determine the best course of action for control of incontinence.
Antidiarrheal medications available without a prescription are either
loperamide (Lomotil®), which works by slowing down the rate of intestinal
motility, or bismuth subsalicylate (Pepto Bismol®), which alters fluid levels
in the intestine to prevent liquid stool.29 These medications are
recommended for short-term use and should not be used for someone with
chronic incontinence as the main form of treatment. They can, however, be
taken when someone experiences occasional stool incontinence on a shortterm basis, such as when suffering from a viral illness that causes diarrhea.
When overflow incontinence develops, as when the patient has fecal
impaction and leaks stool, he or she may benefit from laxatives or stool
softeners. These drugs should be used with caution, however, as they could
worsen diarrhea, and the patient may be even less likely to control stool.
There are various types of laxatives and stool softeners available, which are
designed to change fluid content in the large intestine or the consistency of
stool to make it easier to pass. Normally reserved for cases of constipation,
these drugs can be helpful for some patients with incontinence but a
healthcare provider should direct drug use.
Other non-pharmacological interventions may also be employed that either
prevent diarrhea and stool incontinence or that manage stool incontinence
when it occurs. Examples of changes that could be made to manage stool
incontinence include the use of fecal collection devices, such as pouches, and
bowel retraining programs. A pouch may be placed around the anal opening,
and secured to the skin by an adhesive, to collect stool that leaks
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involuntarily. The pouch is a good idea for patients who are frequently
incontinent of stool, as it saves them from repeated accidents and stool loss.
Alternatively, if a patient is very active and involved in many activities, may
the pouch may not be preferred since it can be bulky and difficult to contain
within clothing. The end of the pouch often has an opening that allows the
stool to be drained out without changing the bag. A person who is immobile
and cannot use a collection device may utilize disposable underpads and
undergarments designed for adults to collect stool, which can be changed
quickly and replaced with a clean, dry garment to promote skin integrity.
Bowel retraining programs are behavioral programs that are designed for
those who have difficulties with fecal incontinence. These types of programs
are developed to help affected persons re-establish control over their bowel
habits. A bowel-training program may not work for everyone but it can help
to develop a routine that some people may benefit from related to building
on necessary skills to recognize the need to defecate and to control their
bowel movements to avoid being incontinent of stool.
A bowel-retraining program first addresses stool consistency. If the patient
is suffering from diarrhea or overflow incontinence because of constipation
and bowel impaction, he or she may need medication to change stool
consistency and to provide bulk.29 After this has been addressed, the
program then focuses on establishing a schedule for elimination in which the
patient attempts to defecate at certain times on a schedule. Finally, part of
bowel retraining includes understanding how to stimulate the rectum to
empty of stool. This may be done through interventions such as laxatives or
enemas; however, the method typically varies between patients depending
on their conditions and success to eliminate stool.
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Biofeedback is a second method of controlling fecal incontinence. With
biofeedback, the patient learns to consciously contract the muscles of the
rectum that control defecation. The healthcare provider may perform
biofeedback during a procedure known as anorectal manometry, which
involves insertion of a balloon past the anal sphincter and inflating the
balloon inside the rectal vault while a manometer records the sphincter’s
response. The patient then learns through this method of biofeedback how
much pressure is needed to apply to the sphincter muscles to retain stool
within the rectum and to avoid incontinence. Biofeedback is a non-invasive
method of re-training some of the muscles in the lower pelvis to control
stool elimination; however, it has not been shown to be successful for
everyone who has difficulties with stool incontinence.
Whether or not to choose biofeedback, as a method of controlling
incontinence, is decided on a case-by-case basis, depending on the patient’s
condition. Studies have shown, though, that when used in combination with
other methods of managing fecal incontinence, biofeedback can be very
helpful for some patients. A study in the Scandinavian Journal of
Gastroenterology showed that women who combined biofeedback therapy
with use of loperamide and stool-bulking agents showed symptom
improvement in terms of fecal consistency, reduced urgency, and increased
rectal sensory thresholds.31 If possible, the provider working with the patient
in this condition may need to explore more than one idea about the best
method of controlling incontinence, even combining more than one method
to provide adequate treatment.
Surgery may be particularly helpful for people who suffer from fecal
incontinence when the cause is from damage to the anal sphincter. Surgical
procedures have been shown to be successful in up to 80 percent of cases of
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fecal incontinence among women who have suffered damage to the anal
sphincter from torn tissue during childbirth.30 Surgery in these cases
involves using a piece of a muscle from another part of the body and
connecting it to the rectum to replace the muscle of the anal sphincter.
Alternatively, a synthetic option is to replace the anal sphincter with a cuff
that can be inflated and deflated as needed to have a bowel movement.
When a patient continues to suffer from fecal incontinence and is unable to
control bowel movements, and the condition is unable to be corrected by
surgical muscle replacement, a colostomy may be yet another option for
management of the condition. A colostomy involves surgically attaching the
end of the colon to the abdominal wall so that feces are collected in a bag
outside of the body instead of being routed through the rectum and
eliminated through the anus. Surgery for colostomy placement is a
complicated procedure and this type of surgery is typically only reserved for
those that have not responded to any other therapy or treatment.
Constipation
Constipation is a common problem that may develop after use of various
drugs, it may occur with fluid loss or after eating certain foods, or it can be a
chronic condition that develops as a result of increasing age or chronic
disease. Constipation describes a situation in which a person has difficulty
with defecation because stool in the large intestine has become dry or
colonic motility has slowed to the point that it takes much longer for feces to
reach the rectum. As stool passes through the colon, it is eventually held in
the rectum before being eliminated. When stool remains in the rectum for a
longer period, the person can develop constipation, which makes feces
difficult to pass due to it being hard and dry.
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Constipation is classified as being either a primary or secondary condition.
Primary constipation is also referred to as functional constipation in that
symptoms are typically ongoing and are frequently a routine part of the
person’s life. Alternatively, secondary constipation develops as a result of a
condition or illness that affects the person’s ability to form stool and pass it
in a normal manner. Primary constipation is further divided into three subgroups: 24
1. Normal transit constipation, in which the person is able to pass
stool at a normal rate, but stools are very hard and difficult to pass.
2. Slow transit constipation, in which the rate at which a person
passes stool is abnormally long, as it takes much longer for the
stool to pass through the large intestine and into the rectum for
defecation.
3. Pelvic floor dysfunction, which affects the person’s ability to pass
stool at all, regardless of transit time or stool consistency. Stool is
more likely to be retained in the rectum, causing feelings of fullness
and incomplete evacuation.
Assessment of the patient involves taking the medical history information
about current or previous illnesses, changes in dietary and lifestyle habits,
and changes noted with the toileting routine. The nurse should consider
whether the patient has noted changes in bowel habits and how long such
changes have been happening, and, if the patient has had to utilize manual
maneuvers to eliminate stool, pain with defecation, and fecal incontinence.
There may be psychosocial factors present that could also contribute to the
patient’s constipation through changes in diet and lifestyle; and,
psychosocial symptoms to consider include the existence of depression,
anxiety, or cognitive changes.
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According to the Rome III Criteria for Functional Gastrointestinal Disorders,
a diagnosis of functional constipation is made when a patient experiences
two or more of the following:

Straining with at least 25 percent of defecations

Passing lumpy or hard stools with each defecation at least 25
percent of the time

Experiencing the feeling of incomplete evacuation for at least 25
percent of the time

Sensing an obstruction or blockage that prevents the passage of
stool for at least 25 percent of evacuations

Using manual maneuvers, such as pelvic floor support, in at least
25 percent of defecations

Having fewer than three defecations per week
Although the diagnostic criteria include defecations fewer than three times
per week, there is great variation with what is considered to be a normal
number of defecations for the average person.23 Some healthcare providers
consider whether the patient has experienced fewer defecations than is
normal for the patient when considering constipation, instead of attaching a
specific number to what is considered normal for the general population.
Secondary constipation can develop from a number of situations; the rate of
stool passage, the length of time stool remains in the rectum, and the
amount of water absorbed can all be affected by situations related to a
medical illness, use of certain medications, or psychological distress that
further contribute to constipation. Common conditions that typically lead to
constipation include:22
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
Pain in the rectum or the anus:
Hemorrhoids and anal fissures can cause pain while having a bowel
movement. The patient may avoid passing stool for as long as
possible to avoid the pain. This actually further aggravates the
situation, as the stool becomes hard and dry from holding it in,
which makes it even more difficult and painful to pass.

Medications:
Certain drugs, particularly opioid medications, contribute to
constipation by decreasing motility of the colon.

Dietary influence:
A diet low in fiber and fluids may contribute to constipation when
there is less bulk and stools become dry.

Medical conditions:
Injuries or illnesses that affect the patient’s ability to sense the
need for a bowel movement, such as diabetes or spinal injury, can
delay defecation and the stool remains in the rectum longer than
needed.

Advancing age:
As a person ages, there is more likelihood to develop constipation
because of impaired mobility, muscle weakness, an increase in the
average number of medications that can affect bowel motility, and
dietary changes that affect stool bulk. Despite the increase in cases
of constipation among older adults, constipation is not considered a
normal part of aging.
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
Obstruction:
At times, partial obstruction of the large intestine, such as through
polyps or colon cancer, can make passage of feces difficult and the
stool becomes hard and dry.
Upon assessment of the patient with constipation, the healthcare provider
should note any abdominal distention or the appearance of abdominal
masses, rectal hemorrhoids, signs of dehydration or anemia, and
characteristics of bowel sounds. The nurse should also assess for any other
factors in the patient’s life that may contribute to bowel changes and the
development of constipation, including checking a list of the patient’s current
medications, noting whether the patient has a history of a medical illness
that could contribute to slowed GI motility, determining if the patient has a
history of any other GI disorders, and assessing for any other clinical
manifestations that could cause bowel obstruction and prevent the patient
from passing normal stools.
Because constipation can develop from so many different situations, the
condition is not simply isolated to those with certain medical illnesses or with
predisposing conditions. Instead, constipation can be a widespread problem
that affects people with illness and healthy people alike; it can occur in older
adults, young- or middle-age adults, and children. In addition to difficulty
with passing stools, the patient with constipation may also suffer from
abdominal pain, bloating and distention, a feeling of fullness in the
abdomen, a feeling of pressure in the rectum, and the sensation of
incomplete emptying after defecation. Some people with constipation also
develop other symptoms such as headache, nausea, fever, pain in the
urinary tract, and decreased appetite.
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While pain is often associated with constipation and may be a factor
determined through the patient’s assessment, pain is not always a
characteristic of constipation and should not be held as a deciding factor
during the diagnostic process. A technical review by the American
Gastroenterological Association in the journal Gastroenterology stated that
abdominal pain with constipation is more often associated with a more
significant disorder, such as in the case of irritable bowel syndrome,
predominant type. In contrast to IBS, a patient with constipation related to
other factors will have symptoms of hard, dry stools that are difficult to
pass, but will not necessarily have abdominal pain.88 This is an important
distinction to make when taking a health history with the patient and
performing a physical exam because the information may assist the
healthcare provider with making a more accurate diagnosis of IBS that
involves predominant constipation versus constipation caused by another
situation or condition that could be remedied.
A patient who suffers from constipation is at risk of certain complications
associated with an inability to pass stool in a timely manner. A patient who
already has a condition that affects the cardiac or respiratory systems could
develop complications from constipation if he or she has to strain to have a
bowel movement. Straining to defecate typically involves the Valsalva
maneuver, which entails exhaling against a closed airway, increasing
pressure and force. The maneuver temporarily decreases venous return to
the heart and increases peripheral venous pressure. If a patient has a
history of certain cardiac illnesses such as heart failure, or has previously
suffered a myocardial infarction, repeated episodes of performing the
Valsalva maneuver could put the patient at risk of cardiac rupture or
death.22
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Constipation has the potential to cause various other complications in
affected patients. A patient who suffers from this condition may also be at
risk of fecal impaction when the mass of stool becomes so dry that it cannot
be passed. If stool obstructs the colon, but the person continues to digest
and absorb food, he or she may be unable to pass more stool around the
obstruction. At times, the patient may be incontinent of liquid stool that
leaks around the site of obstruction. This diarrhea that flows past the
obstruction is known as overflow incontinence.
The treatment for constipation is typically related to the cause of the
condition. Management of constipation may be utilized through nonpharmacological interventions or through medications. Non-pharmacological
interventions involve making dietary changes, encouraging activity, and
helping the patient to develop a normal toileting routine. Constipation that
develops from poor diet could be remedied by lifestyle changes alone, in
which the patient increases fiber intake through foods or supplements to
improve stool bulk. The individual in this case would benefit from increasing
fluid intake as well, which will make stool easier to pass and prevent feces
from becoming hard and dry. As a patient increases dietary fiber intake, he
or she should be counseled to increase fluid intake accordingly.
Significantly increasing fiber intake without adjusting fluid intake can cause
symptoms to worsen and the patient may suffer from abdominal pain,
bloating, and flatulence. The patient should also be counseled to slowly
increase fiber intake each day, rather than suddenly jumping up in total
daily fiber. For example, a person who normally consumes 15 g of fiber daily
and who suffers from constipation should not start eating fiber-rich foods to
increase daily fiber to 60 g per day all at once. Instead, the patient should
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be counseled to increase fiber intake by 5 g to 10 g each day to achieve
appropriate amounts and to avoid uncomfortable side effects.
The patient should include a mixture of foods in the diet that contain soluble
and insoluble fiber, both of which can increase stool bulk; additionally,
insoluble fiber helps to prevent excess water absorption in the colon that can
result in stool becoming too dry. Foods that are good sources of soluble
fibers include cereal, nuts, seeds, and fruits. Items that can be included to
increase insoluble fiber include wheat bran, vegetables, and legumes.24
If possible, the patient should increase physical activity to best prevent
constipation. Exercise helps food to move more quickly through the
intestine, preventing slow motility and its associated problems. It is
important to remind patients that if they are increasing activity levels,
particularly when taking on an exercise routine, they should continue to
drink fluids and increase fluid intake around the time of activity, as increased
exercise could lead to fluid loss through sweat and could further perpetuate
constipation.
It may be helpful for some patients with constipation to develop a toileting
routine and to maintain good habits when using the bathroom. The person
should be taught to try to defecate as soon as the urge is felt, rather than
trying to hold stool in the rectum, which can further contribute to uptake of
water in the colon and dry stools. The patient may also be taught pelvic floor
exercises to strengthen the muscles used for defecation and to sit in a
position that facilitates easier defecation. If the patient has an issue with
using a toilet or does not want to try to eliminate stool because of pain or
discomfort, the nurse may need to help the patient find strategies to
increase efforts at elimination. For example, a patient may avoid trying to
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defecate because of hemorrhoids; and, the nurse may help the patient by
treating the hemorrhoids to alleviate discomfort so that the patient will not
feel the need to avoid defecation because of pain.
Pharmacological interventions for the treatment of constipation include
medications designed to stimulate bowel motility and to relieve the patient’s
constipation through the passage of stool. Medications administered for
constipation are often given if the non-pharmacological interventions have
been unsuccessful or if the patient has a condition that prevents an ability to
pass stool, leading to further risk of constipation. Pharmacological
interventions include medications such as laxatives, stool softeners, enemas,
and oral medications that alter fluid absorption in the large intestine to
manage constipation.
Whether it is an acute case of constipation that is easily resolved with
medications or whether a patient suffers from chronic constipation as a
result of illness or disease, constipation can be difficult to manage and to
accept for some people. The potential for complications associated with this
condition make it even more important of a situation to be remedied to help
the affected patient achieve normal defecation once again. Fortunately,
because constipation is so prevalent, there are many options for treatment
and healthcare providers have discovered numerous ways to prevent
constipation and to manage it if it does occur.
Genetic Factors
The role of genetics may be overlooked when considering some
gastrointestinal motility problems. When dysmotility can be explained by a
chronic illness or its development occurs as a result of medication use or
lifestyle factors, healthcare providers may be less likely to consider whether
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the condition is supported by any genetic factors. There are some cases,
however, when it is not entirely clear how or why a patient develops a GI
motility problem, which may cause clinicians and researchers to dig deeper
into genetic factors that contribute to development of the disease.
There is evidence that suggests there are some genetic factors that
contribute to functional gastrointestinal disorders. These disorders are
classified as conditions in which symptoms are recurring and persistent, and
they typically develop because of abnormal functioning in the GI tract.
However, functional GI disorders can vary extensively in terms of their
causes and manifestations. For instance, irritable bowel syndrome,
functional dyspepsia, and globus (the sensation of something being stuck in
the back of the throat) are all functional GI disorders, yet they have various
characteristics and symptoms. Because of the differences in the types of GI
motility disorders, and of functional motility disorders in particular, they may
be categorized according to the section of the GI tract most commonly
affected.
Esophageal Disorders
Functional gastrointestinal disorders of motility that affect the pharynx and
esophagus include globus, functional chest pain (which is pain that is most
likely caused by esophageal damage and not cardiac problems), functional
heartburn (which is similar to that experienced with gastroesophageal reflux
but without evidence of esophageal sphincter problems), and functional
dysphagia.89
Achalasia, as described earlier, is a motility disorder of the esophagus. It is
characterized by weak or absent esophageal peristalsis, which leads to
difficulties during swallowing with transferring food from the back of the
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throat to the stomach for digestion. Idiopathic achalasia has an unknown
etiology and is also characterized by weakening of the lower esophageal
sphincter (LES), regurgitation of gastric secretions, and non-cardiac chest
pain from heartburn. Achalasia is an example of an upper gastroesophageal
motility disorder that may stem from genetic factors.
It is known that achalasia develops when the affected patient loses neurons
that provide sensation and motor function to the esophagus; the loss of
nerves typically begins in the lower portion of the esophagus and is thought
to be related to nerve cell neurodegeneration.90 Although there is some
understanding about the damage or loss of neurons in the esophagus that
occurs with achalasia, researchers still do not entirely understand why this
occurs and other causes, including genetic factors, continue to be
investigated.
Achalasia has been shown to have familial tendencies in that people who
develop the condition are more likely to have a family member who also
suffers from achalasia. There have been some twin studies that have
examined the incidences of achalasia development between twin siblings,
but these results are still inconclusive. Still, research has confirmed that
there is some amount of familial connection in the development of achalasia
and that affected patients should be aware of the possibility that the
condition may also develop among family members. Furthermore, there are
some genetic syndromes in which achalasia is more likely to develop among
affected patients, for example, persons with Down syndrome are more likely
to have achalasia than the general public; and, the swallowing disorder is
typically manifested just after birth in these situations.90
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Sarnelli, et al., in their work published in the World Journal of
Gastrointestinal Pathophysiology, investigated specific genes that may
contribute to the development of achalasia among certain patients.
Inflammatory-based neurodegeneration of nerve cells affecting the
esophagus is more prevalent among neurons that contain nitric oxide (NO).
Nitric oxide is produced in the body, and, it is a molecule that allows for
greater communication through the nervous system and between tissues.
The production of nitric oxide is genetically regulated. The researchers in the
study determined that achalasia may be more likely to occur in some
patients who express the longer form of a certain gene, as this gene may be
involved in greater amounts of nitric oxide production.90 This concept could
more likely explain some of the breakdown of certain nerves in the lower
esophageal tract associated with the condition.
Clearly, it is important that research continue to find genetic influences and
those other factors that contribute to development of certain conditions such
as achalasia. While it is important to understand familial influences in the
development of the condition in order to better prepare affected patients,
more research is needed to find the connection as to why certain neurons
are destroyed in this condition.
Stomach and Small Intestine Disorders
Disorders of motility affecting the stomach and small intestine can include
any number of conditions, including gastroparesis, functional dyspepsia,
functional vomiting, and aerophagia. As with disorders affecting the pharynx
and esophagus, it is difficult to define the exact etiology of why some of
these conditions occur. Although damage to the nerves or muscles of the GI
tract is typically involved, there may also be familial or genetic factors that
predispose some people to increased risks of developing these conditions.
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Functional dyspepsia is an example of a gastrointestinal motility disorder
that causes recurrent pain and epigastric discomfort, as well as abdominal
distention and a feeling of fullness in the abdomen. It may develop from a
number of acute or chronic conditions, including Helicobacter pylori infection
in the gut, increased pain sensitivity; or psychological factors, such as
increased anxiety or depression.91 Unlike simple indigestion that follows a
meal, symptoms of functional dyspepsia are recurrent and often require
lifestyle changes and medication to control the symptoms.
Another potential cause of functional dyspepsia is damage or other problems
with the nerves and muscles that control the GI tract. When damage occurs
to these structures, the affected person is more likely to experience nausea,
vomiting, and abdominal fullness if the stomach empties more slowly than
normal. The damage done to muscles and nerves of the stomach and small
intestine that causes functional dyspepsia could be related to chronic illness,
such as in cases of diabetes; however, there are some conditions where the
patient may suffer from symptoms of dyspepsia but the cause is unknown.
Researchers continue to look for genetic factors that may explain why
damage sometimes occurs in this area.
There is some evidence that indicates that functional dyspepsia may be an
inherited trait and is more likely to occur within families. Studies have shown
that patients with functional dyspepsia are more likely to have family
members also affected by the condition. A review by Yarandi and Christie in
Gastroenterology Research and Practice discussed the impact of genetic
factors on the development of functional dyspepsia, stating that certain
genes that are more likely to activate G-proteins in the GI system may lead
to dysfunction of the motor neurons in the intestinal tract. G-proteins are
cellular membrane receptors; if they do not work properly, there is potential
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for some communication breakdown between nerve signals. Some people
have certain genes that activate these G-proteins, which can ultimately
cause dysfunction of receptors that control the muscles and nerves of the GI
tract.92
While research continues to investigate the probability of specific genes that
contribute to damage in the GI tract and cause functional motility disorders,
there are well-known factors that also can cause symptoms of dyspepsia.
While most people are unaware if they have a specific gene that contributes
to dyspepsia symptoms, they can still learn more about the symptoms of GI
dysfunction and understand whether family members are affected by similar
symptoms, which may be a better predictor of health.
Large Intestine Disorders
Functional disorders affecting the large intestine can vary from irritable
bowel syndrome, functional constipation, functional diarrhea, and fecal
incontinence to those that are more often associated with disorders of the
rectum and anus, including functional anorectal pain and dyssynergic
defecation.89 There are some genetic factors that play a role in the
development of fecal incontinence. A person with a parent who suffers from
fecal incontinence is at higher risk of developing the condition. Twin studies
have shown similar results in that someone who has a twin who suffers from
fecal incontinence is at greater risk of developing fecal incontinence as well.
Rates are higher between monozygotic twins when compared to dizygotic
twins.93
Similar to other types of functional motility disorders, conditions affecting
the colon and rectum that cause changes in how the GI tract functions can
have obvious causes or their sources may be more obscure. Fecal
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incontinence may often be associated with chronic constipation, resulting in
overflow incontinence when stool leaks out of the rectum around a fecal
impaction in the lower bowel.
There are a number of risk factors that increase the probability that a person
will develop difficulties with retaining stool. Known risk factors for fecal
incontinence include advancing age, female gender, physical disabilities, and
injury to the nerves affecting the anal sphincter, such as through childbirth.
Some risk factors are environmental and could be prevented while others,
including age and gender, are uncontrollable.
There are some genetic conditions that can also contribute to fecal
incontinence. These conditions may be listed as the cause of stool
incontinence itself and they develop because of genetic factors, thereby
indirectly affecting the risk of fecal incontinence. For example, structural
abnormalities may be present in the rectum because of a congenital
condition present at birth. As a result, the patient may suffer from fecal
incontinence because of an inability to properly retain stool within the
rectum. Additionally, a GI condition such as inflammatory bowel disease, can
also contribute to fecal incontinence because of abnormalities in the anal
sphincter. A person who has a close relative with inflammatory bowel
disease is at higher risk of developing the condition as well because of
familial tendencies.
At times, the cause of colonic motility disorders may be obvious, while in
other cases further research and education is needed to fully understand the
risks and causes of these complex conditions. In some cases, genetic factors
do not play a role in whether a patient will develop symptoms of a disorder;
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alternatively, genes and familial tendencies are a large part of whether
certain patients are at high risk of GI motility problems.
Classification Of Gastrointestinal Motility Disorders
It is well known that there are numerous conditions that can be classified as
being gastrointestinal motility disorders. They may affect various portions of
the GI tract and can cause multiple symptoms that range in severity from
mild discomfort to potentially life-threatening complications. In addition to
the different areas affected and their manifestations, GI motility disorders
may also be classified according to the entities that individually demonstrate
abnormalities within one or more areas of the GI tract and that may be
associated with systemic conditions as contributors to the clinical condition.
Charles Knowles and Professor Joanne Martin, in their work studying slow
transit constipation, defined a classification system of gastrointestinal
motility disorders that categorizes the various causative conditions into
different entities.57,58 A classification system to categorize GI motility
disorders based on demonstrated abnormalities and associated clinical
conditions is a sensible approach to performing diagnostic measures when
managing a patient who suffers from dysmotility symptoms. To classify
motility conditions based on certain entities can further assist the clinician
with identifying a diagnosis and providing appropriate treatment for the
patient’s condition.
Motility of the GI tract is more than muscle movements that propel digestive
tissue through the expanse of the system. Instead, motility is described as a
combination of muscular movements that are controlled by specific nerves;
furthermore, innervation of the GI tract can actually be classified as being
motor innervation and sensory innervation.56 If one type of nerve system is
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damaged, it can impact the other; for example, if a person suffers from
illness that damages sensory innervation of the GI tract, he or she may also
suffer from problems with motor movements because the two types of
nerves that control the gut are closely intertwined.
Knowles-Martin Classification System
Motor disorders that affect motility, whether by producing increased motility
that leads to uncontrollable stool output and abdominal pain, or delayed
motility that slows colonic movement and results in constipation and
bloating, can be classified according to the regions affected, such as the
esophagus, small intestine, or large intestine; and, the clinical condition that
causes each entity and any associated disorder involved that would be
causing symptoms. According to the Knowles-Martin classification system,
entities are grouped into different categories, including well-defined entities
(those that are understood and straightforward), variable dysfunctionsymptom relationship entities, questionable entities, and entities related to
behavioral disorders (those impacted by the individual’s habits and actions).
Well-Defined Entities
Well-defined entities may be further broken down into sub-classifications
that affect the different regions of the GI tract, including the esophagus, the
stomach, the small intestine, and the bowel. Within the esophagus, welldefined entities include excessive acid exposure, esophageal spasms, and
achalasia. Excessive acid exposure is often associated with gastroesophageal
reflux disease (GERD), which is most often diagnosed according to the
pattern of damage it causes to the lining of the esophagus. However, GERD
can also be identified because of its causative conditions, such as poor
control in the lower esophageal sphincter, which leads to subsequent acid
reflux and tissue damage.
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Achalasia, which results in poor motility within the esophagus or even lack of
peristalsis entirely, is another example of a well-defined esophageal entity.
The associated motility problems with achalasia also can lead to
regurgitation of food and liquids from the stomach and damage to the tissue
lining of the esophagus. Both achalasia and GERD can occur from damage to
the nerves that affect the esophagus, leading to poor motor control and
dysmotility. Systemic diseases often contribute to nerve damage that
ultimately affects motility; for example, damage from scleroderma may
contribute to loss of muscle tone in the intestinal tract. Scleroderma is a
connective tissue disorder that results in deposits of collagen building up
between smooth muscle fibers.68 According to the Scleroderma Foundation,
the esophagus is the area where most patients with scleroderma suffer from
intestinal motility problems, including symptoms of GERD, and weakening of
esophageal muscles that result in poor peristalsis and increased damage
from regurgitation.59 Other systemic diseases that may contribute to
conditions classified as well-defined entities of the esophagus include
diabetes, enteric neuropathy, and Chagas disease, which is caused by
parasitic infection.
Well-defined abnormalities that specifically impact the stomach and small
intestine involve accelerated gastric emptying and abnormal contractile
activity.56 These occurrences are most often demonstrated as clinical entities
of dumping syndrome and intestinal pseudo-obstruction. As previously
stated, dumping syndrome is defined as rapid gastric emptying, in which
food leaves the stomach at a faster rate than normal and is quickly
deposited into the small intestine. The patient often suffers from symptoms
such as diarrhea, flushing, sweating, heart palpitations, and abdominal
cramping within a few minutes after a meal. Dumping syndrome is not the
same as dyspepsia or indigestion; it is classified as an actual disorder of the
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stomach related to changes in hormone secretion and gastric mucosal
secretions.
Pseudo-obstruction often causes symptoms of intestinal obstruction without
identification of any specific blockage. Both pseudo-obstruction and dumping
syndrome can develop from defects in innervation to the stomach and small
intestine, which ultimately affect the rate of food transition between these
areas during the digestive process. Systemic conditions that often lead to
these clinical entities affecting the stomach include surgical procedures to
treat obesity; these include gastric bypass surgery, as well as vagotomy
surgery (which reduces gastric secretions) when part of the vagus nerve is
cut. Other systemic conditions include enteric neuropathy, and in some
cases, scleroderma.
Within the large intestine, well-defined entities include dilated colon with or
without small bowel involvement, absent rectoanal inhibitory reflex, and
delayed colonic transit.56,57 Dilated portions of the colon may be caused by
such conditions as Ogilvie syndrome or megacolon where the affected areas
of bowel may be localized to one region or may be found throughout the
entire large intestine. Ogilvie syndrome is the same condition as pseudoobstruction of the intestine; it develops when the patient suffers from
symptoms of bowel obstruction but there are no lesions present.
Megacolon
There are various types of megacolon that could be the cause of significantly
dilated portions of the bowel, including acute or toxic megacolon, as well as
the chronic form of the condition. Chronic megacolon may be used as a term
to describe the condition when it is congenital, although it can be later
acquired because of illness or toxicity. Megacolon occurs with dilated
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sections of bowel that are not caused by obstruction. Because the lumen of
the colon is enlarged, the body is unable to carry out normal colonic transit
and to pass stool in the usual manner. Megacolon can develop due to
different reasons, which depend on the type present; however, it may be
associated with damage to the nerves that serve the large intestine and the
rectum in that they are inhibited or do not activate the colon to work in a
normal fashion. Systemic conditions associated with both Ogilvie syndrome
and megacolon include enteric neuropathy and enteric myopathy.
Hirschsprung disease is another clinical entity that affects the large intestine.
It too often occurs due to damage of the nerves that serve the colon, which
causes difficulties for the patient to have normal defecation. Hirschsprung
disease is related to a poor or even absent rectoanal inhibitory reflex, which
is the reflex that controls the anal sphincter to retain stool within the rectum
or to pass stool when defecating. The reasons why some people are born
with this type of nerve damage in the large intestine are not clearly known.
Constipation is a well-defined entity affecting the large intestine; slow-transit
constipation (STC) leads to a long period of time for stool to pass through
the colon. The affected patient often has stools that are hard to pass and are
dry, as well as abdominal pain and, at times, fecal incontinence. As with
other entities defined in this section, slow transit constipation is thought to
occur due to damage to the nerves that serve the large intestine. People
with STC may have abnormal amounts of neurotransmitters in the muscular
layer of the colon, which affects the movements and transit of stool through
the large intestine. Other nerve cells affecting the colon may also be
abnormal in their appearance or there may be too few cells, ultimately
affecting the rate of colonic transit.69
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Variable Dysfunction-Symptom Relationship
Entities classified as having variability in the relationship between
dysfunction and symptoms are those in which the connection between the
abnormalities of the clinical entity present and its associated symptoms may
be inconsistent. The basis for whether certain entities are classified in this
category is not entirely clear, but associated entities within the classification
are often related to increased or decreased muscle pressure within the
intestinal tract as well as delays in intestinal transit rates.
Variable dysfunction-symptom entities found in the esophagus include high
and low amplitude peristalsis, low LES pressure, and incomplete relaxation
of the LES.56 All of these conditions result in abnormalities in how the
esophagus or LES function when compared to normal motility. Whether
esophageal peristalsis is of high amplitude or low amplitude often depends
on the type of innervation affected, whether it is inhibitory or excitatory.
Inhibitory innervation of the nerves affecting the esophagus causes
problems with low amplitude peristalsis and low LES pressure.68 These
conditions can further lead to gastroesophageal reflux when the esophagus
is unable to adequately propel food toward the stomach and when the
muscle tone of the LES is sporadic. Stomach acid and undigested food is
then more likely to reflux back into the esophagus, causing damage to the
esophageal mucosa or interior lining.
Within the stomach, delayed gastric emptying occurs as a type of entity
described as having variable dysfunction-symptom relationship. This most
often occurs as a result of gastroparesis associated with diabetes, however,
there are many other systemic conditions that also contribute to the
situation, including scleroderma, enteric neuropathy, a post-vagotomy state,
and enteric myopathy. Abnormalities within the stomach may also lead to
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impaired gastric relaxation, which often develops in conjunction with
esophageal achalasia and results in the dumping of food into the antrum of
the stomach instead of the fundus where it accumulates. Affected patients
typically suffer from symptoms of dyspepsia and indigestion.
The term enteric dysmotility is used to describe motility disorders of the
small intestine. Enteric dysmotility is also a clinical entity included as an
example of the variable dysfunction-symptom relationship in the small
intestine. It is demonstrated as abnormal contractions in the intestinal tract
that typically lead to delays in the transport of food through the small
intestine. There are a number of systemic conditions that can cause enteric
dysmotility within this section of the GI tract. Some examples include
intestinal neuropathy, as with what occurs through poorly controlled
diabetes, as well as Parkinson’s disease, scleroderma, and spinal injury.56
Within the large intestine, low levels of pressure within the anal canal can
lead to fecal incontinence. When pressure is low in this area, the affected
person is unable to control stool output, often because of muscular
weakness. Fecal incontinence results when low pressures in the anal canal
prevent the individual from retaining stool within the rectum and it passes
through the anus with little to no control. The condition may be caused by
spinal injury when the patient suffers a lack of motor control or sensation in
the lower body, or because of nerve damage due to diabetes and
uncontrolled blood glucose levels. Some women who have endured
traumatic childbirth and had nerve injuries due to tearing of perianal tissue
may also suffer from fecal incontinence and low pressure in the anal canal,
causing difficulties with normal defecation and poor control of stool output.
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Questionable Entities
Conditions classified as questionable entities within the gastrointestinal tract
can vary but often seem to be related to accelerated transit of food and fecal
material through the GI system. This may be due to high pressures found in
the GI tract as well as overstimulation of the nerves that affect the GI
system.
An example of a questionable entity associated with the esophagus is
increased pressure found within the lower esophageal sphincter. The
condition may be referred to as hypertensive LES, in which it maintains high
contraction pressures when it opens and closes. Similar to other disorders of
the LES, hypertensive LES occurs when there are changes to the nerves
affecting the esophagus. In this case, there is increased function of the
excitatory nerves feeding the esophagus, such that the neurons are working
at a faster pace and are causing increased muscle contractions within the
LES.68 Hypertensive LES can cause dysphagia, heartburn, non-cardiac chest
pain, and symptoms of GERD.
Tachygastria is a condition that causes high-frequency electrical activity
within the stomach during digestion. The condition most often occurs
because of motion sickness or as nausea during the first trimester of
pregnancy. The motility of the stomach is somewhat controlled through
myoelectrical activity, typically generated by the antrum portion of the
stomach cavity.56 High frequencies of electrical activity in the stomach lead
to tachygastria, which generally causes feelings of nausea, dyspepsia, and
indigestion.
Within the small intestine, food and undigested materials may be
transitioned too quickly through the GI tract because of intestinal hurry,
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which describes the intestine pushing food through at an accelerated rate.
Intestinal hurry may be a type of malabsorption disorder, in which the
affected person is unable to adequately absorb food because it moves too
quickly through the small intestine. The condition most often occurs
following vagotomy surgery that is done to control gastric secretions.
Finally, questionable entities found within the large intestine involve colonic
hurry and accelerated transit of food and fecal matter through this portion of
the GI tract. Colonic hurry is similar to intestinal hurry in that materials
move through the colon too quickly and there is potential for malabsorption
of electrolytes and fluid. The patient may suffer from diarrhea and watery
stools if too little fluid is absorbed during this section of the GI tract. Colonic
hurry can develop because of electrolyte imbalances, certain metabolic
disorders, and following colon surgery that results in short bowel
syndrome.56
Entities Related to Behavioral Disorders
Psychological symptoms and manifestations of mental illness may impact
gastrointestinal motility and function. Although there are often fewer cases
of behavioral disorders that lead to symptoms when compared to some other
well-known clinical entities, it is still important to consider how behavioral
disorders can impact GI function. The behaviors performed that lead to
problems with motility may appear purposeful in that it would seem the
affected patient is choosing to continue in the behaviors; however, when the
disordered behavior occurs as a result of mental illness, the patient may be
unable to control his or her actions.
Behavioral disorders related to the esophagus include rumination and
aerophagia.56 Rumination refers to swallowing food and then regurgitating it;
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the patient may then repeatedly swallow the food or may vomit it. The
condition is most often seen among people who suffer from eating disorders
such as bulimia as a method of purging food to avoid weight gain after
eating or bingeing. Aerophagia is a rare type of disorder in which a person
swallows large amounts of air. The air passes through the esophagus and
enters the stomach but is then regurgitated, causing frequent belching. The
air may also pass into the intestinal tract, where it causes abdominal
bloating and increased flatulence. Some of the symptoms of aerophagia may
be related to GERD; however, the two conditions are distinct due to their
causes.
Wingate, et al. produced a working party report in the Journal of
Gastroenterology and Hepatology that effectively describes the various
entities found within the Knowles-Martin classification system. As part of this
classification, the authors do not identify any entities associated with
behavioral disorders that directly affect the stomach or small intestine.56
Alternatively, there are two conditions that exist as behavioral entities that
affect the large intestine, including impaired pelvic floor relaxation and
avoidance of defecation.
Anismus is a condition in which the patient is unable to control pelvic floor
muscles normally in order to defecate. Normal defecation requires the
patient to relax the muscles of the pelvic floor to expel fecal contents from
the rectum. However, when the patient does not relax these muscles, or
even contracts them instead while trying to defecate, he or she will be
unsuccessful and will end up retaining stool within the rectum.
Additionally, purposely retaining stool within the rectum is a behavioral
activity done to avoid defecation. The reasons behind why a person would
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deliberately keep stool in the body instead of excreting it are varied. Some
people may avoid defecation because of pain while passing stool, such as
when hemorrhoids are present; alternatively, some people choose to avoid
defecation because of muscle weakness with straining, discomfort with the
act of having a bowel movement, or the feeling of an obstruction in the
rectum or the anus. Regardless of the reason, the purposeful holding of stool
within the body leads to constipation when excess fluid is absorbed from
feces held in the rectum. This paradoxically can lead to an even more
difficult time with having a bowel movement if the original reason for
avoiding defecation is because of the effort it takes to pass stool. The clinical
entity in these situations is known as functional fecal retention; it is the
most common behavioral disorder that causes motility problems in the large
intestine, rectum, and anus.56
Diagnosis Of A Gastrointestinal Motility Disorder
Correct diagnosis of a gastrointestinal motility disorder is essential to avoid
unintentionally missing a potentially life-threatening condition or
complication affecting the GI tract. The healthcare provider has several tools
that can be used to identify and analyze problems of dysmotility. Using
imaging studies, laboratory measures, and other forms of diagnostic testing
along with an accurate medical history from the patient, the healthcare
provider is more likely to formulate a diagnosis of a GI motility disorder and
its contributing factors.
Medical History
With the increase in diagnostic capabilities in the form of surgical practices,
imaging techniques, and laboratory measurements, the patient’s account of
his or her health may seem unnecessary as part of diagnosis. However,
taking a patient’s medical history, particularly as it relates to the patient’s
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current symptoms of gastrointestinal motility problems is still important, as
the patient is aware of his or her signs and symptoms and medical condition.
Furthermore, many causes of GI motility disorders have microscopic
sources; for example, when nerve damage causes delays in motility and
problems with intestinal motor function, the exact cause of the condition
cannot be observed without specialized equipment that is able to visualize
affected tissues at the microscopic level. This then requires in-depth
examination and testing to fully diagnose the cause of the patient’s
symptoms.
The patient’s history is therefore important to begin to narrow down the
mechanisms that may be causing GI motility problems, what the individual
has done or not done to manage the condition, and if there are any other
factors affecting the particular situation that can be changed to best control
uncomfortable symptoms. GI motility disorders can produce a number of
symptoms that can range from mild and intermittent to those severe
symptoms significantly affecting bowel function and decreasing the patient’s
quality of life. It cannot be overemphasized that a thorough patient history
at the beginning of the provider-patient relationship, and again periodically
over the course of care as the patient’s condition changes, is very important.
The healthcare provider should obtain information about the patient’s
current condition, including how long the patient has been suffering from GI
motility problems, since the length of time a person has been experiencing
symptoms will help the provider to make a diagnosis. Other information to
gather from the patient may include the symptoms being experienced, and
whether the patient has had any other complications associated with a
condition.
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Upon the initial meeting, the patient may present with symptoms that vary
according to the disorder present. Because the patient most likely will not
know the cause of his or her symptoms upon arrival, it is up to the
healthcare provider to make a diagnosis based on the information presented.
The nurse should ask questions that focus not only on symptoms affecting
the GI system, but also other symptoms that may be impacting different
areas of the body. Starting with the GI system, the nurse should question
the patient about symptoms, including history of pain, changes in stool
output, feelings of pressure or bloating in the abdomen and lower pelvis, and
any changes in toileting practices.
The nurse may also need to assess the patient's abdomen by performing a
focused physical examination. This involves inspection of the abdomen,
auscultation of bowel sounds to determine GI motility, and palpation to
assess for areas of tenderness or abnormalities, such as any abdominal
swelling or solid areas. The nurse should include an assessment of the
patient's dietary intake, including food and fluid consumption, to check for
possible electrolyte imbalance, dehydration, or malnutrition, all of which can
impact GI motility.
In addition to reviewing the patient’s current symptoms, the nurse should
also question the patient about any known GI disorders, such as
gastroesophageal reflux, dyspepsia, constipation, or diarrhea. The nurse
should include questions about any recent illness or injury that may have
affected the GI system. For example, the patient may have recently
recovered from a bout of food borne illness that caused vomiting and
diarrhea, from which he or she has since recovered. Although the patient
may no longer be suffering from acute symptoms of the illness, it could still
have an impact on the patient’s GI motility that leads to long-term
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symptoms that are slower to resolve. Further questions regarding patient
history should include a history of chronic disease, food allergies, and
surgical procedures that would affect the intestine.
Following the gastrointestinal portion of the patient's history, the nurse
should question the patient about other previous illnesses or injuries that
could indirectly lead to GI motility problems. For instance, a patient with
diabetes who has uncontrolled blood glucose levels could develop
neuropathy and gastroparesis to the point that he or she is unable to detect
the need to have a bowel movement. Although it may seem that diabetes
would not directly affect GI motility, it is important to be aware of this
chronic disease as the change in blood glucose levels can cause nerve
damage.
Other conditions that should be included as part of the assessment and
patient history consist of metabolic disorders, a history of injury or infection
to the spinal cord or the central nervous system, history of drug or alcohol
abuse, autoimmune diseases or those affecting the muscles and nerves,
such as lupus or scleroderma; additionally, previous injuries or accidents
that have caused periods of immobility, previous head injuries that have
resulted in changes in level of consciousness, and any neurological or
neurodegenerative disorders, such as Alzheimer's disease, Parkinson's
disease, or multiple sclerosis should be considered.
Imaging Studies
Imaging studies create visual depictions of the internal organs and are very
useful as diagnostic procedures when assessing gastrointestinal motility
dysfunction. Most imaging studies are non-invasive for the patient and the
results can be obtained relatively quickly. Imaging studies may consist of
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general examination of the abdomen to assess for global issues that affect
GI motility, or they could specifically analyze certain structures within the GI
tract. Most imaging studies involve various forms of radiology, such as Xrays, ultrasound, computed tomography, or magnetic resonance imaging.
Endoscopic procedures have been included in this section as well, as they
often involve a combination of radiological imaging with technology to
visualize the interior structures of the GI tract through instruments placed
within the cavity.
Scintigraphy
Scintigraphy utilizes radiographic isotopes that are transferred into the
gastrointestinal tract to assess a patient’s motility and gastric emptying
time. The patient eats a meal, typically scrambled eggs, which contain the
isotopes needed for the study; the most common isotopes used are
technetium and iodine. After consuming the meal, the images are taken to
detect the food as it passes through the patient’s GI tract. The measuring
device that monitors food passage is a scintiscanner, which scans the
isotopes and can follow them through the body. This type of study is often
used when the provider suspects a disorder of GI motility affecting the
stomach and small intestine, including cases of gastroparesis and dumping
syndrome.
A similar form of scintigraphy is a colonic transit test, which checks the
motility of the large intestine. This test also uses radionuclide markers,
which are placed in a capsule that the patient swallows. The person then
goes through normal, everyday activities, including eating normal meals.
The capsule contains 20 radionuclide markers and the patient will have an
abdominal X-ray approximately every 24 hours until each of the markers has
been excreted. The process typically takes about five days.1 Each X-ray can
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visualize the markers and determine at which points they are at in the
intestinal tract. The test analyzes how the markers move through the GI
tract and can determine their rate of motility and whether it is too fast or too
slow. According to the test, if after five days more than 20 percent of the
markers are still present in the patient’s body, the patient is said to have
delayed colonic transit times.47
X-Ray
Radiographic testing through an X-ray takes an image of the gastrointestinal
tract at one specific point in time. The X-ray machine sends energy beams
into the body, which form a picture of the structures inside. It allows the
medical provider to view what is happening in the GI tract through one
snapshot, such as with a single-view X-ray, or it could be more complex and
could involve taking images of the GI tract from various angles or while food
or liquid is passing through the intestines.
A radiographic procedure that looks at the upper portion of the GI tract,
including the esophagus, stomach, and small intestine, is the upper GI series
that can help to diagnose conditions possibly causing GI motility problems in
these segments of the GI tract. The procedure is often referred to as an
upper GI test. The upper GI test requires that the patient drink barium
contrast in order to visualize sections of the GI tract. As the patient drinks
the barium contrast, the medical provider monitors the passage of the fluid
through the esophagus, stomach, and small intestine, since the contrast will
show up on X-ray examination. The process involves taking several X-rays
over time to check where the barium is in the GI tract and how quickly it is
moving through.
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An upper GI test is appropriate for diagnosing dysmotility conditions that
affect the upper gastrointestinal tract, including achalasia, gastroparesis, or
dumping syndrome. The test may also note whether there are obstructions
in the GI tract that can affect food passage; strictures or narrowing, such as
with pyloric stenosis, or whether inflammation is present, which can affect
the body’s ability to digest and absorb food.48 However, this test is not able
to detect certain other conditions that could cause GI motility problems,
such as small ulcers or infection with H. pylori, which could also cause
symptoms. Often, confirmation testing, such as through endoscopy, is
necessary to authenticate the results seen on the X-ray.
Enterography
A type of imaging test that uses a CT scan or MRI, enterography allows the
provider to visualize the small intestine and other areas of the abdomen. To
perform the exam, the patient drinks a liquid contrast medium or is
administered the contrast intravenously. The contrast then shows up in the
patient’s GI tract where the MRI can pick up images in the intestine and
check for abnormalities that may be causing GI motility problems, such as
obstructions, inflammation, or bleeding.
Enterography is beneficial because it is less invasive than endoscopic
procedures. The images produced through enterography are more complex
and can reach certain areas that an endoscopic tube would miss and the
type of study is sensitive to pick up small changes that can occur in the GI
tract that affect motility. A study by Menys, et al., in the journal Radiology
demonstrated that MRI enterography can detect changes with administration
of drugs to patients that will stimulate small bowel motility. The study
showed that the test was able to pick up the differences in GI motility
whether the participants were administered drugs that affected motility or
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placebo.50 Because of the non-invasive process involved with this type of
study, and that it is sensitive enough to pick up changes in GI motility,
enterography is a viable option for diagnostic treatment among patients who
are suffering GI motility disturbances.
Endoscopy
Endoscopy is an umbrella term used to describe any test that involves
insertion of a tube into the gastrointestinal tract to visualize and take
pictures of the internal structures. Upper GI endoscopy involves testing of
the throat, esophagus, stomach, and small intestine, while lower GI
endoscopy involves testing of the large intestine, sigmoid colon, rectum, and
anus. Endoscopy differs slightly from other imaging studies in that contrast
medium is not always used and the GI endoscopist does not always utilize
radiographic images to make a diagnosis. However, endoscopy is a valuable
process that helps the endoscopist to visualize the internal segments of the
GI tract, which can better pinpoint a diagnosis when GI motility problems
are present.
Upper endoscopy, also called esophagogastroduodenoscopy or EGD, involves
insertion of a tube into the patient’s mouth and then advancing it down the
esophagus. Depending on the area of concern, the endoscopic tube insertion
may also need to be advanced into the stomach or the duodenum of the
small intestine. The patient’s mouth is sprayed with anesthetic to maintain
comfort during the procedure; in many cases, the patient is mildly sedated
for the procedure as well so that he or she will be relaxed.
The EGD is performed in an endoscopy suite where the patient can be
monitored closely before, during, and after the procedure. The process does
not require contrast media because it does not involve radiographic imaging,
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but it does allow the endoscopist to look at images of the esophagus,
stomach, and a portion of the small intestine. The test is beneficial to look
for conditions that may be causing the patient’s symptoms of pain, nausea,
or vomiting, which may or may not be related to GI motility problems. It
may also be done to rule out another condition and narrow down the cause
of the motility issues.
The upper endoscopy is more accurate than traditional X-rays when looking
for certain issues within the gastrointestinal tract, such as inflammation.49
The endoscope can also be used to insert biopsy forceps through the channel
to remove small tissue samples from the GI tract if the endoscopist
determines its necessary to perform a tissue pathology test.
To examine the entire large intestine, a colonoscopy is typically performed,
which allows the endoscopist to visualize the colon. The colonoscopy is often
used as a cancer screening tool to initially assess and perform surveillance
exams for colon cancer, but it may also be utilized to assess for potential
obstructions in the large intestine, the presence of inflammation or polyps,
bleeding, diverticulosis, or whenever the patient is suffering symptoms and
is experiencing a change in bowel habits. A colonoscope, a flexible tube is
inserted into the anus and advanced through the large intestine all the way
from the left colon to the right colon and cecum. Prior to the procedure, the
patient must undergo a bowel cleanse as preparation in order to remove any
fecal matter in the intestine. This often requires a clear liquid diet for one
day before the procedure and administration of a laxative that will empty the
colon. During the procedure, the patient lies on a table, usually on the left
side, and is given a mild sedative to be comfortable. The procedure is
expected to last 30 to 60 minutes.
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Because the colonoscopy is relatively invasive, there is another option to
visualize the bowel for some patients who would not tolerate a colonoscopy.
A procedure known as CT colonography, also referred to as virtual
colonoscopy, can be performed to assess for similar changes in the colon
that would be detected during a colonoscopy. The patient typically has to
undergo the same amount of bowel preparation, using a laxative and
changing the diet temporarily before the procedure. The patient will need to
drink a contrast medium and then lie on a table while the radiologist inserts
a tube into the anus and injects air into the rectum and the colon. This air
allows for better viewing during the procedure.
The colonography uses CT imaging to take pictures of the patient’s colon and
then demonstrate the results on a monitor to better visualize the interior of
the large intestine. Like the colonoscopy, the colonography test can detect
changes that can cause GI motility disorders and that lead to patient
symptoms; and, because it uses CT, it can identify areas of concern.
Alternatively, the colonography does not allow for biopsy sampling or direct
tissue examination as would be available through the colonoscopy, as there
is no endoscope being inserted into the large intestine to provide access to
tissue to biopsy.49
Endoscopic procedures of the anus, the rectum, and the sigmoid colon are
known as anoscopy, proctoscopy, and sigmoidoscopy, respectively. These
tests can be performed to assess GI motility and to determine if there are
obstructions within the descending colon and areas of the lower GI tract that
are preventing normal motility and slowing colonic transit, preventing
normal defecation. Some conditions that these tests may be used to
diagnose include fecal incontinence and chronic diarrhea.
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Anoscopy is performed to look at the structures of the anus, the anal
sphincter, and the lower portion of the rectum. The medical provider may
perform a digital rectal exam before the procedure to ensure that there are
no blockages that would prevent passing the scope. The patient may also
need to take a laxative or have an enema prior to the procedure to clear the
bowel, particularly the sigmoid colon and the rectum, if stool is present in
these areas. Anoscopy is done by insertion of an anoscope, also called an
anal speculum, into the anal opening. The patient lies on a table but is
generally not sedated for the procedure. Instead, the insertion tube is
coated with an anesthetic cream that desensitizes the area to prevent much
discomfort.
The insertion tube has a light source and a camera, similar to other
equipment used for endoscopic procedures. The anoscope allows the
provider to view approximately 2 inches of the distal portion of the anal
canal. Anoscopy is most often performed to check for patient hemorrhoids or
polyps, which could be obstructing the anal opening, making stool passage
difficult. The test may also diagnose other conditions, such as inflammation
or anal fissures; although these conditions do not directly affect GI motility,
they can make it painful for the patient to defecate, potentially leading to
problems with constipation.
Proctoscopy involves examination of the rectum. The process is similar to
that of a colonoscopy or anoscopy in that the physician inserts a scope into
the patient’s anus and advances it to the rectum to visualize the internal
structures of this portion of the colon. The proctoscopy allows the physician
to visualize whether there are obstructions in the rectum that prevent the
passage of stool or whether any other abnormalities are present that would
affect gastrointestinal motility.
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As with other endoscopic procedures, the patient may need to be in a fasting
state for several hours before the test and may need to use an enema or a
laxative to clear the rectum of stool. The medical provider may also perform
a digital rectal exam just before the procedure. The entire procedure takes
about 15 to 20 minutes, plus time before and after the procedure for
preparation and recovery. Because proctoscopy allows visualization of the
rectum, the main area where stool is stored before defecation, it is useful to
ability the patient’s ability to defecate normally and to diagnose conditions
that affect GI motility, such as fecal impaction or chronic constipation.
Furthermore, if there is inflammation or bleeding present in the rectum that
affects the patient’s ability to defecate, the proctoscopy can pick up on these
conditions as well. The patient may have polyps present in the rectum; by
utilizing a specialized snaring or biopsy tool, the physician can remove some
of the polyp tissue and send it for a pathology study.
Sigmoidoscopy examines the sigmoid colon, which is the lower portion of the
large intestine that connects the descending colon with the rectum. Because
the procedure involves further advancement of the sigmoidoscope as
compared to an anal or rectal exam, the patient may need to be lightly
sedated for the procedure. Sigmoidoscopy requires that the patient lie on a
table with the knees drawn toward the chest, and the physician generally
will perform a digital rectal exam to ensure there are no obstructions or
tenderness in the area. The physician will advance the sigmoidoscope past
the rectum and into the sigmoid colon; and, the scope is flexible so that it
can be navigated according to the shape of the intestinal tract.
During the sigmoidoscopy, air may be instilled into the bowel to help with
viewing the internal structures. The patient will pass this air back out of the
rectum following the test. The procedure typically only lasts a few minutes
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and most patients tolerate it well without any pain. The sigmoidoscopy can
be used to assess for obstructions, such as polyps, found in the sigmoid
colon, the presence of stool or inflammation of the intestinal lining, or
whether any bleeding is present in this portion of the large intestine. If
polyps or other suspicious tissue is present, the physician can use
instruments that are inserted through the endoscope channel to extract
tissue for biopsy.
Barium Studies
Barium is a commonly used contrast medium for imaging studies. It is
radiopaque contrast used to coat the internal structures of the
gastrointestinal tract that can be seen during X-ray or CT scan. Barium
studies can be performed to assess the GI tract. By using barium, the
healthcare provider can assess for changes in the intestinal tract that could
contribute to GI motility problems. Barium studies can be performed to test
for upper GI tract disorders, often called barium swallows, or for lower GI
tract disorders in which the contrast is typically administered as a barium
enema.
The barium swallow is actually called an esophagography. It is referred to in
simpler terms as a barium swallow because the patient actually drinks
barium contrast that has been prepared as a mixture. When the patient
drinks the mixture, the clinician can take X-rays to follow the barium
contrast as it moves through the digestive tract. The barium can be seen
flowing down from the posterior pharynx where it was swallowed and the
physician may note how the esophagus propels the contrast toward the
lower esophageal sphincter and stomach, using peristaltic waves. The test
also examines patency of the lower esophageal sphincter as it opens to allow
the contrast to pass into the stomach.51
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Although the barium swallow may demonstrate some factors that contribute
to the patient’s GI motility problems, they must typically be confirmed with
manometry or biopsy after the barium swallow. For example, if the physician
were to determine that the patient’s motility problems were the result of
lesions found in the intestinal lining, the condition could not actually be
diagnosed using the barium swallow results alone and would require biopsy
to do so.51 The barium swallow may be combined with an upper GI test to
identify a GI motility problem before other studies, such as biopsy, are
completed to confirm a diagnosis.
A barium enema is an examination of the lower gastrointestinal tract that
uses contrast medium, and it is administered rectally as an enema to allow
the medical provider to visualize the internal structures of the large intestine
when using imaging studies. The single-contrast technique describes
application of contrast through administration of barium enema alone, while
the double-contrast technique involves administration of a barium enema
and air into the large intestine. The colon expands slightly with the barium in
place and the contrast coats the inside of the intestinal tract. In this way,
the healthcare provider can see many details of the surface of the colon,
including whether obstructions are present or any other reason why the
patient may be experiencing changes in bowel habits. After enema
administration, the patient may lie on a table but be asked to change
positions occasionally while the healthcare provider visualizes the results
within the large intestine.
A further test that may use imaging of the large intestine is known as
defecography, which utilizes barium contrast and X-ray to take images while
the patient defecates. The test is done to determine how the stool moves
through the rectum and out of the body in situations where the patient
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reports difficulties with colonic motility and stool evacuation. Barium paste is
inserted into the anal and rectal canals using a tube similar to an enema.
During the test, the patient sits on a specialized chair that can record the
movement of the contrast through defecation. The test then analyzes the
process of how the rectum empties itself of the barium paste. It can
determine whether there are problems associated with the rectal muscles
and the rectum’s ability to retain the contrast, motility problems with
passage of stool between the rectum and the anus, or whether there are
structural problems with the anus, such as poor sphincter control, that affect
the patient’s ability to evacuate stool.
Defecography is a useful test for identifying a number of GI motility
problems. Among others, it has been successfully used to identify and
diagnose patients who suffer from chronic functional constipation and
dyssynergic defecation. A study in the British Journal of Radiology showed
that magnetic resonance (MR) defecography can detect abnormal findings in
adults who suffer from dyssynergic defecation, which is defined as a
functional defecation disorder characterized by impaired pushing forces,
paradoxical contractions, or an inability to relax the anal sphincter muscle.52
The test has also been shown to be useful in identifying other disorders of GI
motility, including fecal incontinence and anismus, which occurs as
inappropriate spasms of the anal sphincter.
Capsule Endoscopy
Capsule endoscopy is a newer technique that allows the healthcare provider
to visualize the inside of the gastrointestinal tract when the patient swallows
a capsule that contains a tiny camera. The patient wears a recording device
during the test and the camera has its own light so that when it enters the
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gastrointestinal tract, it can record data and send it wirelessly to the storage
device. The camera transmits the images over the course of approximately
eight hours. The test is beneficial because the capsule can reach certain
areas of the GI tract that could otherwise not be visualized through upper
endoscopy or colonoscopy.
Prior to the exam, the patient must have an empty stomach before
swallowing the capsule. If the patient takes medications that can cause
stomach irritation, such as NSAIDs, he or she may need to stop taking them
temporarily before swallowing the capsule. The recording device that
receives the information from the capsule is typically worn on the upper
body, where it keeps note of the images from the capsule throughout the
time of testing. At the end of the testing period, the patient will excrete the
capsule normally and it does not need to be retrieved from the intestine.
A drawback to capsule endoscopy is that if it detects a problem within the
gastrointestinal tract, it only takes pictures of it with the camera; the
healthcare provider must still follow up with further testing to diagnose a
condition or to obtain tissue samples. Because of the length of time the
capsule is able to function, it often does not examine areas past the small
intestine. There is also the small chance that the capsule could become stuck
in one of the loops of the intestine or at the junction between sections of the
GI tract, such as near one of the muscular sphincters. Despite these risks,
capsule endoscopy is generally safe to use for most patients and is a very
convenient method of visualizing the internal structures of the intestinal
tract for patients with GI disorders that may be co-occurring and/or
contributing to a problem of motility.
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Electromyography
Electromyography (EMG) describes testing conducted to examine the
function of motor neurons, the nerves that control muscles. Normally, motor
neurons work by sending electrical signals to stimulate the muscle tissue. An
EMG is performed to monitor these signals to determine whether the motor
neurons are working at an appropriate amount. While EMG is often used as
part of diagnostic testing to analyze skeletal muscle tissue, it may also be
used to assess gastrointestinal function. The process tests the motor
neurons that stimulate the muscles that control intestinal tissue and checks
whether they are sending signals too quickly, or whether they are working at
a pace that is too slow.
The process of electromyography is one of the only diagnostic tests available
that can directly analyze specific muscle activity. Muscles are made up of
motor neurons as their basic units of function. When a nerve impulse arrives
at the junction of the muscle and the nerve, the body secretes acetylcholine
in response and the muscle contracts. The electrodes from the EMG gather
information from the surrounding muscle fibers and send a signal to an
amplifier where the information is displayed on a digital screen. The
information is also recorded so that it can be referred to later, if necessary.
Electromyography picks up the signals sent by motor neurons when
electrodes are positioned in specific locations in the muscles of the GI tract.
Contrary to the surface electrodes used as part of cardiac testing, electrodes
used with EMG are often special types of needles that are placed within the
muscle tissue. Electromyography is performed whenever there are potential
problems with different muscles and the organs and body systems that they
affect. For example, EMG may be utilized if there has been damage to the
spinal cord, which can impact muscle movement and nerve function, and to
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determine the amount of damage to the muscles that has occurred from the
injury. If a patient suffers from a degenerative condition, EMG can be used
to analyze the extent of nerve damage and its effects on the muscles.
Electromyography recordings can be difficult to undertake when studying GI
function. For instance, when needle electrodes are used for measurement,
there are few people who wish to undergo intramuscular needle placement
into the jaw, pharynx, or esophagus. Likewise, it may be difficult to place
needle electrodes into locations such as sphincter muscles to obtain
measurements. However, it is possible that some patients could undergo
needle placement of electrodes for EMG monitoring as part of a surgical
process; the testing could be performed during a surgical procedure, even if
the procedure is not intended for surgical diagnosis or correction of a GI
disorder.114
A study published in the Journal of Investigative Surgery utilized EMG to test
for LES function in persons with reflux. The study examined patients who
were undergoing surgical procedures and who underwent simultaneous EMG
recordings of the lower esophageal sphincter during the process. At the end
of the surgical procedure, the patients were stimulated to cough by
manipulation of the endotracheal tube and researchers examined the
differences between the amount of pressure and muscle activity of the
esophageal sphincter on the EMG with coughing as compared to time at rest.
The results showed higher-level pressures during induced coughing, which
suggests that the LES is less likely to function normally during periods of
straining or coughing, which may contribute to weakened musculature found
among those with GERD.115
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Alternatively, EMG may be used to diagnose conditions associated with the
lower GI tract, such as within the colon, rectum, and anus. A patient who
suffers from fecal incontinence or abnormalities associated with the rectum
and anus may undergo anal sphincter EMG. The test is indicated for any
patient who has had changes in bowel habits related to loss of sensation in
the anal tract, damage to the pudendal nerve in the lower pelvis, or spinal
cord lesions that can affect motor and sensory function in the lower GI
tract.116 To utilize this method of EMG recordings, the clinician may take
measurements using a combination of needle and skin electrodes for the
test. The patient is placed in a position that allows for easy access to the
anal sphincter and the clinician inserts the electrode needle directly into the
muscle of the sphincter. The patient may be asked to contract the sphincter
muscle during the test, using muscles normally involved for holding stool
within the rectum. The process takes approximately 60 minutes.
An EMG is typically performed at a hospital or through a specialty clinic. The
patient rests on a table or bed and the technician performing the test places
electrodes in the appropriate locations. During the test, the patient will most
likely need to lie still in order to get the most accurate results, although he
or she may be directed to change positions or use certain muscles during the
test to determine how these movements will affect the test outcome.
Because the electrodes typically puncture the skin or muscle tissue during
the test, the patient should be monitored for a period of time after the test
for safety.
The EMG is not necessarily the first choice of diagnostic procedures to
consider with a patient who suffers from a GI motility disorder. The process
is relatively invasive and may involve patient discomfort, particularly related
to electrode placement. However, because the EMG has the potential to
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measure such miniscule muscle contractions and can record very slight
changes in muscle tone and movement, this test can be capable of detecting
abnormalities that cause GI motility problems that other types of testing
may miss.
Manometry Testing
Manometry testing measures the amount of pressure within the
gastrointestinal tract. The muscular layer within the lining of the intestine
exerts a certain amount of pressure to stimulate peristalsis and movement
of chyme and stool through the intestine. Manometry is a specialized form of
diagnostic testing that can measure and analyze the pressure exerted by the
muscles in the intestinal tract. Colonic manometry measures the strength of
muscle contractions in the large intestine, while esophageal manometry is
performed to assess motility of the esophagus.
Esophageal Manometry
Esophageal manometry gauges the patterns of peristalsis that move food
from the pharynx after swallowing to the stomach where it can be further
digested. Patients who suffer from esophageal motility disorders may
experience epigastric pain, heartburn, of difficulty swallowing; in cases of
achalasia, the patient may also experience chronic cough or regurgitation of
food, fluid, or stomach acid into the back of the throat. Esophageal
manometry can measure the motility of the esophagus by checking the
lower esophageal sphincter and the muscle tone of the esophagus, as nerve
damage in these areas can result in many of the patient’s symptoms.
According to Katz, author of an article called Esophageal Manometry, this
test is indicated for specific conditions, including evaluation of symptoms
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that have not been diagnosed through endoscopy, evaluation of non-cardiac
related chest pain, assessment of dysphagia not caused by an obstruction,
analysis for diagnosis of achalasia, pre- or post-operative measurements for
patients undergoing procedures for treatment of gastroesophageal reflux
disease, and monitoring for placement prior to pH probe and electrode
positioning in the lower esophageal sphincter.39 The patient should remain in
a fasting state for at least four hours prior to the start of the esophageal
manometry study.
Many patients are apprehensive about the procedure, as it involves inserting
a tube into the nose and advancing it into the stomach. The nurse who is
working with the patient undergoing this procedure should carefully explain
the process and provide appropriate education and guidance to best alleviate
the patient’s fears. In most cases, the patient does not have to stop taking
medications that are taken on a daily basis, even if they are drugs used to
control gastrointestinal motility, as the test will measure the effects of these
drugs in the system anyway. The patient remains awake during the
procedure, but the nose and the back of the throat may be anesthetized with
lidocaine spray prior to starting the process.
To perform the test, a catheter is passed into the esophagus and all the way
through the lower esophageal sphincter into the stomach. The manometry
tube is slowly pulled back up from the stomach through the esophagus, and
it is during this time that pressure measurements are taken. Some of the
newer manometry equipment have increased catheter sensors and potential
to measure pressures within the esophagus thereby requiring less
manipulation or movement of the tube to complete testing, and producing
less discomfort to the patient undergoing the manometry procedure.
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The results of the manometry vary depending on the patient’s condition. For
example, if the patient has achalasia, the manometry will measure abnormal
muscular contraction in the esophagus and pressures of the lower
esophageal sphincter characteristic of the condition. Abnormal esophageal
contractions measured through the test may indicate esophageal spasm or
some form of hypermotility disorder. When the lower esophageal sphincter
lacks tone and is prone to loosening and allowing gastric fluids to escape,
the patient may have a history of gastroesophageal reflux. Manometry is
often useful with other studies performed to diagnose and treat reflux, such
as with fundoplication or surgery to strengthen the lower esophageal
sphincter.
Antroduodenal Manometry
Another test, known as antroduodenal manometry, measures the motility of
the stomach and the small intestine. It is a valuable test that can be
performed on some patients who have motility problems that are otherwise
difficult to detect through X-ray or clinical manifestations. A patient with GI
motility problems may have generalized symptoms of nausea, vomiting, or
constipation but, in some cases, it can be difficult to determine the location
of the motility problems through clinical symptoms alone. According to a
study in the Journal of Neurogastroenterology & Motility, antroduodenal
manometry is most likely indicated for patients with certain clinical
manifestations, including patients with suspected pseudo-obstruction in the
small intestine, persons with unexplained abdominal pain and nausea and
vomiting, and for those who require GI motility tests to exclude
disseminated GI motility disorders.37
Although the antroduodenal test can measure gastrointestinal motility after
eating, the patient must remain in a fasting state for several hours before
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starting the test. If the patient has prescription medications for drugs that
affect stomach activity or motility, such as metoclopramide or antispasmodic
medication, they will usually be stopped for at least 3 to 7 days before the
test as well, as these types of drugs can affect the test outcome.
The antroduodenal manometry test is performed through the insertion of a
flexible catheter into the patient’s nose and threading the catheter down into
the esophagus, stomach, and then the small intestine. Confirmation of tube
placement is done via X-ray before starting the test. The tube contains
sensors spaced at various intervals along its length that measure pressure
levels during the test; and, a transducer picks up the readings from the
sensors and displays the output as pressure tracings. There are two types of
tubes that may be used for the procedure. One tube requires that the
patient remain on bed rest during the test, while the other tube allows the
patient to be ambulatory and will record pressure readings for up to 24
hours.
The study measures small intestine motility during the fasting period, during
the time that the patient ingests a meal, and then for several hours after the
meal. Studies have shown that when patients undergo the ambulatory test,
the results are often clearer for clinicians who review them since the
ambulatory system test is performed over 24 hours and through several
meals. This permits the clinician reading the results to see the effects of
more than one meal and the fasting period on the patient’s motility, rather
than checking motility during a stationary period and one meal.
The test records the patterns of muscle contractions made within the GI
tract, and consider three phases of muscle contractions, which appear at
various times throughout the digestive process. Phases I and II involve
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periods of rest and mild or intermittent contractions, respectively. Often, the
test checks the frequency and duration of Phase III contractions, which are
rhythmic movements that transfer undigested material from the stomach
into the small intestine.38 It is understood that eating a meal produces more
frequent Phase III contractions, which is why the patient will eat a meal
during the manometry test to determine how the stomach and small
intestine respond. The test can further measure whether GI motility
problems are caused by muscle weakness that do not allow for normal Phase
III contractions, or whether the motility disorder is caused by interruption in
nerve conduction, which can affect the rate and force of stomach
contractions.
Colonic Manometry
Colonic manometry determines the amount of pressure present in the large
intestine. A patient may suffer from symptoms of constipation or chronic
diarrhea associated with changes in colonic motility that might be identified
and diagnosed through colonic manometry. In fact, the
Neurogastroenterology and Motility Society has issued a recommendation
that patients who are constipated should undergo colonic manometry
testing, particularly when they have not responded to other forms of testing
and treatments. This means that the colonic manometry test can be very
beneficial for patients affected by alterations in GI motility and that have not
had any other clear answers about their conditions.45
The process of completing colonic manometry is somewhat similar to
measuring pressure results of other portions of the gastrointestinal tract.
With colonic manometry, however, the manometry tube is inserted into the
patient’s anus and advanced through the rectum to reach the large intestine.
Although colonic manometry has been shown to be beneficial in diagnosing
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the cause of patient symptoms, the test can sometimes still not identify the
actual condition causing the underlying clinical manifestations.
Researchers have discovered that when recording the frequency of colonic
contractions through manometry, most patients will exhibit a certain number
of contractions as evidenced by increases in colonic pressure during a 24hour period. Increases in events have been shown following meal
consumption as the body is digesting food. Alternatively, some patients who
suffer from severe constipation have been shown to have very few or no
periodic increases in colonic pressure during the time period measured,
indicating a lack of movement in the large intestine, which contributes to
constipation. However, the changes in pressure within the colon can be very
subtle at times, because the manometry tube that measures these pressure
changes is quite thin and could miss some of the very small movements in
the wall of the large intestine; this means that the patient could still be
experiencing colonic contractions but the test is not necessarily accurately
measuring them.46
Nevertheless, manometry studies of the large intestine have been very
useful in helping clinicians determine colonic function for some patients who
experience GI motility problems. Because the manometry tube is placed
within the colon, the manometry test itself allows the healthcare provider to
gain better insight into what is going on inside the large intestine to better
be able to analyze the patient’s GI motility problems and to diagnose the
cause.
The colonic motility test can be done on an outpatient basis in a hospital or
clinic that has endoscopy capabilities. Prior to the test, the patient will be in
a fasting state and will need to have the colon cleansed to clear the
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intestinal tract of stool and fecal matter. This is typically accomplished when
the patient consumes a laxative or has an enema designed to stimulate stool
excretion. The patient is sedated for the study, and a thin, flexible
manometry tube, which is the pressure-monitoring device, is inserted into
the anus and passed into the rectum and the large intestine. A guide wire is
threaded through the manometry tube, which acts to direct and position the
tube to obtain as accurate manometric measurements as possible until
completion of the test. After the guide wire is removed, the manometric tube
measures the pressure at various points along the colon and records the
movements as a sequence of events on a monitor so that the medical
provider can see the patterns of intestinal contractions through the test.
In some cases of colonic testing, the patient may be given a meal; after
eating, the medical provider will then check the manometer to determine
how the body is responding with colonic contractions during meal digestion.
The actual testing period may vary but it is approximately three hours long
after the tube is positioned in place and through the recording, with
additional time required both before and after the test to prepare the patient
and to recover from the procedure.
Colonic manometry testing is performed on both adults and children,
although studies have shown that the procedure has been more successful
when used in children. According to a study in the World Journal of
Gastroenterology, there are few studies that indicate much success with this
type of colonic study among adults, but when performed among children,
the results of colonic manometry are much more likely to guide the
provider’s treatment options. One study cited 88 percent of parents whose
child underwent colonic manometry testing, and who then received
treatment to manage the child’s condition, believed that the process was
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helpful and improved their child’s health.45 Regardless of whether colonic
manometry is used for an adult or for a child, this specific type of testing has
been shown to be effective to detect changes in pressure levels within the
large intestine of patients affected by GI motility problems. As a result,
manometry testing remains a useful diagnostic tool to be considered
whenever the need for GI motility testing arises.
Diagnostic Laparoscopy/Laparotomy
At times, surgery may be indicated for some patients who suffer from
gastrointestinal motility problems, either to diagnose the condition that is
causing the problems or to correct a health condition to facilitate normal
motility once again. Laparoscopy and laparotomy are two types of surgical
procedures that may be implemented for various conditions.
Laparoscopy is a minimally invasive surgery. The patient will need
anesthesia and the surgeon will create a small opening in the skin but the
procedure is performed using a scope or tube that is inserted into the
opening. A camera on the end of the scope allows the surgeon to see inside
of the abdominal cavity without needing to open the skin further.
Laparoscopy can also allow the surgeon to take small amounts of tissue
samples and to take pictures of the inside of the abdomen. Alternatively,
laparotomy is an open procedure that involves a larger incision that can be
pulled apart slightly to allow the surgeon to see inside of the abdominal
cavity. Laparotomy may be exploratory, in which the surgeon is investigating
the potential cause of the patient’s symptoms. It may also be done to
correct a situation if the patient has had testing before the surgery and the
cause of the problem has been identified.
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Surgical procedures may be part of diagnostic testing to take samples of
gastrointestinal tissue to determine the potential cause of the motility
problems. In many cases, diagnostic testing can be performed through
various imaging studies and minimally invasive techniques that do not
require surgery. Surgery may be necessary as part of treatment once the
condition has been diagnosed and the cause of the motility problems
identified, but laparoscopy or laparotomy may otherwise be indicated to
collect tissue for biopsy to determine how well the cells and tissues of the GI
tract are functioning.
Acquisition of tissues may be done as part of diagnostic testing;
alternatively, tissue samples may be taken as part of another type of
surgical procedure related to the patient’s symptoms and then the tissue is
examined for biopsy. Tissue samples from the GI tract are often taken from
the lining at various points along the tract, such as the lining of the
esophagus, small intestine, or colon. Biopsy specimens from the intestinal
lining may include tissue from the mucosal or submucosal surfaces, or even
full thickness of tissue from the lining of the bowel.55 Alternatively, if there is
an obstruction present, such as a polyp or lesion, a sample of this tissue
may also be surgically removed for biopsy.
Natural orifice transluminal endoscopic surgery (NOTES) is a relatively new
surgical technique that is minimally invasive and that allows the surgeon to
manage or treat a GI condition without creating an external surgical incision.
It may be performed as a type of surgical procedure to retrieve specimens
for biopsy or to collect tissue cultures as well as to remove samples and
specimens from within the body, whether as part of diagnosis or as a
method of treatment.
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Normally, surgery to obtain tissue samples as part of diagnostic procedures
requires puncturing the exterior skin of the abdomen to reach the internal
cavity. When the surgeon is taking a tissue sample from an interior portion
of an organ, such as with biopsy from the internal lumen of the intestinal
tract, this could involve further perforation of the tract to reach the area
needing to be biopsied. With NOTES, however, the surgeon may puncture
the cavity of the intestinal tract to reach the interior portion, but the surgeon
has approached the internal incision through a natural orifice.117 For
example, the surgeon may take a sample of tissue from the stomach but is
able to reach the interior tissue by passing a tube through the esophagus,
rather than making an external incision.
The process of NOTES uses a combination of laparoscopic and endoscopic
techniques to obtain tissue samples and to perform diagnostic procedures.
According to a report in the Annals of the Royal College of Surgeons of
England, the techniques utilized for a NOTES procedure must uphold certain
principles of safe access, including minimal tissue injury, good exposure,
avoidance of vascular and visceral injuries, and the ability to maintain a seal
to manipulate the instrument.118 This information is important, as the NOTES
procedure is designed to access those internal structures of the body,
including the GI tract, which could otherwise be exposed and laid bare
during surgical procedures. Any type of surgery places the patient at higher
risk of infection because of the invasiveness of the process. When a surgical
procedure is performed to diagnose a GI motility disorder, the surgery can
place the patient at risk of other complications. The NOTES procedure may
be performed as an alternative means of accessing the intestinal tract for
diagnostic purposes but that also keeps the patient safe and that minimizes
potential complications.
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Laboratory Testing
Complete Blood Count
The complete blood count (CBC) is a
test of the health of the blood cells;
and, it is often done to test the
patient’s overall health and wellbeing.
It can be used as part of diagnosis for a
number of different medical conditions,
including anemia, infection, cancer, or
conditions that cause inflammation in
the gut. Any of these disorders could lead to gastrointestinal motility
problems. The CBC consists of various components as it tests different cells,
each of which can be related to gastrointestinal motility changes. An
alteration in the levels of certain blood cells as seen on the CBC results can
indicate if there is a specific problem present that may be affecting the
patient’s GI motility, such as the presence of an illness that affects intestinal
function.
There are three main types of cells found in the blood and the CBC
components test the amounts of each of these cells. The main cell types are
white blood cells, red blood cells, and platelets. Each category can be further
broken down into different elements that measure specific indicators within
the blood sample.
The white blood cell components of the CBC include a test of the total
number of white blood cells in the blood sample, as well as the white blood
cell differential, which measures the type and amounts of the various types
of white blood cells, including lymphocytes, monocytes, neutrophils,
basophils, and eosinophils.41 The white blood cells are responsible for
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fighting infection, so when they are elevated or decreased in the CBC
sample, it can indicate that an infection is causing the GI motility problems.
For example, a patient may develop nausea, vomiting, and diarrhea after
suffering a viral gastrointestinal infection. The presence of infection can be
detected through the CBC, even though it will not detect the specific virus
causing the symptoms.
The patient who has an infection will most likely have an increased number
of white blood cells in the CBC. The normal amount of white blood cells in a
sample is 4,000 to 10,000/mm3; and, the differential portion of the CBC tells
the clinician the specific amounts of each type of white blood cell. Since each
type performs distinct functions in fighting off infection, it is important to
check the white blood cell differential to help to determine the cause of
infection. For example, if a patient complains of abdominal pain and
increased GI motility and the CBC shows an elevated white blood cell count,
the healthcare provider may consider that there is an infectious process
causing the patient’s condition. When checking the differential, it may show
that lymphocytes are elevated, which are important for fighting infection
caused by viruses. This result may better help the healthcare provider to
understand the cause of the infection.
The red blood cells are the second type of cells measured through the CBC.
The red blood cells are responsible for oxygenation of body tissues because
they contain hemoglobin and carry oxygen through the bloodstream. The red
blood cell portion of the test is further broken down to test such elements as
the total red blood cell count, hemoglobin, hematocrit, red blood cell indices,
and the reticulocyte count.
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The normal red blood cell count is approximately 4.7 to 6.1 million cells/mcl
for men and 4.2 to 5.4 million cells/mcl for women, which could be increased
when a patient is dehydrated or has poor kidney function, or decreased in
cases of anemia, hemorrhage, and severe infection. The red blood cell
indices include components such as mean corpuscular volume (MCV), which
measures the average size of a red blood cell. If the red blood cells are too
large, they are considered macrocytic; this condition could occur because of
certain vitamin deficiencies or with hypothyroidism. Alternatively, microcytic
cells refer to those red blood cells that have an MCV result that is smaller
than normal. Microcytic red blood cells typically develop if the patient is
suffering from iron deficiency anemia. Other segments of the red blood cell
test include the mean corpuscular hemoglobin (MCH), which measures the
average amount of hemoglobin found within each red blood cell in the
sample; mean corpuscular hemoglobin concentration (MCHC), which is the
concentration of hemoglobin within a red blood cell; and, the red cell
distribution width (RDW), which is a measurement of the various sizes of red
blood cells found within the sample.42
The hemoglobin is the portion of the red blood cell that attaches to oxygen
molecules in the bloodstream. The normal amount of hemoglobin varies
between men and women but is typically 14 to 18 g/dL for men and 12 to 15
g/dL for women. Decreased levels of hemoglobin can indicate possible
anemia, kidney disease, toxicity, or even cancer. The hematocrit is an
indication of the volume of red blood cells within the blood sample. It is
expressed in percentage form and the normal result is between 45 and 55
percent, although this may be slightly lower in women. A patient may have a
low hematocrit if he or she has had excess fluid intake or if blood loss has
occurred.
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The CBC may also include the reticulocyte count, which is a measurement of
immature red blood cells found within the blood sample. The reticulocyte
count is most often elevated in cases of anemia. If a patient has anemia and
a high reticulocyte count, there may be another condition causing blood loss
or a situation that would require the body to produce too many immature
blood cells, such as in cases of hemolysis. The reticulocyte count may be
decreased if there is a vitamin deficiency present, such as with vitamin B12
deficiency.41
Hypothyroidism, which is associated with a number of gastrointestinal
motility problems, including constipation and malabsorption, can also lead to
a drop in red blood cells and some kinds of anemia. Low thyroid levels can
impact iron absorption, which could result in iron deficiency anemia.43 This
could potentially create a negative cycle in which the intestines receive even
less oxygenated blood than what they need when red blood cells and
hemoglobin are lacking; which could then further perpetuate motility
problems if the intestinal tract is not adequately oxygenated through
circulation.
The final type of blood cells measured in the CBC is for platelet counts.
Platelets are fragments of cells that support blood clotting. This may also be
referred to as the thrombocyte count and it detects how well the patient is
able to clot blood or is prone to blood loss. A normal platelet count is
150,000 to 450,000 mm3 among men and women.
Patients with some gastrointestinal disorders may have changes in platelet
counts that range from minor variations in total counts to significantly low or
high numbers. According to Houghton, et al., in the journal
Neurogastroenterology & Motility, patients with irritable bowel syndrome
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may have platelet changes. As discussed with irritable bowel syndrome,
many patients suffer from GI motility changes that are regulated with
administration of antidepressants that affect serotonin levels. This is because
a significant amount of the body’s serotonin resides in the GI tract, where it
regulates intestinal movements. Serotonin in the GI tract may also be
referred to as 5-hydroxytriptamine (5-HT). The researchers in the study
have shown that patients with irritable bowel syndrome typically have
platelet-depleted 5-HT concentrations in the bloodstream.44 The study
demonstrated that patients with constipation and diarrhea associated with
irritable bowel syndrome had elevated levels of platelet-depleted 5-HT in
serum samples, leading the researchers to believe there was a connection
between these platelet-depleted cells and sigmoid colon motility.
A CBC is a very common blood test that can be easily performed within most
healthcare facilities that have laboratory capabilities. This test should be
ordered for any patient who presents with symptoms of a gastrointestinal
motility problem that is potentially caused by infection, hemorrhage, or
anemia. In some cases, the CBC may be ordered as part of diagnostic
testing, but the results come back within normal limits. For example, a
patient who presents with symptoms associated with irritable bowel
syndrome may have completely normal laboratory studies, yet may continue
to struggle with uncomfortable symptoms of increased or decreased GI
motility.
When a patient receives treatment for a GI motility disorder, the CBC could
also be performed to check the effectiveness of such treatment. If the GI
motility problem is caused by another medical condition and the patient
receives treatment, the CBC may be repeated after the treatment process to
ensure that treatments are effective. The patient may also demonstrate a
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lack of GI motility symptoms when the underlying condition is treated.
Combined with the CBC, these signs are an indication that treatment
measures are effective for the patient.
Treatment And Clinical Criteria
Treatment of gastrointestinal motility disorders is an individual course of
action that considers the symptoms, medical history, and current health
management strategies of each patient. One patient may need medication to
control pain associated, for example, with achalasia, while another patient
who takes the same drug for pain may experience drug side effects, such as
severe constipation. The healthcare provider must consider the unique needs
of the patient after diagnosing a GI motility disorder, utilizing standard
interventions such as pharmacologic therapy, changes in lifestyle factors,
and surgical approaches. Other more novel interventions may be considered
as well, including stem cell therapy.
Neural Stem Cells
Stem cells are remarkable cellular bodies that are able to divide and develop
into different types of cells. As a stem cell divides, it forms two new cells;
each new cell can perform functions or it can remain a stem cell to divide
again later. Stem cells are also important in that they may be able to repair
certain defects in the body by replacing other cells because they can
repeatedly divide and replenish them. On its own, a standard stem cell is
non-specific; however, once it divides, it can take on the functions of cells in
specialized areas of the body, including in the brain, the muscles, and the
gastrointestinal tract.
Neural stem cells are also self-renewing, in that they are able to divide and
then take on the characteristics and functions of cells of the brain and
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nervous system. Neural stem cells form specific types of cells after they
divide, including neurons and astrocytes, which are primary parts of the
nervous system. Because nerves that serve various portions of the intestinal
tract control GI motility, neural stem cells have been considered as part of
treatment to replace damaged neurons that lead to GI motility disorders.
Neural cells are normally found in the submucosal or the muscular layers of
the intestinal tract. These cells stimulate peristalsis after release of
substances such as acetylcholine when nerve impulses reach the
neuromuscular junction in the intestine. Normally, the release of
neurotransmitters stimulates the muscles of the GI tract to contract and
produce peristalsis in order to move digestible materials through the system.
When a GI motility disorder develops, however, there may be damage to the
nerves that stimulate peristalsis and the person may develop dysmotility.
In 2006, researchers were able to modify some of the actions of stem cells
to essentially force certain stem cells into reproducing into specific types of
tissue. These cells are known as induced pluripotent stem cells (iPSC). In
essence, iPSC bodies can be directed to create new cells that specifically
focus on one area where new cells are needed most, such as by creating
new neurons to work in the GI tract when these cells have been damaged.
Treatment with neural stem cells involves transplanting the cells into the
gastrointestinal tract where they can then divide and reproduce some of the
neurons that affect muscular activity in the intestine. The researcher first
reprograms fibroblasts to become iPSCs that will divide to form neural stem
cells. The cells that result from this process are known as induced neural
cells. Alternatively, stem cells for transplant could be taken from a healthy
portion of the gut or from the brain.119 These cells are known as precursors,
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in that they eventually form the cells needed for regeneration into healthy
neurons.
Transplantation of the cells may be performed through endoscopy, in which
the intestine is visualized and the cells may be injected directly into the
tissue. A study by Cheng, et al., in the journal Neurogastroenterology &
Motility, worked with transplanting neural stem cells into the gut as a
method of controlling Hirschsprung disease. The stem cells were injected
using endoscopic procedures to directly reach the affected areas. The study
showed that endoscopic transplantation of neural cells can be beneficial to
deliver a large number of cells to a greater area, such as with cases of
Hirschsprung disease, in which the bowel may be enlarged.120
When considering specific diseases of the gastrointestinal system, neural
stem cell transplantation shows promise as a form of treatment. The
transplant of neural stem cells into GI tissue has the potential to manage
several forms of GI motility disorders that are caused by degenerative
conditions of the nervous system, including achalasia, Hirschsprung disease,
or congenital megacolon. Researchers are continuing to expand their work to
include use of stem cells in the treatment of various other forms of GI
motility disorders, particularly those that are unresponsive to other forms of
therapy or that otherwise have no cure. The potential for technological
advances that can create cells designated to treat certain GI disorders is an
exciting thought that deserves continued study and future discussion.
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Dietary History and Assessment
For many patients with gastrointestinal
motility disorders, changes in dietary
habits alone can make a significant
difference in the severity of symptoms.
Unfortunately, many Americans have
eating habits that include increased
intake of high-fructose corn syrup,
sugar alcohols, saturated fats and trans
fats, and too few vitamins, minerals,
and other important nutrients to
maintain good health. During the health
assessment, the nurse should include
dietary history as part of the evaluation of the patient’s condition, as diet
contributes significantly to the cause of many GI dysfunction symptoms.
There are many dietary changes that patients can make that will help to
alleviate some symptoms, even if they do not actually cure the motility
disorder. For symptoms of diarrhea, fluid and dietary changes can impact
stool constitution and can resolve some symptoms of loose stools, as well as
prevent excess fluid and electrolyte loss associated with diarrhea. The
patient is at high risk of developing electrolyte imbalances in sodium and
potassium with increased fluid loss through watery stool. It is important that
the patient understands the significance of food and fluid intake when
diarrhea is present, particularly when the condition has been happening for
more than several days or is the result of another underlying medical
condition that requires more extensive treatment. The patient should be
encouraged to drink plenty of fluid, including at least one cup of fluid added
for every loose stool.
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The BRAT diet, while often employed as part of dietary management of
diarrhea, is not necessarily effective in managing symptoms of diarrhea in
patients with GI motility disorders. BRAT stands for bananas, rice,
applesauce, and toast, which are all relatively bland and soft foods that are
said to calm the stomach and prevent indigestion. However, there is no
evidence that states that this diet is effective in preventing diarrhea, and its
recommended use seems to be purely anecdotal.54 The diet contains very
little protein and is low in fiber, and, while it may offer some nutrients, it
does not necessarily affect diarrhea; in fact, the BRAT diet was once
recommended as part of treatment for diarrhea among children but it is now
no longer suggested by healthcare providers as part of diarrhea
management for children.60
Mild dehydration can be managed with intake of foods that provide calories
and fluid but that are easy on the gastrointestinal tract, such as soda
crackers, broth-based soup, and fruit juice. However, because of the
potential for electrolyte imbalances that can occur with chronic diarrhea, the
patient should be advised to continue to eat foods that are good sources of
vitamins and minerals. Historically, a patient with chronic diarrhea was only
given clear liquids and was not advised to eat solid foods for fear of
worsening the condition. It is now understood that the cells of the intestinal
tract are more likely to recover from damage when they are stimulated, such
as through movement and digestion of food after eating.61
When eating, the patient should eat foods that are high in nutrients but
should avoid excess sugar, caffeine, and alcohol. Some patients feel worse
after consuming dairy products, so it is often best to avoid milk or cheese
until diarrhea has resolved. Oral rehydration solutions that contain
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electrolytes may prevent fluid loss and can provide balance in the intestinal
tract. The patient may choose commercial preparations that can be taken as
a drink to restore fluid and electrolytes; an example sometimes used for
children with diarrhea is Pedialyte®. Alternatively, the patient may prepare
his or her own mixture of oral rehydration solution, which should include
salt, potassium chloride, bicarbonate of soda, and a small amount of sugar
mixed with water.
Probiotics have been shown to be an effective preventive measure against
some types of diarrhea and they may be incorporated into the patient’s diet
through food intake that contain the bacteria or through specially designed
supplements. Probiotics are microorganisms that support growth of healthy
bacteria in the GI tract. They are effective in that, after ingestion, probiotics
can destroy some toxins that contribute to illness-causing diarrhea, prevent
harmful bacteria from infecting the gastrointestinal tract, stimulate increased
mucus production in the intestinal tract, may help to decrease GI
inflammation, and diminish the effects of gas and bloating.62
The two most common types of bacteria used as part of probiotics are
Lactobacillus and Bifidobacterium. These bacteria can be purchased through
supplements that the patient may buy over-the-counter to take. However, if
the patient is suffering from diarrhea, he or she should consult with a
healthcare provider about the best type of probiotic supplement to use.
Alternatively, probiotics are also found in many foods; a patient with
diarrhea may choose to include many foods that contain probiotics into the
diet to help with GI motility and to potentially relieve some of the patient’s
symptoms. Probiotics are found in foods such as yogurt and kefir, and in
many fermented products, such as sauerkraut, sourdough bread, sour
pickles, and tempeh.
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Based on information available, probiotics can potentially shorten the time
period that a patient suffers from acute diarrhea, although the individual will
need to take enough of a dose of probiotics to impact the digestive system.
A minimum suggested amount to achieve positive effects is at least 5 billion
per day.54 Although the efficacy of probiotics has been demonstrated in
controlling symptoms of diarrhea among affected patients, they do not
necessarily counteract diarrhea from all causes. A study in the Scandinavian
Journal of Gastroenterology presented a summary of conditions that can be
effectively managed by probiotic use, including diarrhea caused by antibiotic
use, acute infectious diarrhea, diarrhea that developed as a healthcare
associated infection, and persistent diarrhea.65 The evidence for probiotics
continues to demonstrate that inclusion of foods with these beneficial
microorganisms is helpful to patients with GI motility problems, particularly
those with diarrhea.
While dietary changes are not always a complete cure for certain GI motility
disorders and many patients suffer from symptoms due to damage of an
underlying disease, a proper diet can make a significant difference in the
patient’s symptoms. For the patient struggling with nausea, food may not
sound appealing and it may be difficult to eat or prevent vomiting. However,
food and fluid intake is important for patients who suffer from nausea and
vomiting because of GI dysmotility, in order to best prevent anorexia and
dehydration.
For the patient suffering from gastroparesis that causes nausea, there are
several dietary suggestions that may help. The patient should be advised to
monitor food consumption, not only in the kinds of foods eaten, but also how
food is eaten. The patient should be advised to chew foods carefully and
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thoroughly and to avoid taking large bites or swallowing pieces of food
whole. Instead of eating three large meals a day, the patient would more
likely benefit from six small meals each day, which can prevent stomach
distention.
Many patients benefit from sitting at the table to eat and then sitting up or
walking around for at least one hour after the meal is finished. Lying down
after eating may slow the rate of stomach emptying and the patient may be
more likely to experience nausea after the meal. The individual should also
avoid greasy foods or those items that contain a lot of fat, as fat is slow to
leave the stomach and enter the duodenum. If the patient is still unable to
keep down solid food without vomiting, he or she may still try to take sips of
liquids and consume foods that are less likely to lead to nausea, including
broth, popsicles, or citrus juice. The patient may also be encouraged to
blend foods with extra liquid to break them down so that they are in a liquid
or semi-solid state, which could make them easier to tolerate.
Certain foods have been organized into a descriptive classification known as
FODMAP: fermentable, oligo-, di-, and monosaccharides and polyols. These
foods, when eaten in excess, could increase the risk of bacterial infection,
may not be absorbed well, and may increase the amount of water pulled into
the digestive tract. Examples of these types of foods include those with high
fructose corn syrup, dairy products, foods containing wheat or rye, beans
and legumes, honey; and those containing certain sweeteners, such as
xylitol, sorbitol, and isomalt. Studies have shown that FODMAP foods tend to
worsen symptoms of certain GI motility disorders, including irritable bowel
syndrome.20
One element of dietary management is removing FODMAP foods or
significantly limiting their intake to reduce symptoms of IBS. An article by
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Halmos, et al., in the journal Gastroenterology explained that decreasing
FODMAPs in the diet has been shown to help patients with IBS. The study
examined the effects of a diet low in FODMAPs when compared to a standard
diet; the subjects with IBS who followed a low FODMAP food diet suffered
from fewer symptoms of bloating, gas, and abdominal pain when compared
to those who followed standard fare diets.21 The study suggests that limited
intake of FODMAP foods should be considered as first-line therapy for
functional GI conditions such as IBS.
Not all symptoms associated with gastrointestinal motility disorders can be
successfully managed with changes to the diet; however, managing dietary
habits and choosing healthy foods in the right amount can make a difference
for many people. Because the GI tract is responsible for digestion,
absorption, and excretion of food and nutrients, it is essential to consider the
effects of dietary intake when assessing patients who suffer from disorders
of GI motility.
Activity and Exercise
Activity and exercise have been shown to be beneficial for many patients
who suffer from gastrointestinal conditions, particularly those who are
struggling with GI dysmotility. The healthcare provider may recommend
increasing activity levels for some patients, as exercise can improve
symptoms of some types of motility problems. Even when exercise does not
directly impact GI dysmotility symptoms, the patient should be encouraged
to continue with normal activities and to avoid immobility if possible, since
exercise and activity are beneficial for organ systems beyond just the GI
tract.
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Among patients who suffer from
diarrhea, increasing activity levels may
be undesirable, particularly if diarrhea
is so severe that it impacts the person’s
ability to participate in exercise or
many other activities outside of the
home. For instance, if a person is
struggling with fecal incontinence in the
form of diarrhea, he or she may have
difficulties with leaving the house for
fear of being incontinent of stool when
away from home. It may be difficult to
help a patient understand the
importance of maintaining activity levels in this type of situation.
Normally, decreased activity levels and immobility are associated with
slowed colonic motility and constipation, not necessarily diarrhea. In fact,
strenuous exercise may actually increase GI motility and could contribute
further to diarrhea when the body shunts blood away from the intestinal
tract to meet the high needs of the muscles with activity. Some people
struggle with activity-induced diarrhea when they exercise and then
experience abdominal pain and an increased urge to have a bowel
movement.
When a patient is suffering from diarrhea, rest and rehydration are typically
recommended to cope with the situation, rather than encouraging an
increase in activity levels. The healthcare provider can recommend the
appropriate amount of exercise for a patient who is already accustomed to
regular activity but who has developed diarrhea. Likewise, a patient who
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suffers from fecal incontinence may be less likely to engage in regular
exercise and may have difficulties with participating in any outside activities,
so increasing activity levels is not always an option; however, the patient
who suffers from overflow incontinence as a result of fecal impaction from
constipation should avoid long periods of immobility, if possible, and strive
to increase activity levels to prevent further constipation. While it is not
necessary to take on a vigorous exercise regimen, an increase in activity
levels in a previously sedentary person can help by improving circulation,
stimulating peristalsis, and enhancing overall feelings of well being, which is
important for the patient who feels embarrassed and humiliated because of
fecal incontinence.
Similar to diarrhea or fecal incontinence, a patient with nausea and vomiting
associated with pseudo-obstruction or gastroparesis may have reduced
activity levels and may be less likely to participate in exercise or other
activities. Movement sometimes worsens symptoms of nausea and the
patient may experience dizziness, which can further increase the risk of
vomiting. Some antiemetic drugs can cause drowsiness and may make the
patient feel lethargic, such that he or she does not have enough energy to
participate in extra activities.
However, exercise can be helpful in some situations in which the underlying
cause of the nausea could be managed. In the case of gastroparesis, a
patient may benefit from mild exercise to help improve GI motility;
recommendations associated with eating and activity levels in this situation
often advise taking a walk after eating to avoid lying down and to promote
gastric emptying of stomach contents. Often, gastroparesis is associated
with diabetes, a condition that can also benefit from regular exercise to
control weight and to promote healthy blood circulation. It is therefore
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important that the patient, who suffers from nausea as a result of intestinal
dysmotility, whether it is due to gastroparesis or some other medical
condition, consult with a healthcare provider for guidance about the
appropriate amount of exercise and activity.
Surgery — A Palliative Approach
Surgical treatment of gastrointestinal
motility disorders is palliative in nature
in that the procedures are performed to
keep the patient comfortable and to
manage symptoms. Among patients
who suffer from primary intestinal
motility disorders, surgery is not
necessarily an effective form of
treatment to cure the situation.57 The
exception is in cases of refractory
constipation that has the potential to
cause severe complications for the affected patient.
Surgical interventions for the management of GI dysmotility is done to
relieve symptoms of distress and to help the patient to manage the condition
despite its presence. Many GI motility disorders, particularly those caused by
degenerative or congenital conditions, have no cure. However, complications
that develop as a result of these disorders can cause painful and debilitating
symptoms and may even shorten the life of the affected patient. For
example, a patient who suffers from scleroderma may develop swallowing
difficulties and slow peristalsis between the esophagus and the stomach.
Surgery may be performed to eliminate some of the scar tissue present,
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which will help the situation; however, the surgery is not able to cure the
scleroderma.
Surgical treatment of esophageal conditions, such as in cases of achalasia, is
primarily aimed at improving swallowing, peristaltic action of the esophagus,
and muscular tone of the lower esophageal sphincter. Because achalasia is
caused by nerve damage or lack of neurons that serve the esophagus,
surgical treatment will not actually treat the condition. Instead, the goal of
surgery is to relieve any obstructions that have developed in the esophagus
and to alter the muscle tone of the LES so that it can allow food and fluids to
pass into the stomach.121 Surgery does help to manage symptoms of
achalasia, though, and will help to control the patient’s pain as well as
prevent certain conditions that could develop as complications, such as
malnutrition or dehydration.
Within the large intestine, disorders of motility can cause chronic diarrhea or
constipation. When constipation is severe, or the patient suffers from a GI
motility disorder because of a degenerative condition, surgical intervention
may be required to remove part of the colon and to make the patient more
comfortable. As with other types of surgical intervention for dysmotility,
surgery may initially cause discomfort because of the procedure, but the
ultimate goal is to improve the patient’s quality of life by reducing symptoms
of disease and extending the patient’s life that may otherwise be shortened
because of his or her condition.
Surgery may be indicated if a patient suffers from a GI condition that could
cause such complications as to be life threatening, such as toxic megacolon.
The condition occurs as a complication of inflammatory bowel disease or with
colon infection. When infection develops in the gut, the large intestine swells
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and expands, potentially leading to severe dehydration and even shock.
Treatment of the inflammation is paramount to avoid critical consequences.
An article by Autenrieth and Baumgart in Inflammatory Bowel Diseases
explained that surgical intervention in cases of toxic megacolon is sometimes
necessary to treat the underlying disorder causing the inflammation and
swelling.122 In this case, surgery takes a palliative approach in that the
patient will be more comfortable following the procedure, and it prevents
widespread inflammation and possible septic shock.
Colectomy is one of the more common types of surgical procedures
performed on the large intestine in order to treat some disorders of motility.
Also called a colon resection, a colectomy involves removal of some or all of
the large intestine when it is diseased and then rerouting the remaining
portions so that stool exits outside of the body through a stoma. The surgery
may be performed laparoscopically or it may be an open procedure. After
removal of the diseased part of the bowel, the healthy ends of the bowel are
then reattached. Depending on the amount of tissue removed, the colostomy
may be temporary, requiring another surgery to restore normal bowel
function, or it may be a permanent fixture.
Colectomy may be performed as a surgical procedure in a number of colonic
conditions that affect gastrointestinal motility. A study in the Journal of
Laparoendoscopic Surgeons demonstrated that a combination of subtotal
colectomy, which is a procedure that removes most of the colon but leaves
the rectum behind, combined with a modified Duhamel procedure, which
involves anastomosis of lower and upper segments of the GI tract, could be
used for the management of mixed constipation. Mixed constipation in this
case is described as a combination of slow-transit constipation and outlet
obstructive constipation. The study showed that when implemented into
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adults who suffered from mixed constipation, combination subtotal
colectomy with modified Duhamel, patients had favorable long-term effects,
including improved constipation and bowel function, as well as improved
quality of life.123
Because gastrointestinal motility disorders can arise from various pathologic
processes and their symptoms can vary widely, there is not one surgical
procedure designed to manage all types. In some cases of GI motility
disorders, such as irritable bowel syndrome, surgery is not necessarily
indicated at all. However, for those who have suffered from symptoms of GI
dysmotility as the result of an underlying disease process, surgery could be
an option that would reduce or even eliminate some uncomfortable
symptoms. The goal of palliative care is to provide comfort for the patient
and to improve quality of life. When surgery for GI dysmotility takes a
palliative approach, the patient will not necessarily receive a cure for his or
her condition but may benefit from control of symptoms, prevention of
complications, and improved feelings of wellbeing.
Pharmacologic Therapy
Prescription and over-the-counter
medication use has increased rapidly in
recent decades, with almost one-half of
Americans using some form of
prescription drug on a daily basis.
Medications are well known for their
positive benefits in controlling
symptoms associated with illness and
disease, and yet medications are also
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responsible for a number of unpleasant side effects that may prohibit some
patients from taking them. Furthermore, some medications place certain
patients at risk of complications that make their use too hazardous.
There are several classes of medications that cause gastrointestinal motility
problems. While side effects of nausea or upset stomach are extremely
common to many types of drugs and are listed on pharmaceutical
packaging, there are a few medications that can cause significant motility
problems in the GI tract. When these issues arise, patients often need to
examine whether the drug is worth the GI motility problems it causes or if
their conditions can be controlled through other means.
Opioids
One of the most well-known medication culprits that cause gastrointestinal
motility problems is the opioid analgesic. Taken for pain and used widely in
all manner of settings, including outpatient treatment centers, in-hospital
intravenous administration, or home prescription use, opioids are often
responsible for keeping patients comfortable and managing moderate-tosevere pain from procedures and from the complications of illness. Patients
suffer from the effects of pain, whether it is chronic pain from a wound or
due to illness, or acute pain as that from an injury.
Hospitals and healthcare centers have also increased their focus on
improving pain relief for patients and ensuring that patients within their
facilities gain control over their pain, and do not suffer when they are
receiving treatment. As a result, use and administration of analgesics is
more prominent than ever in the United States as healthcare providers
continue to seek methods of best controlling patient pain and maintaining
appropriate comfort levels.
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Analgesics are medications taken to control pain; they typically are
differentiated between opioid and non-opioid analgesics, with the type and
amount of the drug administered varying depending on the kind of pain the
patient is experiencing. Mild-to-moderate pain is often controlled through
non-opioid analgesics, while moderate-to-severe pain is more often
managed with opioid analgesics. Drugs described as opioids are those that
come from opium of the poppy plant; and, they may be natural or synthetic
versions of the drug. After administration, opioid medications attach to
certain receptors in the brain, producing a chemical response that induces
feelings of pleasure by stimulating the brain to release dopamine. This
attachment to receptors also produces feelings of calm and it blocks the
sensation of pain.
Because of the increase in use of opioids within healthcare facilities and
within the community, patients are also experiencing an increase in their
side effects. Opioid medications have been known to cause neurological
changes such as confusion or mental “fog,” may slow the breathing rate,
sometimes to a dangerously low level; and, they produce gastrointestinal
side effects, typically including nausea, vomiting, and constipation. Opioids
can attach to various receptors, including the mu, kappa, and delta
receptors, which affect different sites throughout the body, so they are able
to control pain but also cause side effects in numerous locations in the body.
There are many opioid receptors in the gastrointestinal tract. When opioids
are administered, they can affect these receptors and cause changes,
including a decrease in mucus secretions, an increase in fluid reabsorption,
and delayed gastric emptying. As a result, the patient who takes these drugs
is more likely to suffer from GI complaints such as nausea and constipation.
Approximately 25 percent of patients who are treated with opioids
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experience nausea as a side effect.35 This effect can be worsened if the
patient with nausea also experiences central nervous system changes that
cause dizziness or that affect balance.
Even more common as a side effect, constipation may impact up to 95
percent of patients who use opioid analgesics.35 The development of hard,
dry stools and slowed transit times in the large intestine results from
decreased intestinal mucus production and increased reabsorption of fluid
from the colon, thereby slowing GI motility and making stools difficult to
pass. In some cases, constipation may also be worsened if the patient has
gone for periods without eating, such as with anorexia that has developed
because of nausea or because of requirements for certain medical
procedures. In such cases, the patient does not have the food intake needed
to stimulate the GI tract to promote motility.
Fortunately, the awareness and knowledge of the gastrointestinal side
effects of opioid analgesics is so well known that healthcare providers can
take measures to prevent these complications before they begin. For
patients at risk of nausea because of slowed gastric motility, the provider
may order antiemetic drugs to be administered prophylactically. Other
measures to prevent or control nausea include distraction and relaxation
techniques, as well as administration of other types of drugs to control
dizziness or vertigo that may accompany the nausea, such as antihistamines
and anticholinergic preparations.
For prevention and control of constipation, the provider may need to ensure
that the patient maintains adequate fluid intake while taking opioid
analgesics and that dietary fiber intake is adequate to prevent fluid
reabsorption in the GI tract. For many patients, stool softeners are ordered
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concomitantly with the opioid analgesics to help maintain normal bowel
habits. Bulk forming and stimulant laxatives may also be needed to improve
bowel function and to reduce constipation. Many patients reduce intake or
even eliminate taking opioids because of the GI side effects; however, with
the availability of these measures to treat nausea and constipation, the
patient may not need to cut back on opioid medications to avoid their
adverse effects.
Antidepressants
One of the most commonly prescribed medications in the United States,
antidepressants are recommended for treatment of depression and some
other forms of mental illness, as well as certain other chronic conditions that
can cause pain or anxiety, including fibromyalgia and chronic fatigue
syndrome. Antidepressants, while helpful to many, can also cause symptoms
of gastrointestinal distress and can affect GI motility.
Antidepressants regulate levels of serotonin, which are found in the brain
and in the GI tract. Serotonin is a neurotransmitter that affects human
behavior and emotion; consequently, a person may take antidepressants to
control depression or regulate anxiety. Since serotonin receptors are present
in the GI tract and associated with pain from rectal distention, i.e., as occurs
with irritable bowel syndrome (IBS), antidepressants are used as part of
treatment for IBS, as well as depression.36 In fact, antidepressant
prescription is part of routine management of irritable bowel syndrome. This
may be because of the effects of these medications on serotonin in the GI
tract; however, it could also be due to the psychological symptoms
associated with IBS. Persons who suffer from chronic constipation or
diarrhea associated with IBS may experience a worsening of symptoms
during times of stress or emotional suffering.
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Antidepressants can cause a number of gastrointestinal side effects. Patients
with IBS who take antidepressants, as part of treatment for IBS, should also
be aware of the potential side effects associated with these drugs. Likewise,
other individuals who take antidepressants but who have not necessarily
been diagnosed with a gastrointestinal condition may also suffer the
abnormal GI effects that these drugs can cause.
The most common offenders in these cases are tricyclic antidepressants and
selective serotonin reuptake inhibitors. Tricyclics have the potential to slow
intestinal transit because they have anticholinergic activity, in which they
block the action of acetylcholine in the parasympathetic nervous system. As
a result, the affected person is more likely to suffer constipation and slowed
colonic transit due to decreased GI motility.70 These drugs also may diminish
secretions in the stomach and intestines and salivation in the mouth,
resulting in xerostomia, abdominal pain, bloating, and nausea.
Alternatively, selective serotonin reuptake inhibitors (SSRIs) can have the
opposite effect on the gastrointestinal system and may cause increased
intestinal transit.70
As stated previously, serotonin is found in the GI tract and exerts some
control over sensorimotor function. When food is digested and chyme passes
through the intestinal tract, certain cells known as enterochromaffin cells
release serotonin, which triggers peristalsis through nerve pathways. When
a person takes a SSRI antidepressant, the availability of serotonin in the GI
tract is prolonged, thereby potentially increasing the rate of peristalsis and
intestinal motility.71 Selective serotonin reuptake inhibitors are often
prescribed for patients who suffer from IBS with predominant constipation,
as the increased GI motility associated with their use can reduce these
symptoms. However, SSRI use may also cause the opposite effects and may
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set off too rapid of peristaltic action, resulting in diarrhea. The affected
individual may also suffer from abdominal pain and excess flatulence.
A study by Choung, et al., in the journal Neurogastroenterology & Motility,
used questionnaires to examine patient responses to discern the effects of
antidepressant use on the gastrointestinal system. The most common
symptom reported by participants in the study was abdominal bloating and
distention. The researchers in the study believed that this was possibly due
to slowed GI motility, delayed gastric emptying, or that antidepressants
promote bacterial overgrowth within the small bowel, leading to excess gas
production and bloating.70 When a patient needs an antidepressant for
support for mental health issues, or if these drugs are prescribed as adjunct
medications for other conditions, affected patients should be counseled
about the GI effects they can cause. Some effects may be transient and may
cause minor symptoms; while other effects can be significant enough that
affected patients may want to change prescriptions entirely.
Anticholinergics
Anticholinergic drugs are prescribed to work against the effects of the
neurotransmitter acetylcholine within either the central or the peripheral
nervous systems. There are a number of anticholinergic drugs available and
their uses vary, depending on the body system involved. Anticholinergics are
prescribed for respiratory disorders, as they act as bronchodilators in cases
of asthma or chronic bronchitis; and, they may be prescribed for dizziness or
insomnia, and they may also be used for some genitourinary conditions,
such as when patients suffer from bladder dysfunction. Additionally, some
anticholinergics are prescribed to control GI conditions and may be
prescribed in cases of ulcerative colitis, gastritis, diarrhea, nausea, and
vomiting.
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There are two main types of cholinergic receptors in the body: nicotinic and
muscarinic receptors. Nicotinic receptors are found in the neuromuscular
junction between the nerve and the muscle, whereas muscarinic receptors
are found in cell membranes of certain neurons. As a neurotransmitter,
acetylcholine binds to both types of receptors. There are different sub-types
of muscarinic receptors, which are found in specific locations throughout the
body. For example, muscarinic-1 receptors are found in the brain, the
salivary glands, and the stomach, while muscarinic-3 receptors are located
in certain smooth muscles. Stimulation of muscarinic-3 receptors in the
smooth muscle can lead to increased production of gastric acid.40 Within the
gastrointestinal system, stimulation of muscarinic receptors has been shown
to increase GI motility and to potentially cause nausea and vomiting.
Alternatively, antagonism of muscarinic receptors has been shown to
decrease both GI motility and gastric acid production.
When an anticholinergic medication is administered and the drug blocks the
effects of acetylcholine, there is less of the neurotransmitter to bind to the
nicotinic and muscarinic receptors in the body. A study in the journal BMC
Geriatrics investigated defecation frequency among older adults with chronic
obstructive pulmonary disease (COPD) who used muscle relaxant
medications to control some of their respiratory symptoms. The study
showed that those adults who used the drugs to control respiratory
symptoms also had lower levels of defecation frequency and were more
likely to suffer from constipation and slowed colonic transit.86 Because
anticholinergic drugs are prescribed for so many different conditions, there is
potential for patients to develop a number of gastrointestinal motility
disorders with regular use of these drugs. As with other medications,
patients should be counseled to understand the GI side effects associated
with anticholinergic drugs when they begin taking them.
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Loperamide
There may be times when an individual takes medications specifically for
symptomatic management of gastrointestinal motility problems but then
ends up suffering adverse effects, sometimes because the medication seems
to have too much of an effect on intestinal transit. An example of this is the
use of antidiarrheal medications such as loperamide, which are often
prescribed for the management of acute or chronic diarrhea, as well as
traveler’s diarrhea among patients who are suffering from loose stools.
Antidiarrheal medications such as loperamide are typically indicated for use
on a controlled or short-term basis, rather than being taken daily on a longterm basis. In general, many antidiarrheal drugs are not necessarily meant
to be taken for an indefinite period of time; if a patient needs to take these
types of drugs because of chronic diarrhea that is not responding to other
medication, then the situation should be discussed with a healthcare
provider first.
Loperamide works by decreasing gut motility to slow down the rate of
intestinal transit so that the affected person is less likely to suffer from
diarrhea. When colonic transit slows, more fluid is absorbed and the stools
are less watery and become more formed. For some people, though, the
effects of the drug can go in the opposite direction and can slow colonic
transit so much that constipation develops. If excess fluid is reabsorbed in
the colon to avoid watery stools, the body could ultimately absorb too much
fluid from the intestinal tract, creating hard and dry stools associated with
constipation.
The potential for constipation with loperamide use is enough that
researchers sometimes induce constipation using the drug in lab animals in
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order to study treatment options for constipation symptoms.87 For many,
however, use of antidiarrheals such as loperamide is effective in treating
diarrhea and controlling its unpleasant symptoms without causing
constipation. Patients who want to use this type of drug for treatment of
diarrhea should take it carefully and according to directions. Side effects can
often occur when a person takes the drug incorrectly.
Anti-Parkinson Drugs
Although Parkinson’s disease (PD) was originally classified as a nervous
system disorder, it is now considered a multi-organ syndrome, affecting
various systems throughout the body.32 Gastrointestinal symptoms have
been shown to worsen as Parkinson’s disease progresses; alternatively, a
patient with PD who takes medication to control symptoms of the illness may
be more likely to end up suffering from gastrointestinal effects as well.
Certain drugs used for management of disorders such as Parkinson’s disease
have been shown to affect gastrointestinal motility, typically within the
stomach, causing delayed gastric emptying. Parkinson’s disease is more
common among older adults; this population of patients often suffers from
symptoms of nausea, vomiting, constipation, and feelings of gastric fullness
after taking medication. Levodopa is the most common agent prescribed for
management of Parkinson’s disease. Levodopa is a precursor of dopamine.
This drug may be more likely to slow GI motility because of its effects on
dopamine receptors in the intestinal tract. Levodopa has also been shown to
act on the stomach wall, decreasing movement of the pyloric sphincter and
slowing the rate of gastric emptying.34
A person with Parkinson’s disease often develops neurological deficits
including tremor, slow motor movements, and rigidity; and, these symptoms
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are caused by lack of dopamine in the brain. After administration of
levodopa, the brain converts it into dopamine, where it is stored until the
body needs it to regulate its movement. Levodopa has been used
successfully for management of PD for years. Its formulation has changed
somewhat since the time of its initial release. Levodopa is now available in
extended release forms that may have less of an effect on the GI system if
the drug is released over a longer period of time.
The introduction of carbidopa, another medication used to enhance the
effects of levodopa, results in a much lower dose requirement of levodopa
when the two drugs are taken together.33 Carbidopa on its own has little to
no therapeutic benefit, so it must be taken with levodopa for the patient to
gain positive effects. Sinemet® is an example of a drug that is a
combination of levodopa and carbidopa.
Dopamine cannot be administered to patients with PD because dopamine
cannot cross the blood-brain barrier. Levodopa is the next best option
because it is converted to dopamine in the body. However, because of its
gastrointestinal side effects, there is a catch to taking this drug on its own;
the patient often must either suffer from neuromuscular side effects
associated with PD or must endure GI problems related to levodopa.
Fortunately, the administration of carbidopa along with levodopa inhibits
certain enzymes that affect levodopa’s conversion to dopamine, thereby
reducing the amount of levodopa needed. The patient can still achieve the
desired effects of the drug but with fewer instances of GI disturbances.
Medications used for the management of GI dysmotility may be administered
to treat the underlying cause of the motility problems. Alternatively, they
may also be given to counteract many of the negative symptoms the patient
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with a motility disorder is experiencing. In many cases, drugs for symptom
control and for treatment of the medical condition may be administered
concomitantly.
Pharmacologic intervention for management of the symptoms of GI motility
problems may make the patient more comfortable in terms of coping with
his or her condition, but administering medication to counteract symptoms
will not treat the underlying disease. Drugs are often given to work against
some of the more common symptoms of dysmotility, including diarrhea,
constipation, nausea and vomiting, and stool incontinence. Pharmacologic
management of diarrhea is often administered in the form of antidiarrheal
medications. These drugs slow peristalsis in the intestinal tract, thereby
prolonging the time that food and waste is digested and absorbed. Some
medications also allow more time for fluid to be absorbed in the intestinal
tract so that stools are not liquid and watery.
Antidiarrheal medications are best indicated for conditions that cause
increased GI motility and diarrhea, including irritable bowel syndrome with
predominant diarrhea, for occasional use among patients who struggle with
fecal incontinence, and with other situations that cause transient bouts of
diarrhea. Antidiarrheals are available in prescription strength but they can be
purchased over the counter as well. The patient who wants to consider using
this type of drug should consult with a healthcare provider first to determine
the most appropriate medication for use and to find out if the drugs would
otherwise mask an illness that requires further treatment. Some common
types of antidiarrheal medications that are available without a prescription
include loperamide (Imodium®) and bismuth subsalicylate (Kaopectate®).
In addition to controlling diarrhea, these drugs can also help to manage
other unpleasant symptoms the patient may be experiencing as a result of
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the illness. For example, the makers of Pepto Bismol, which is a brand name
for bismuth subsalicylate, state that their product is also able to treat
indigestion, nausea, and heartburn.53 Other drugs used for management of
diarrhea and that may be available by prescription include diphenoxylate
with atropine (Lomotil®), which can be also be accessed without a
prescription but the dosage available as an over-the-counter product is lower
than prescription strength. Note that this drug is considered to be a
Schedule V controlled substance. Difenoxin with atropine (Motofen®) is
another prescription antidiarrheal that has been discontinued in the United
States and there is no generic equivalent.
Patients who take antidiarrheal medications should be aware that these
drugs can sometimes work too well, and they may end up struggling with
constipation and slowed GI motility instead of diarrhea. A patient who has
had chronic diarrhea may or may not be an appropriate candidate for
antidiarrheal therapy, at least not on a long-term basis. Antidiarrheals
change the motility of the gastrointestinal tract but they are often not meant
to be permanent additives to a therapeutic regimen. A patient who takes
antidiarrheal medications on a long-term basis without the advice of a
healthcare professional may only conceal underlying symptoms of illness
without treating the actual disease. Long-term use may also lead to chronic
constipation and the process should only be undertaken with the help of a
healthcare provider.
When diarrhea is suspected of having an infectious cause, antibiotics may be
administered to not only manage the symptoms of the diarrhea, but also to
treat the underlying bacterial infection that is causing the GI motility
problems. Antibiotics are not recommended in all cases, and they should not
be used if the patient’s cause of diarrhea is because of viral infection. It
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should also be noted that antibiotic use for treatment of diarrhea is less
common than using other non-pharmacological forms of treatment, such as
with fluid and electrolyte rehydration. However, there are some cases in
which a patient who suffers from prolonged diarrhea because of a specific
type of infection would benefit from the administration of antibiotics,
including infection with Clostridium difficile, prolonged infection with
Escherichia coli bacteria, and Salmonella infection in very young children.54
Antimicrobials are given to break down the infectious organism and prevent
its further spread within the gastrointestinal tract. The type and brand of
medication to use depends on the organism and the extent of the patient’s
symptoms. Isolation of the specific kind of organism causing the infection
may be necessary through serum or stool samples. Antibiotics manage
bacterial infections; and, they may be broad spectrum, in which they harm
many different strains of bacteria, or narrow spectrum, in which they target
specific types of bacteria. The healthcare provider may prescribe a broadspectrum antibiotic as coverage against the bacterial infection but may
change to a specific drug when the exact organism has been isolated.
Examples of antibiotics that may be prescribed for the management of
infectious diarrhea include cefotaxime (Claforan®), vancomycin, and
erythromycin.54
Parasitic infection may also lead to diarrhea, which should be treated with
antiparasitic medications to control spread and to prevent worsening of
symptoms. Antiparasitic drugs may target certain species or they may be
broad-spectrum types that provide coverage against any number of parasitic
organisms. An example of this type of drug is furazolidone (Furoxone®). It
is important to remember that whenever a patient is suffering from
infectious diarrhea, antimicrobial medications can help to manage symptoms
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and to control the spread of the infection in the body, but the patient must
still take precautions to prevent spreading the infection to others.
Unfortunately, the nature of diarrhea excretion increases the risk of
exposure to infectious microorganisms to caregivers and healthcare
personnel, so the patient should be taught safety measures to practice good
hygiene and prevent further spread of microorganisms.
There are several pharmacological treatment options available when the
patient is suffering from prolonged constipation as a symptom of dysmotility.
The slowed colonic transit may be best managed through certain types of
drugs that are designed to speed up passage of stool through the intestinal
tract; as with antidiarrheal medications, these drugs are often available
without a prescription. Laxatives are commonly used for the intermittent
management of constipation. Many laxatives can be purchased without a
prescription, making them easy and inexpensive to use.
Bulk-forming laxatives prevent and
treat constipation, and are typically
made up of products such as
psyllium or methylcellulose; and,
include Metamucil® and Citrucel®.
Magnesium laxatives treat
constipation by causing the colon to
retain more fluid, thereby preventing
the hardening of stool. An example
of this type of laxative is Phillips Milk
of Magnesia®. Stimulant laxatives
(Senokot®, Ex-Lax®, Dulcolax®)
manage constipation by stimulating the nerves that feed the large intestine,
promoting colonic motility.
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Stool softeners are usually taken as oral medications or as liquid
preparations to help some patients who are unable to strain while
defecating. They are optimally for those who have pain with defecation
because of obstruction or a medical condition, such as anal fissures.
Examples include docusate (Colace®, Correctol®).25 When using
medications to control constipation, the patient should be informed about
the potential side effects that some of these drugs can cause. Most laxatives
and stool softeners are able to adequately treat constipation, which can be
further prevented with changes in lifestyle habits. However, if the patient
takes too much of the medication, takes it unnecessarily out of fear of
developing constipation, or otherwise uses the drug inappropriately, he or
she could develop diarrhea and could be at risk of complications associated
with that symptom. As with drugs to control any symptoms of GI motility
disorders, the patient must always be educated about the correct use of the
drug in order to best control his or her condition but also to stay safe while
using medication.
Nausea and vomiting can develop as significant symptoms from GI motility
disorders. These two common symptoms are most frequently seen with GI
dysmotility conditions such as gastroparesis, intestinal pseudo-obstruction,
and dumping syndrome. As a symptom, nausea may be treated with certain
medications to control the unpleasant feeling and to prevent vomiting. Antinausea medications are designed to control nausea and motion sickness
without necessarily treating the underlying disorder. If the patient has
developed nausea as a result of a GI condition, antiemetic drugs will only be
a temporary solution until the underlying cause is also controlled.
There are various drugs available for treatment of nausea. These drugs may
be accessible to the patient with or without a prescription. Some nonprescription medications that are used to symptomatically control diarrhea
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may also be used to manage nausea, such as bismuth subsalicylate. Overthe-counter antihistamines can also control nausea by preventing the inner
ear from sensing motion and sending the message about the sense of
nausea to the brain. Prescription antiemetic medications can be used for
more severe cases of nausea and they may be administered in other
methods beyond the oral route, which can be particularly effective if the
patient has been vomiting.
Prescription antiemetics may work in a manner similar to non-prescription
drugs in that they can block messages to the brain that stimulate the sense
of nausea. An example of this type of drug is promethazine (Phenergan™).
Additionally, some prescription antiemetics work by increasing gut motility to
speed up the rate that food moves through the intestine. Metoclopramide
(Reglan®) is an example of this type of drug. In addition to oral
preparations, antiemetics may be administered as rectal suppositories,
transdermal patches, intramuscular injections, or as intravenous injections.
Symptomatic management of fecal incontinence involves control of the rate
at which the bowel moves stool through the intestinal tract. If a person
suffers from diarrhea associated with fecal incontinence, he or she may
benefit from antidiarrheal medication to reduce fluid loss and to retain stool
bulk to avoid accidental loss of stool from the rectum. When overflow fecal
incontinence occurs, the patient may need to try medications to control
constipation without further inducing diarrhea. Medications such as
loperamide will reduce stool frequency among patients with fecal
incontinence, which can help them to achieve greater control. As with other
symptomatic treatments, though, unless the underlying condition is
managed, these medications may only temporarily control the situation.
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Certain drugs may be administered to manage not only the symptoms
associated with a gastrointestinal motility disorder, but also to control the
underlying cause of the condition. Cholinergic agonists are drugs that act in
a manner similar to the neurotransmitter acetylcholine. The cholinergic
system is also referred to as the parasympathetic nervous system; when this
system is stimulated, the body responds through vasodilation, increased
secretion of sweat and saliva, and increased mucus secretion. Studies have
shown that patients who suffer from intestinal pseudo-obstruction may have
excessive suppression of the parasympathetic system.57 Administration of
cholinergic agonist medications may then change this response and help to
alleviate some symptoms. Some cholinergic agonists that may be used
specifically for the management of intestinal motility disorders include
neostigmine (Prostigmin®) and bethanechol (Uricholine®).
Delayed gastric motility, such as that seen with gastroparesis, can lead to
nausea that may well respond with antiemetic medications. However, these
drugs only manage some of the symptoms of the condition but do not treat
the underlying GI motility problems. Prokinetic medications can be
administered to increase the speed of GI motility to move food through the
intestinal tract at a faster rate. These drugs have been mentioned as
treating nausea associated with gastroparesis, in that they facilitate faster
gastric emptying, thereby reducing symptoms of nausea as well as other
complications, such as abdominal distention, pain, and bloating.
Drugs known as dopamine antagonists are also useful when administered to
some patients with GI motility disorders, namely those who suffer from
delayed motility problems. Normally, dopamine inhibits certain activities
within the gastrointestinal tract, such as the ability of the LES to close
properly as well as the overall rate of motility.65 Dopamine antagonist
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medications block dopamine receptors in the GI tract, although they may
also be used for the management of some other conditions to prevent
dopamine’s effects in other parts of the body. The main dopamine antagonist
medications used for management of delayed GI motility are domperidone
and metoclopramide, which has been mentioned as an antiemetic medication
and is also called Reglan. Macrolides, which are drugs that are traditionally
used as antibiotics, may also be administered for GI motility disorders, as
they have been shown to increase the rate of transit in the GI tract. The
most commonly used drug in this class is erythromycin, which may be
administered intravenously or orally, depending on the patient’s condition.
Erythromycin has been shown to accelerate the rate of gastric emptying in
patients who suffer from gastroparesis in which they otherwise experience
delayed gastric motility.64
Future Trends in Treatment
In earlier sections, Rome III Criteria
to diagnose and treat varied
functional gut disorders was
discussed. The growing field of
neurogastroenterology involves a
unique body of research, and
medical specialists have come
together to form working
committees to develop improved
algorithms aimed at supporting
clinicians to identify GI dysmotility symptoms, and to diagnose and to treat
GI motility disorders. Presently, Rome IV guidelines are being developed
related to novel treatments for gut microflora and the nature and severity of
functional gut disorders. Additionally, the role of dietary nutrients is a major
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area of clinical research focused on the development of new diagnostic
criteria to treat gastrointestinal conditions. Clinicians are encouraged in
newer treatment guidelines to utilize screening questionnaires and quality of
life assessment tools when developing a plan of care for patients affected by
a GI motility disorder. In addition to existing pharmacotherapy approaches
to care, a systematic multidisciplinary approach to evaluate GI symptoms,
chronicity and complexity of treatments to control symptoms, has evolved to
assist primary care clinicians by clarifying important treatment questions and
implementing up to date solutions for patients.
The burden of health care for patients affected by a GI motility disorder has
been a major impetus in the development of multidisciplinary approaches to
treatment to assist primary care providers to translate newer criteria into
ways that better meet patient care needs. While this growing body of
research is beyond the scope of this study, clinicians should know of newer
helpful screening tools and algorithms to guide patient care. More diverse,
cross-cultural influences in the treatment of a GI motility disorder that
involves a growing body of research and practice guidelines have emerged.
The field of neurogastroenterology has increasingly developed into multidimensional working committees of clinical researchers organized to develop
improved therapeutic options for the wide spectrum of individuals suffering
from functional gut disorders.
Summary
Gastrointestinal motility disorders comprise a complex grouping of conditions
that affect the rate at which the intestinal system is able to process food and
excrete waste. Motility disorders may produce mild symptoms or even no
symptoms at all for some people. Alternatively, symptoms from pathologic
processes that cause GI dysmotility may lead to pain and other debilitating
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symptoms that can significantly decrease quality of life. Healthcare providers
have many options for technological procedures that can successfully
diagnose specific types of GI motility disorders. Furthermore, scientific
advancements, new research developments, and proven methods of surgical
intervention can all effectively assist patients who suffer with these
conditions to be able to live normal and healthy lives despite having a GI
motility disorder.
Clinicians are increasingly able to rely upon improved diagnostic
classification systems and treatment approaches that capture a patient’s
clinical profile more completely than in previous years. The burden on
healthcare due to the chronicity and complexity of the nature of many GI
motility disorders has been an impetus of many working groups to develop a
diagnostic classification system that supports clinicians to diagnosis and
treat conditions at various stages of progress. Patients with a diagnosis of
IBS seen in primary care settings today may be treated quite differently
according to newer practice guidelines, including greater consideration of
psychological and physiological co-morbidities. The direction of future
research and new clinical guidelines considers the multi-dimensional profile
of patients, enabling clinicians to better identify and classify GI motility
disorders than in prior years.
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1. Ninety percent of absorption of nutrients occurs in the
a.
b.
c.
d.
stomach.
duodenum.
small intestine.
large intestine.
2. True or False: The small intestine is referred to as “small”
because it is the shortest segment of the GI tract.
a. True
b. False
3. The junction between the small intestines and the colon is the
a.
b.
c.
d.
ileocecal valve.
cecum.
pyloric sphincter.
duodenum.
4. When disorders of motility occur in the small intestine, the
affected patient may suffer from
a.
b.
c.
d.
malnutrition.
fluid and electrolyte imbalances.
overgrowth of intestinal bacteria.
All of the above
5. True or False: An opioid analgesic, a drug used to manage
moderate-to-severe pain, may cause side effects, such as nausea,
vomiting, and constipation.
a. True
b. False
6. Within the gastrointestinal system, stimulation of muscarinic
receptors has been shown
a.
b.
c.
d.
to decrease gastric acid production.
to decrease gastrointestinal motility.
to increase GI motility.
slow colonic transit.
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7. Adults who use anticholinergic medication to control respiratory
symptoms
a.
b.
c.
d.
may have lower levels of defecation frequency.
may have increased colonic transit.
may have improved gastrointestinal motility.
will suffer from diarrhea as a side effect.
8. Intestinal neuropathy may occur as a result of
a.
b.
c.
d.
poorly controlled diabetes.
Parkinson’s disease.
spinal injury.
All of the above
9. True or False: Carbidopa is a dopamine precursor.
a. True
b. False
10. Loperamide is given to patients
a.
b.
c.
d.
to accelerate the rate of intestinal transit.
as a treatment for diarrhea.
as a treatment for constipation.
None of the above
11. True or False: Carbidopa on its own has little to no therapeutic
benefit, so it must be taken with levodopa for the patient to
treat diarrhea.
a. True
b. False
12. Scintigraphy is a diagnostic test that uses the following item(s):
a.
b.
c.
d.
radiographic isotopes.
scrambled eggs.
technetium or iodine.
All of the above
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13. True or False: The term enteric dysmotility is used to describe
motility disorders of the colon.
a. True
b. False
14. Enteric dysmotility is demonstrated as abnormal contractions in
the intestinal tract that typically lead to delays in the transport
of food through
a.
b.
c.
d.
the small intestine.
the large intestine.
duodenum.
anal canal.
15. In hypertensive lower esophageal sphincter,
a. there is decreased function of the excitatory nerves feeding the
esophagus.
b. the neurons in the esophagus work at a faster pace.
c. a patient will have increased muscle contractions within the lower
esophageal sphincter.
d. All of the above
16. Anismus describes a condition in which the patient
a.
b.
c.
d.
swallows large amounts of air.
is unable to control his pelvic floor muscles normally.
passes stool through the anus with little to no control.
swallowing food and then regurgitating it.
17. Hypothyroidism is associated with
a.
b.
c.
d.
weight loss.
an decrease in thyroid hormone production.
constipation.
decreased sensitivity to cold.
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18. To reduce symptoms of IBS, a patient should remove or limiting
FODMAP foods; FODMAP foods include
a.
b.
c.
d.
high fructose corn syrup.
dairy products.
foods containing wheat or rye.
All of the above
19. True or False: Patients diagnosed with IBS cannot take tricyclic
antidepressants (TCAs) or selective serotonin reuptake
inhibitors (SSRIs).
a. True
b. False
20. If a patient increases dietary fiber intake to combat
constipation, the patient should
a. increase daily fiber to 60 g per day all at once for immediate
results.
b. avoid insoluble fiber completely.
c. increase fluid intake.
d. avoid nuts and seeds.
21. Achalasia is a condition that affects how food is transitioned
between the mouth and the stomach, and it typically
a.
b.
c.
d.
develops as an acute condition.
develops over time.
causes initial symptoms of mild reflux.
Answers b., and c., above
22. Chronic intestinal pseudo-obstruction (CIP) develops as a
disorder that
a.
b.
c.
d.
results in poor intestinal motility.
causes the bowel to become hyperactive.
always involves a tumor.
Answers b., and c., above
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23. Management of chronic intestinal pseudo-obstruction (CIP) is
a.
b.
c.
d.
palliative.
curative.
supportive (treat symptoms and prevent complications).
None of the above
24. Examples of degenerative diseases that affect swallowing
include
a.
b.
c.
d.
Huntington’s disease.
Dementia.
Creutzfeldt-Jakob disease.
All of the above
25. One condition that may be more likely to develop with
polymyositis is
a.
b.
c.
d.
chronic constipation.
genetic predisoposition to polyp formation.
gastroparesis.
reflux disease.
26. Dumping syndrome is best managed with
a.
b.
c.
d.
changes in dietary practices.
long-acting insulin.
routine use of a prokinetic agent.
Answers b., and c., above
27. Much of the peristalsis and transit of food occurs by
a.
b.
c.
d.
voluntary chewing action that stimulates chyme.
involuntary control of smooth muscles in the GI tract.
voluntary and involuntary actions.
None of the above
28. True or False: A person with Hirschsprung’s disease has GI
hypermotility.
a. True
b. False
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29. _________________ most often occurs because of motion
sickness or as nausea during the first trimester of pregnancy.
a.
b.
c.
d.
Peristalsis
Tachygastria
Achalasia
Gastroparesis
30. True or False: Too much glucose in the bloodstream damages
parts of the GI system.
a. True
b. False
31. Drugs that promote gastric emptying are
a.
b.
c.
d.
Metoclopramide (Reglan®).
Erythromycin.
Amitiza.
Answers a., and b., above
32. Thyroid abnormalities may
a.
b.
c.
d.
later develop GI motility problems.
have no correlation to GI motility conditions.
cause constipation or diarrhea.
Answers a., and c., above
33. Addison’s disease is also called
a.
b.
c.
d.
Cushing syndrome.
hypocortisolism.
hypercortisolism.
hypothyroidism.
34. True or False: Brain-gut dysfunction describes a condition in
which a patient may experience GI symptoms in response to
emotions and psychological distress.
a. True
b. False
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35. A patient with IBS-C type may need medications that include
a.
b.
c.
d.
osmotic laxatives, stool softeners, and non-bulking agents.
stool softeners and non-bulking agents.
osmotic laxatives, stool softeners, and bulking agents.
None of the above
36. Biofeedback helps patients with fecal incontinence and can be
done with
a.
b.
c.
d.
manometric measures of the LES.
an anorectral manometry procedure.
both LES and duodenal manometry.
Answers b., and c., above
37. Pelvic floor dysfunction affects the person’s ability to
a.
b.
c.
d.
pass stool regardless of transit time or stool consistency.
pass stool due to transit time.
pass stool due to stool dryness.
Answers b., and c., above
38. Sarnelli, et al., in the World Journal of Gastrointestinal
Pathophysiology, investigated
a.
b.
c.
d.
IBS.
biliary stenosis.
specific genes contributing to development of achalasia.
gastroparesis.
39. A known risk factor for fecal incontinence include
a.
b.
c.
d.
ages 1 – 2.
male gender.
having a physical disability.
nerve injuries affecting the LES.
40. True or False: Genes and familial tendencies are a large part of
whether certain patients are at high risk of GI motility problems.
a. True
b. False
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41. Chronic megacolon may be
a.
b.
c.
d.
a congenital condition.
an acquired condition because of illness.
an acquired condition due to toxicity.
All of the above
42. Tachygastria is a condition that causes
a.
b.
c.
d.
high-frequency electrical activity in the stomach with digestion.
low frequency electrical activity in the stomach between meals.
fainting spells.
extreme hunger pains.
43. Rumination is a behavior disorder where a person
a.
b.
c.
d.
swallows food and then regurgitates it.
thinks about food all the time.
swallows large amounts of air and does not expel it.
belches but does not vomit.
44. True or False: Anismus is a condition in which the patient is
unable to control pelvic floor muscles normally in order to
defecate.
a. True
b. False
45. A person with aerophagia
a.
b.
c.
d.
has GERD.
will experience increased flatulence, not belching.
swallows large amounts of air.
All of the above
46. True or False: Functional fecal retention is the most common
behavioral disorder that causes motility problems in the large
intestine, rectum, and anus.
a. True
b. False
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47. At an initial meeting with a patient, the nurse should question
the patient about
a.
b.
c.
d.
symptoms, including history of pain.
changes in stool output or toileting practices.
feelings of pressure or bloating in the abdomen and lower pelvis.
All of the above
48. A patient with diabetes who has uncontrolled blood glucose
levels could develop neuropathy and gastroparesis to the point
that the patient
a.
b.
c.
d.
develops high-frequency electrical activity in the stomach.
develops low-frequency electrical activity in the stomach.
is unable to detect the need to have a bowel movement.
has regular, extreme hunger pains.
49. Scintigraphy is an X-ray that is performed
a.
b.
c.
d.
before meal consumption.
after meal consumption.
to help diagnose a GI motility disorder.
Answers b., and c., above
50. True or False: Enterography is seldom done because it is more
invasive than endoscopic procedures.
a. True
b. False
51. A colonoscopy involves the following preparation
a.
b.
c.
d.
a clear liquid diet for 6 hours before the procedure.
a clear liquid diet 1 day before the procedure.
a clear liquid diet 3 days before the procedure.
None of the above
52. Proctoscopy involves examination of
a.
b.
c.
d.
the rectum.
the distal portion of the small bowel.
the second portion of the small bowel to rule out inflammation.
Answers a., and b., above
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53. True or False: Another name for an esophagography is the
barium swallow test.
a. True
b. False
54. True or False: The single-contrast technique describes
application of contrast using a barium enema alone, while the
double-contrast technique involves administering a barium
enema and air into the large intestine.
a. True
b. False
55. A drawback to capsule endoscopy is that it
a.
b.
c.
d.
only takes pictures of GI conditions in the bowel.
is mostly designed to take pictures of only the large bowel.
must be retrieved endoscopically.
Answers b., and c., above
56. Electrodes used with EMG are often special types of __________
that are placed within the muscle tissue.
a.
b.
c.
d.
electrodes
needles
calibrators
sensors
57. Dyssynergic defecation may be defined and characterized as
a.
b.
c.
d.
a functional defecation disorder.
paradoxical contractions of anal sphincter muscle.
inability to relax the anal sphincter muscle.
All of the above
58. Three main types of cells in the blood and CBC test are
a.
b.
c.
d.
white blood cells, absolute neutrophils and eosinophils.
white blood cells, red blood cells and platelets.
red blood cells, platelets and neutrophils.
red blood cells, basophils and absolute neutrophils.
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59. Microcytic red blood cells typically develop if the patient
a.
b.
c.
d.
has an iron deficiency anemia.
is suffering from a GI motility disorder.
has hyponatremia.
has a vitamin deficiency.
60. Hypothyroidism is a condition associated with
a.
b.
c.
d.
a number of GI motility problems.
a possible drop in red blood cells.
hyponatremia (low sodium).
Answers a., and b., above
61. Normal platelet count in men and women is
a.
b.
c.
d.
90,000 to 100,000 mm3.
150,000 to 450,000 mm3.
120,000 to 135,000 mm3.
60,000 to 100,000 mm3.
62. A standard stem cell is non-specific, but once it divides it can
a.
b.
c.
d.
take on the functions of cells in specialized areas of the body.
no longer be of use and atrophies.
only take on functions in the muscles.
only take on functions in the liver and pancreas.
63. True or False: Induced pluripotent stem cells (iPSC) can create
new cells that specifically focus on one area where new cells are
needed most.
a. True
b. False
64. Cheng, et al., published a study that worked with transplanting
neural stem cells into the gut as a method of controlling
a.
b.
c.
d.
Crohn’s disease.
Ulcerative colitis.
Hirschsprung disease.
Answers a., and b., above
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65. True or False: During the health assessment, the nurse should
include dietary history as part of the evaluation of the patient’s
GI condition.
a. True
b. False
66. The BRAT diet is often employed as part of a dietary
management of diarrhea
a.
b.
c.
d.
and it is recommended especially for children today.
because evidence supports its efficacy.
but its recommended use seems to be purely anecdotal.
because it is high in protein.
67. ___________ have been shown to be an effective preventive
measure against some types of diarrhea.
a.
b.
c.
d.
Antidiarrheal medications
Probiotics
Electrolytes
Answer a., and c., above
68. ____________ can destroy some toxins that contribute to
illness-causing diarrhea, among other benefits to GI motility.
a.
b.
c.
d.
Antibiotics
Antidiarrheals
Electrolytes
Probiotics
69. True or False: The two most common types of bacteria used as
part of probiotics are Lactobacillus and Bifidobacterium.
a. True
b. False
70. Patients with gastroparesis that causes nausea should
a.
b.
c.
d.
monitor food consumption.
chew foods carefully and thoroughly.
eat six small meals each day.
All of the above
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71. FODMAP foods, when eaten in excess, could
a.
b.
c.
d.
increase risk of bacterial infection.
decrease risk of bacterial infection.
decrease water in the digestive tract.
None of the above
72. Activity-induced diarrhea can lead to
a.
b.
c.
d.
abdominal pain.
increased urge to have a bowel movement.
the need for rest and rehydration.
All of the above
73. True or False: With gastroparesis, a patient is recommended to
avoid even mild exercise due to GI dysmotility.
a. True
b. False
74. True or False: Surgery for dysmotility is done with the goal to
improve the patient’s quality of life by reducing symptoms of
disease.
a. True
b. False
75. Opioid receptors in the gastrointestinal tract affected by opioid
medication can cause
a.
b.
c.
d.
increase in mucus secretions.
decrease in fluid reabsorption.
increased gastric emptying.
None of the above
76. Approximately _____ percent of patients who are treated with
opioids experience nausea as a side effect
a.
b.
c.
d.
15
25
50
70
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77. ___________________ are ordered concomitantly with the
opioid analgesics to help maintain normal bowel habits.
a.
b.
c.
d.
Bowel preparations
Purgatives
Stool softeners
Prokinetics
78. Antidepressant medication may be used as part of treatment for
________________________ as well as depression.
a.
b.
c.
d.
irritable bowel syndrome
inflammatory bowel disease
diabetic gastroparesis
None of the above
79. An upper endoscopy or EGD may be used
a.
b.
c.
d.
to insert biopsy forceps.
to narrow down the cause of the motility issues.
to look for inflammation in the gastrointestinal tract.
All of the above
80. True or False: Endoscopy is a valuable process that helps to
visualize the internal segments of the GI tract to better pinpoint
a diagnosis when GI motility problems are present.
a. True
b. False
81. Predominant forms of IBS are known as
a.
b.
c.
d.
IBS-C (IBS with constipation) or IBS-D (IBS with diarrhea).
Irritable bowel syndrome or inflammatory bowel disease.
IBS-S (IBS with fatty stools) or IBS-U (IBS untyped).
IBS or IBS with brain-gut dysfunction.
82. A patient with dysphagia may be recommended the following to
facilitate easier swallowing
a.
b.
c.
d.
thin liquids.
thickening liquids.
solid foods only.
None of the above
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83. Dysphagia can develop as a consequence of conditions, such as
a.
b.
c.
d.
stroke.
carcinoma.
degenerative disorders.
All of the above
84. Choung, et al., reported the most common symptom experienced
by participants using antidepressants was
a.
b.
c.
d.
diarrhea.
constipation.
abdominal bloating/distention.
both diarrhea and constipation.
85. True or False: Two main types of cholinergic receptors in the
body are nicotinic and muscarinic receptors.
a. True
b. False
86. A study of older adults with chronic obstructive pulmonary
disease (COPD) who used muscle relaxant medications also
showed
a.
b.
c.
d.
higher levels of defecation frequency.
lower levels of defecation frequency.
constipation.
Both b., and c., above
87. Loperamide works by _____________ gut motility to slow down
the rate of intestinal transit and reduce diarrhea.
a.
b.
c.
d.
increasing
both increasing and decreasing
decreasing
eliminating
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88. Certain drugs used to manage Parkinson’s disease have been
shown to affect GI motility, typically within the stomach,
causing
a.
b.
c.
d.
tachygastria.
delayed gastric emptying.
globus.
Both a., and c., above
89. ______________ cannot be administered to patients with
Parkinson’s disease (PD) because it cannot cross the bloodbrain barrier.
a.
b.
c.
d.
Dopamine
Levodopa
Reglan
Both b., and c., above
90. True or False: Antidiarrheals are available only in prescription
strength.
a. True
b. False
91. Antibiotics are administered for infection
a.
b.
c.
d.
with Clostridium difficile.
that is prolonged due to Escherichia coli bacteria.
with Salmonella infection in very young children.
All of the above
92. Examples of antibiotics that may be prescribed for the
management of infectious diarrhea include
a.
b.
c.
d.
cefotaxime.
vancomycin.
augmentin.
Both a., and b., above
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93. ______________ is a broad-spectrum antiparasitic medication.
a.
b.
c.
d.
Furazolidone (Furoxone®)
Augmentin
Erythromycin
Ampicillin
94. True or False: Psyllium or methylcellulose is given to treat
diarrhea by causing the colon to retain more fluid, thereby
preventing diarrhea.
a. True
b. False
95. Nausea and vomiting are common symptoms most frequently
seen with GI dysmotility conditions such as
a.
b.
c.
d.
gastroparesis.
intestinal pseudo-obstruction.
dumping syndrome.
All of the above
96. Antiemetics can ____________ messages to the brain that
stimulate the sense of nausea.
a.
b.
c.
d.
block
send
facilitate
mimic
97. Antiemetics may be administered as
a.
b.
c.
d.
rectal suppositories.
transdermal patches.
intramuscular/intravenous injections.
All of the above
98. True or False: Cholinergic agonists are drugs that act in a
manner opposite to the neurotransmitter acetylcholine.
a. True
b. False
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99. Prokinetic medications can be administered to __________ the
speed of GI motility.
a.
b.
c.
d.
decrease
moderate
increase
impair
100. _______________ is a growing medical field with working
committees to develop improved algorithms to diagnose and
treat GI motility disorders.
a.
b.
c.
d.
Gastroenterology
Neuropsychiatry
Neurogastroenterology
Neurology
CORRECT ANSWERS:
1. Ninety percent of absorption of nutrients occurs in the
c. small intestine.
“Absorption occurs because of the microscopic projections on the
surface of the small intestine; these projections, known as villi, are
located on the mucosal surface and are where absorption takes
place. Ninety percent of absorption occurs in the small intestine
along its full length.”
2. True or False: The small intestine is referred to as “small”
because it is the shortest segment of the GI tract.
b. False
“Although it is referred to as ‘small,’ the small intestine is actually
the longest segment of the GI tract. Its description as being small
refers to its diameter, which is less than that of the nearby colon.”
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3. The junction between the small intestines and the colon is the
a. ileocecal valve.
“The ascending colon is connected to the small intestine at the
ileocecal valve and is located on the right side of the body;
undigested material travels through this portion of the colon first.”
4. When disorders of motility occur in the small intestine, the
affected patient may suffer from
a.
b.
c.
d.
malnutrition.
fluid and electrolyte imbalances.
overgrowth of intestinal bacteria.
All of the above [correct answer]
“Because the small intestine is responsible for much of the
absorption that takes place in the GI tract, when motility disorders
occur, the affected patient may then suffer consequences
associated with malabsorption, including malnutrition, fluid and
electrolyte imbalances, and overgrowth of intestinal bacteria.”
5. True or False: An opioid analgesic, a drug used to manage
moderate-to-severe pain, may cause side effects, such as nausea,
vomiting, and constipation.
a. True
“Taken for pain and used widely in all manner of settings, including
outpatient treatment centers, in-hospital intravenous
administration, or home prescription use, opioids are often
responsible for keeping patients comfortable and managing
moderate-to-severe pain from procedures and from the
complications of illness ... Because of the increase in use of opioids
within healthcare facilities and within the community, patients are
also experiencing an increase in their side effects. Opioid
medications have been known to ... produce gastrointestinal side
effects, typically including nausea, vomiting, and constipation.”
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6. Within the gastrointestinal system, stimulation of muscarinic
receptors has been shown
c. to increase GI motility.
“Within the gastrointestinal system, stimulation of muscarinic
receptors has been shown to increase GI motility and to potentially
cause nausea and vomiting.”
7. Adults who use anticholinergic medication to control respiratory
symptoms
a. may have lower levels of defecation frequency.
“The study showed that those adults who used the drugs to control
respiratory symptoms also had lower levels of defecation frequency
and were more likely to suffer from constipation and slowed colonic
transit.”
8. Intestinal neuropathy may occur as a result of
a.
b.
c.
d.
poorly controlled diabetes.
Parkinson’s disease.
spinal injury.
All of the above [correct answer]
“There are a number of systemic conditions that can cause enteric
dysmotility within this section of the GI tract. Some examples
include intestinal neuropathy, as with what occurs through poorly
controlled diabetes, as well as Parkinson’s disease, scleroderma,
and spinal injury.”
9. True or False: Carbidopa is a dopamine precursor.
b. False
“The introduction of carbidopa, another medication used to enhance
the effects of levodopa, results in a much lower dose requirement of
levodopa when the two drugs are taken together.”
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10. Loperamide is given to patients
b. as a treatment for diarrhea.
“Some common types of antidiarrheal medications that are
available without a prescription include loperamide ... In addition to
controlling diarrhea, these drugs can also help to manage other
unpleasant symptoms the patient may be experiencing as a result
of the illness.”
11. True or False: Carbidopa on its own has little to no therapeutic
benefit, so it must be taken with levodopa for the patient to
treat diarrhea.
a. True
“Carbidopa on its own has little to no therapeutic benefit, so it must
be taken with levodopa for the patient to gain positive effects.
Sinemet® is an example of a drug that is a combination of
levodopa and carbidopa.”
12. Scintigraphy is a diagnostic test that uses the following item(s):
a.
b.
c.
d.
radiographic isotopes.
scrambled eggs.
technetium or iodine.
All of the above [correct answer]
“Scintigraphy utilizes radiographic isotopes that are transferred into
the gastrointestinal tract to assess a patient’s motility and gastric
emptying time. The patient eats a meal, typically scrambled eggs,
which contain the isotopes needed for the study; the most common
isotopes used are technetium and iodine.”
13. True or False: The term enteric dysmotility is used to describe
motility disorders of the colon.
b. False
“The term enteric dysmotility is used to describe motility disorders
of the small intestine.”
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14. Enteric dysmotility is demonstrated as abnormal contractions in
the intestinal tract that typically lead to delays in the transport
of food through
a. the small intestine.
“The term enteric dysmotility is used to describe motility disorders
of the small intestine.”
15. In hypertensive lower esophageal sphincter,
c. a patient will have increased muscle contractions within the lower
esophageal sphincter.
“An example of a questionable entity associated with the esophagus
is increased pressure found within the lower esophageal sphincter.
The condition may be referred to as hypertensive LES, ...
hypertensive LES occurs when there are changes to the nerves
affecting the esophagus. In this case, there is increased function of
the excitatory nerves feeding the esophagus, such that the neurons
are working at a faster pace and are causing increased muscle
contractions within the LES.”
16. Anismus describes a condition in which the patient
b. is unable to control his pelvic floor muscles normally.
“Anismus is a condition in which the patient is unable to control
pelvic floor muscles normally in order to defecate.”
17. Hypothyroidism is associated with
c. constipation.
“Hypothyroidism is associated with slowing of many metabolic
processes, and affected patients often struggle with symptoms of
weight gain, fatigue, muscle and joint pain, depression, and
increased sensitivity to cold. One of the most common GI
complaints among patients with hypothyroidism is constipation ...”
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18. To reduce symptoms of IBS, a patient should remove or limiting
FODMAP foods; FODMAP foods include
a.
b.
c.
d.
high fructose corn syrup.
dairy products.
foods containing wheat or rye.
All of the above [correct answer]
“Certain foods have been organized into a descriptive classification
known as FODMAP: ... Examples of these types of foods include
those with high fructose corn syrup, dairy products, foods
containing wheat or rye, beans and legumes, honey; and those
containing certain sweeteners, such as xylitol, sorbitol, and
isomalt.”
19. True or False: Patients diagnosed with IBS cannot take tricyclic
antidepressants (TCAs) or selective serotonin reuptake
inhibitors (SSRIs).
b. False
“Antidepressants can cause a number of gastrointestinal side
effects. Patients with IBS who take antidepressants, as part of
treatment for IBS, should also be aware of the potential side effects
associated with these drugs.”
20. If a patient increases dietary fiber intake to combat
constipation, the patient should
c. increase fluid intake.
“As a patient increases dietary fiber intake, he or she should be
counseled to increase fluid intake accordingly.”
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21. Achalasia is a condition that affects how food is transitioned
between the mouth and the stomach, and it typically
a.
b.
c.
d.
develops as an acute condition.
develops over time.
causes initial symptoms of mild reflux.
Answers b., and c., above [correct answer]
“Achalasia typically does not develop all at once; instead,
symptoms progressively worsen over time as the patient loses more
ability to drink liquids and to eat solid food. The condition may
initially cause symptoms of mild reflux that can eventually develop
into severe pain any time that the individual tries to eat.”
22. Chronic intestinal pseudo-obstruction (CIP) develops as a
disorder that
a. results in poor intestinal motility.
“Chronic intestinal pseudo-obstruction (CIP) develops as a disorder
that results in poor intestinal motility.”
23. Management of chronic intestinal pseudo-obstruction (CIP) is
c. supportive (treat symptoms and prevent complications).
“Management of CIP is usually not curative and the best approach
is to treat the patient’s symptoms and to prevent complications,
such as malnutrition or dehydration that may develop from the
condition.”
24. Examples of degenerative diseases that affect swallowing
include
a.
b.
c.
d.
Huntington’s disease.
Dementia.
Creutzfeldt-Jakob disease.
All of the above [correct answer]
“Examples of degenerative diseases that affect neurological function
and swallowing include such conditions as Huntington’s disease,
dementia, or Creutzfeldt-Jakob disease.”
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25. One condition that may be more likely to develop with
polymyositis is
c. gastroparesis.
“One condition that may be more likely to develop with polymyositis
is delayed gastric emptying, also called gastroparesis, which occurs
when food moves too slowly from the stomach and into the small
intestine.”
26. Dumping syndrome is best managed with
a. changes in dietary practices.
“Dumping syndrome is best managed with changes in dietary
practices, including avoiding anything that would overstimulate the
muscles of the stomach and cause it to contract too quickly.”
27. Much of the peristalsis and transit of food occurs by
b. involuntary control of smooth muscles in the GI tract.
“While some of the gastrointestinal tract utilizes the work of
voluntary muscles, much of the peristalsis and transit of food and
chyme is done through involuntary control of the smooth muscles
lining the GI tract.”
28. True or False: A person with Hirschsprung’s disease has GI
hypermotility.
b. False
“... patients with Hirschsprung’s disease are at risk of intestinal
infection because of poor motility.”
29. _________________ most often occurs because of motion
sickness or as nausea during the first trimester of pregnancy.
b. Tachygastria
“Tachygastria is a condition that causes high-frequency electrical
activity within the stomach during digestion. The condition most
often occurs because of motion sickness or as nausea during the
first trimester of pregnancy.”
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30. True or False: Too much glucose in the bloodstream damages
parts of the GI system.
a. True
“... too much glucose in the bloodstream that circulates without
being used for energy damages parts of the GI system, including
the nerves that serve the intestinal tract, which may lead to severe
GI motility disturbances.”
31. Drugs that promote gastric emptying are
a.
b.
c.
d.
Metoclopramide (Reglan®).
Erythromycin.
Amitiza.
Answers a., and b., above [correct answer]
“Additionally, some prescription antiemetics work by increasing gut
motility to speed up the rate that food moves through the intestine.
Metoclopramide (Reglan®) is an example of this type of drug....
Erythromycin has been shown to accelerate the rate of gastric
emptying in patients who suffer from gastroparesis in which they
otherwise experience delayed gastric motility.”
32. Thyroid abnormalities may
a.
b.
c.
d.
later develop GI motility problems.
have no correlation to GI motility conditions.
cause constipation or diarrhea.
Answers a., and c., above [correct answer]
“A commonly seen gastrointestinal motility disorder associated with
hyperthyroidism is diarrhea, as the transit times in the intestine are
increased due to the effects of the hormones.... One of the most
common GI complaints among patients with hypothyroidism is
constipation, as colonic motility slows with a decrease in thyroid
hormone production.... Patients who suffer from thyroid
abnormalities may not initially develop gastrointestinal motility
problems. These difficulties may occur later in the course of thyroid
disease, particularly when there is poor control over thyroid
hormone secretion and poor management of thyroid disease.”
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33. Addison’s disease is also called
b. hypocortisolism.
“Addison’s disease is most often caused by an autoimmune disorder
in which the body attacks its own tissues and causes the adrenal
glands to work inappropriately. Eventually, the damage from the
autoimmune system destroys the adrenal cortex, which is the outer
protective covering to the adrenal glands. The patient is no longer
able to secrete sufficient amounts of cortisol and aldosterone
needed to regulate various body functions, including weight control,
the ability to fight infection, and control of heart rate and blood
pressure. For this reason, Addison’s disease is also known as
hypocortisolism.”
34. True or False: Brain-gut dysfunction describes a condition in
which a patient may experience GI symptoms in response to
emotions and psychological distress.
a. True
“Brain-gut dysfunction describes a condition in which a patient may
experience gastrointestinal symptoms in response to emotions and
psychological distress.”
35. A patient with IBS-C type may need medications that include
c. osmotic laxatives, stool softeners, and bulking agents.
“... a patient who struggles with IBS-C type may need medications
and diet therapy that manages and prevents hard stools from
forming, such as osmotic laxatives, stool softeners, and bulking
agents.”
36. Biofeedback helps patients with fecal incontinence and can be
done with
b. an anorectral manometry procedure.
“Biofeedback is a second method of controlling fecal incontinence.
With biofeedback, the patient learns to consciously contract the
muscles of the rectum that control defecation. The healthcare
provider may perform biofeedback during a procedure known as
anorectal manometry,...”
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37. Pelvic floor dysfunction affects the person’s ability to
a. pass stool regardless of transit time or stool consistency.
“Pelvic floor dysfunction ... affects the person’s ability to pass stool
at all, regardless of transit time or stool consistency.”
38. Sarnelli, et al., in the World Journal of Gastrointestinal
Pathophysiology, investigated
c. specific genes contributing to development of achalasia.
“Sarnelli, et al., in their work published in the World Journal of
Gastrointestinal Pathophysiology, investigated specific genes that
may contribute to the development of achalasia among certain
patients.”
39. A known risk factor for fecal incontinence include
c. having a physical disability.
“Known risk factors for fecal incontinence include advancing age,
female gender, physical disabilities, and injury to the nerves
affecting the anal sphincter, such as through childbirth.”
40. True or False: Genes and familial tendencies are a large part of
whether certain patients are at high risk of GI motility problems.
a. True
“In some cases, genetic factors do not play a role in whether a
patient will develop symptoms of a disorder; alternatively, genes
and familial tendencies are a large part of whether certain patients
are at high risk of GI motility problems.”
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41. Chronic megacolon may be
a.
b.
c.
d.
a congenital condition.
an acquired condition because of illness.
an acquired condition due to toxicity.
All of the above [correct answer]
“Chronic megacolon may be used as a term to describe the
condition when it is congenital, although it can be later acquired
because of illness or toxicity.”
42. Tachygastria is a condition that causes
a. high-frequency electrical activity in the stomach with digestion.
“Tachygastria is a condition that causes high-frequency electrical
activity within the stomach during digestion.”
43. Rumination is a behavior disorder where a person
a. swallows food and then regurgitates it.
“Rumination refers to swallowing food and then regurgitating it; the
patient may then repeatedly swallow the food or may vomit it.”
44. True or False: Anismus is a condition in which the patient is
unable to control pelvic floor muscles normally in order to
defecate.
a. True
“Anismus is a condition in which the patient is unable to control
pelvic floor muscles normally in order to defecate.”
45. A person with aerophagia
c. swallows large amounts of air.
“Aerophagia is a rare type of disorder in which a person swallows
large amounts of air. The air passes through the esophagus and
enters the stomach but is then regurgitated, causing frequent
belching.”
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46. True or False: Functional fecal retention is the most common
behavioral disorder that causes motility problems in the large
intestine, rectum, and anus.
a. True
“... the purposeful holding of stool within the body leads to
constipation when excess fluid is absorbed from feces held in the
rectum ... The clinical entity in these situations is known as
functional fecal retention; it is the most common behavioral
disorder that causes motility problems in the large intestine,
rectum, and anus.”
47. At an initial meeting with a patient, the nurse should question
the patient about
a.
b.
c.
d.
symptoms, including history of pain.
changes in stool output or toileting practices.
feelings of pressure or bloating in the abdomen and lower pelvis.
All of the above [correct answer]
“Upon the initial meeting, the patient may present with symptoms
that vary according to the disorder present. Because the patient
most likely will not know the cause of his or her symptoms upon
arrival, it is up to the healthcare provider to make a diagnosis
based on the information presented. The nurse should ask
questions that focus not only on symptoms affecting the GI system,
but also other symptoms that may be impacting different areas of
the body. Starting with the GI system, the nurse should question
the patient about symptoms, including history of pain, changes in
stool output, feelings of pressure or bloating in the abdomen and
lower pelvis, and any changes in toileting practices.”
48. A patient with diabetes who has uncontrolled blood glucose
levels could develop neuropathy and gastroparesis to the point
that the patient
c. is unable to detect the need to have a bowel movement.
“... a patient with diabetes who has uncontrolled blood glucose
levels could develop neuropathy and gastroparesis to the point that
he or she is unable to detect the need to have a bowel movement.”
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49. Scintigraphy is an X-ray that is performed
a.
b.
c.
d.
before meal consumption.
after meal consumption.
to help diagnose a GI motility disorder.
Answers b., and c., above [correct answer]
“Scintigraphy utilizes radiographic isotopes that are transferred into
the gastrointestinal tract to assess a patient’s motility and gastric
emptying time. The patient eats a meal, typically scrambled eggs,
which contain the isotopes needed for the study; the most common
isotopes used are technetium and iodine. After consuming the meal,
the images are taken to detect the food as it passes through the
patient’s GI tract.”
50. True or False: Enterography is seldom done because it is more
invasive than endoscopic procedures.
b. False
“Enterography is beneficial because it is less invasive than
endoscopic procedures ... Because of the non-invasive process
involved with this type of study, and that it is sensitive enough to
pick up changes in GI motility, enterography is a viable option for
diagnostic treatment among patients who are suffering GI motility
disturbances.”
51. A colonoscopy involves the following preparation
b. a clear liquid diet 1 day before the procedure.
“The colonoscopy is often used as a cancer screening tool [and] it
may also be utilized to assess for potential obstructions in the large
intestine, the presence of inflammation or polyps, bleeding,
diverticulosis, or whenever the patient is suffering symptoms and is
experiencing a change in bowel habits ... Prior to the procedure, the
patient must undergo a bowel cleanse as preparation in order to
remove any fecal matter in the intestine. This often requires a clear
liquid diet for one day before the procedure and administration of a
laxative that will empty the colon.”
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52. Proctoscopy involves examination of
a. the rectum.
“Proctoscopy involves examination of the rectum. The process is
similar to that of a colonoscopy or anoscopy in that the physician
inserts a scope into the patient’s anus and advances it to the
rectum to visualize the internal structures of this portion of the
colon.”
53. True or False: Another name for an esophagography is the
barium swallow test.
a. True
“The barium swallow is actually called an esophagography. It is
referred to in simpler terms as a barium swallow because the
patient actually drinks barium contrast that has been prepared as a
mixture.”
54. True or False: The single-contrast technique describes
application of contrast using a barium enema alone, while the
double-contrast technique involves administering a barium
enema and air into the large intestine.
a. True
“The single-contrast technique describes application of contrast
through administration of barium enema alone, while the doublecontrast technique involves administration of a barium enema and
air into the large intestine.”
55. A drawback to capsule endoscopy is that it
a. only takes pictures of GI conditions in the bowel.
“A drawback to capsule endoscopy is that if it detects a problem
within the gastrointestinal tract, it only takes pictures of it with the
camera; the healthcare provider must still follow up with further
testing to diagnose a condition or to obtain tissue samples.”
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56. Electrodes used with EMG are often special types of __________
that are placed within the muscle tissue.
b. needles
“Contrary to the surface electrodes used as part of cardiac testing,
electrodes used with EMG are often special types of needles that
are placed within the muscle tissue.”
57. Dyssynergic defecation may be defined and characterized as
a.
b.
c.
d.
a functional defecation disorder.
paradoxical contractions of anal sphincter muscle.
inability to relax the anal sphincter muscle.
All of the above [correct answer]
“... dyssynergic defecation ... is defined as a functional defecation
disorder characterized by impaired pushing forces, paradoxical
contractions, or an inability to relax the anal sphincter muscle.”
58. Three main types of cells in the blood and CBC test are
b. white blood cells, red blood cells and platelets.
“There are three main types of cells found in the blood and the CBC
components test the amounts of each of these cells. The main cell
types are white blood cells, red blood cells, and platelets.”
59. Microcytic red blood cells typically develop if the patient
a. has an iron deficiency anemia.
“If the red blood cells are too large, they are considered
macrocytic; this condition could occur because of certain vitamin
deficiencies or with hypothyroidism. Alternatively, microcytic cells
refer to those red blood cells that have an MCV result that is
smaller than normal. Microcytic red blood cells typically develop if
the patient is suffering from iron deficiency anemia.”
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60. Hypothyroidism is a condition associated with
a.
b.
c.
d.
a number of GI motility problems.
a possible drop in red blood cells.
hyponatremia (low sodium).
Answers a., and b., above [correct answer]
“Hypothyroidism, which is associated with a number of
gastrointestinal motility problems, including constipation and
malabsorption, can also lead to a drop in red blood cells and some
kinds of anemia. Low thyroid levels can impact iron absorption,
which could result in iron deficiency anemia. This could potentially
create a negative cycle in which the intestines receive even less
oxygenated blood than what they need when red blood cells and
hemoglobin are lacking; which could then further perpetuate
motility problems if the intestinal tract is not adequately
oxygenated through circulation.”
61. Normal platelet count in men and women is
b. 150,000 to 450,000 mm3.
“A normal platelet count is 150,000 to 450,000 mm3 among men
and women.”
62. A standard stem cell is non-specific, but once it divides it can
a. take on the functions of cells in specialized areas of the body.
“On its own, a standard stem cell is non-specific; however, once it
divides, it can take on the functions of cells in specialized areas of
the body, including in the brain, the muscles, and the
gastrointestinal tract.”
63. True or False: Induced pluripotent stem cells (iPSC) can create
new cells that specifically focus on one area where new cells are
needed most.
a. True
“... iPSC bodies can be directed to create new cells that specifically
focus on one area where new cells are needed most, such as by
creating new neurons to work in the GI tract when these cells have
been damaged.”
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64. Cheng, et al., published a study that worked with transplanting
neural stem cells into the gut as a method of controlling
c. Hirschsprung disease.
“A study by Cheng, et al., in the journal Neurogastroenterology &
Motility, worked with transplanting neural stem cells into the gut as
a method of controlling Hirschsprung disease.”
65. True or False: During the health assessment, the nurse should
include dietary history as part of the evaluation of the patient’s
GI condition.
a. True
“During the health assessment, the nurse should include dietary
history as part of the evaluation of the patient’s condition, as diet
contributes significantly to the cause of many GI dysfunction
symptoms.”
66. The BRAT diet is often employed as part of a dietary
management of diarrhea
c. but its recommended use seems to be purely anecdotal.
“The BRAT diet, while often employed as part of dietary
management of diarrhea, is not necessarily effective in managing
symptoms of diarrhea in patients with GI motility disorders.... there
is no evidence that states that this diet is effective in preventing
diarrhea, and its recommended use seems to be purely anecdotal.”
67. ___________ have been shown to be an effective preventive
measure against some types of diarrhea.
b. Probiotics
“Probiotics have been shown to be an effective preventive measure
against some types of diarrhea and they may be incorporated into
the patient’s diet through food intake that contain the bacteria or
through specially designed supplements.”
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68. ____________ can destroy some toxins that contribute to
illness-causing diarrhea, among other benefits to GI motility.
d. Probiotics
“Probiotics are microorganisms that support growth of healthy
bacteria in the GI tract. They are effective in that, after ingestion,
probiotics can destroy some toxins that contribute to illness-causing
diarrhea, prevent harmful bacteria from infecting the
gastrointestinal tract, stimulate increased mucus production in the
intestinal tract, may help to decrease GI inflammation, and diminish
the effects of gas and bloating.”
69. True or False: The two most common types of bacteria used as
part of probiotics are Lactobacillus and Bifidobacterium.
a. True
“The two most common types of bacteria used as part of probiotics
are Lactobacillus and Bifidobacterium.”
70. Patients with gastroparesis that causes nausea should
a.
b.
c.
d.
monitor food consumption.
chew foods carefully and thoroughly.
eat six small meals each day.
All of the above [correct answer]
“For the patient suffering from gastroparesis that causes nausea,
there are several dietary suggestions that may help. The patient
should be advised to monitor food consumption, not only in the
kinds of foods eaten, but also how food is eaten. The patient should
be advised to chew foods carefully and thoroughly and to avoid
taking large bites or swallowing pieces of food whole. Instead of
eating three large meals a day, the patient would more likely
benefit from six small meals each day, which can prevent stomach
distention.”
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71. FODMAP foods, when eaten in excess, could
a. increase risk of bacterial infection.
“Certain foods have been organized into a descriptive classification
known as FODMAP: ... These foods, when eaten in excess, could
increase the risk of bacterial infection ...”
72. Activity-induced diarrhea can lead to
a.
b.
c.
d.
abdominal pain.
increased urge to have a bowel movement.
the need for rest and rehydration.
All of the above [correct answer]
“Some people struggle with activity-induced diarrhea when they
exercise and then experience abdominal pain and an increased urge
to have a bowel movement. When a patient is suffering from
diarrhea, rest and rehydration are typically recommended to cope
with the situation, rather than encouraging an increase in activity
levels.”
73. True or False: With gastroparesis, a patient is recommended to
avoid even mild exercise due to GI dysmotility.
b. False
“In the case of gastroparesis, a patient may benefit from mild
exercise to help improve GI motility; recommendations associated
with eating and activity levels in this situation often advise taking a
walk after eating to avoid lying down and to promote gastric
emptying of stomach contents.”
74. True or False: Surgery for dysmotility is done with the goal to
improve the patient’s quality of life by reducing symptoms of
disease.
a. True
“As with other types of surgical intervention for dysmotility, surgery
may initially cause discomfort because of the procedure, but the
ultimate goal is to improve the patient’s quality of life by reducing
symptoms of disease and extending the patient’s life that may
otherwise be shortened because of his or her condition.”
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75. Opioid receptors in the gastrointestinal tract affected by opioid
medication can cause
a.
b.
c.
d.
increase in mucus secretions.
decrease in fluid reabsorption.
increased gastric emptying.
None of the above [correct answer]
“There are many opioid receptors in the gastrointestinal tract. When
opioids are administered, they can affect these receptors and cause
changes, including a decrease in mucus secretions, an increase in
fluid reabsorption, and delayed gastric emptying.”
76. Approximately _____ percent of patients who are treated with
opioids experience nausea as a side effect
b. 25
“Approximately 25 percent of patients who are treated with opioids
experience nausea as a side effect.”
77. ___________________ are ordered concomitantly with the
opioid analgesics to help maintain normal bowel habits.
c. Stool softeners
“For many patients, stool softeners are ordered concomitantly with
the opioid analgesics to help maintain normal bowel habits.”
78. Antidepressant medication may be used as part of treatment for
________________________ as well as depression.
a. irritable bowel syndrome
“Since serotonin receptors are present in the GI tract and
associated with pain from rectal distention, i.e., as occurs with
irritable bowel syndrome (IBS), antidepressants are used as part of
treatment for IBS, as well as depression. In fact, antidepressant
prescription is part of routine management of irritable bowel
syndrome. This may be because of the effects of these medications
on serotonin in the GI tract; however, it could also be due to the
psychological symptoms associated with IBS.”
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79. An upper endoscopy or EGD may be used
a.
b.
c.
d.
to insert biopsy forceps.
to narrow down the cause of the motility issues.
to look for inflammation in the gastrointestinal tract.
All of the above [correct answer]
“Upper endoscopy, also called esophagogastroduodenoscopy or
EGD, involves insertion of a tube into the patient’s mouth and then
advancing it down the esophagus.... The test is beneficial to look for
conditions that may be causing the patient’s symptoms of pain,
nausea, or vomiting, which may or may not be related to GI
motility problems. It may also be done to rule out another condition
and narrow down the cause of the motility issues.
The upper endoscopy is more accurate than traditional X-rays when
looking for certain issues within the gastrointestinal tract, such as
inflammation. The endoscope can also be used to insert biopsy
forceps through the channel to remove small tissue samples from
the GI tract if the endoscopist determines it is necessary to perform
a tissue pathology test.”
80. True or False: Endoscopy is a valuable process that helps to
visualize the internal segments of the GI tract to better pinpoint
a diagnosis when GI motility problems are present.
a. True
“... endoscopy is a valuable process that helps the endoscopist to
visualize the internal segments of the GI tract, which can better
pinpoint a diagnosis when GI motility problems are present.”
81. Predominant forms of IBS are known as
a. IBS-C (IBS with constipation) or IBS-D (IBS with diarrhea).
“Irritable bowel syndrome can cause symptoms that predominantly
involve diarrhea or constipation, although some patients suffer from
both. It is classified according to the predominant forms of stool
that occur with symptoms, and may be considered IBS with
constipation (IBS-C), IBS with diarrhea (IBS-D), IBS mixed (IBSM), or IBS unsubtyped (IBS-U) in which the stool consistency does
not meet the criteria for the other forms of the condition.”
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82. A patient with dysphagia may be recommended the following to
facilitate easier swallowing
b. thickening liquids.
“The healthcare provider who works with a patient with dysphagia
may provide some interventions that would facilitate easier
swallowing. As mentioned, this may involve thickening liquids and
otherwise modifying food textures and consistencies.”
83. Dysphagia can develop as a consequence of conditions, such as
a.
b.
c.
d.
stroke.
carcinoma.
degenerative disorders.
All of the above [correct answer]
“Dysphagia can develop as a consequence of a number of
conditions, including physical disabilities, stroke, and carcinoma,
and, it may also develop because of difficulties related to certain
types of degenerative disorders.”
84. Choung, et al., reported the most common symptom experienced
by participants using antidepressants was
c. abdominal bloating/distention.
“A study by Choung, et al., in the journal Neurogastroenterology &
Motility, used questionnaires to examine patient responses to
discern the effects of antidepressant use on the gastrointestinal
system. The most common symptom reported by participants in the
study was abdominal bloating and distention.”
85. True or False: Two main types of cholinergic receptors in the
body are nicotinic and muscarinic receptors.
a. True
“There are two main types of cholinergic receptors in the body:
nicotinic and muscarinic receptors.”
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86. A study of older adults with chronic obstructive pulmonary
disease (COPD) who used muscle relaxant medications also
showed
a.
b.
c.
d.
higher levels of defecation frequency.
lower levels of defecation frequency.
constipation.
Both b., and c., above [correct answer]
“A study in the journal BMC Geriatrics investigated defecation
frequency among older adults with chronic obstructive pulmonary
disease who used muscle relaxant medications to control some of
their respiratory symptoms. The study showed that those adults
who used the drugs to control respiratory symptoms also had lower
levels of defecation frequency and were more likely to suffer from
constipation and slowed colonic transit.”
87. Loperamide works by _____________ gut motility to slow down
the rate of intestinal transit and reduce diarrhea.
c. decreasing
“Loperamide works by decreasing gut motility to slow down the rate
of intestinal transit so that the affected person is less likely to suffer
from diarrhea.”
88. Certain drugs used to manage Parkinson’s disease have been
shown to affect GI motility, typically within the stomach,
causing
b. delayed gastric emptying.
“Certain drugs used for management of disorders such as
Parkinson’s disease have been shown to affect gastrointestinal
motility, typically within the stomach, causing delayed gastric
emptying.
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89. ______________ cannot be administered to patients with
Parkinson’s disease (PD) because it cannot cross the bloodbrain barrier.
a. Dopamine
“Dopamine cannot be administered to patients with PD because
dopamine cannot cross the blood-brain barrier.”
90. True or False: Antidiarrheals are available only in prescription
strength.
b. False
“Antidiarrheals are available in prescription strength but they can
be purchased over the counter as well.”
91. Antibiotics are administered for infection
a.
b.
c.
d.
with Clostridium difficile.
that is prolonged due to Escherichia coli bacteria.
with Salmonella infection in very young children.
All of the above [correct answer]
“However, there are some cases in which a patient who suffers
from prolonged diarrhea because of a specific type of infection
would benefit from the administration of antibiotics, including
infection with Clostridium difficile, prolonged infection with
Escherichia coli bacteria, and Salmonella infection in very young
children.”
92. Examples of antibiotics that may be prescribed for the
management of infectious diarrhea include
a.
b.
c.
d.
cefotaxime.
vancomycin.
augmentin.
Both a., and b., above [correct answer]
“Examples of antibiotics that may be prescribed for the
management of infectious diarrhea include cefotaxime (Claforan®),
vancomycin, and erythromycin.”
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93. ______________ is a broad-spectrum antiparasitic medication.
a. Furazolidone (Furoxone®)
“Antiparasitic drugs may target certain species or they may be
broad-spectrum types that provide coverage against any number of
parasitic organisms. An example of this type of drug is furazolidone
(Furoxone®).”
94. True or False: Psyllium or methylcellulose is given to treat
diarrhea by causing the colon to retain more fluid, thereby
preventing diarrhea.
b. False
“Bulk-forming laxatives prevent and treat constipation, and are
typically made up of products such as psyllium or
methylcellulose...”
95. Nausea and vomiting are common symptoms most frequently
seen with GI dysmotility conditions such as
a.
b.
c.
d.
gastroparesis.
intestinal pseudo-obstruction.
dumping syndrome.
All of the above [correct answer]
“Nausea and vomiting can develop as significant symptoms from GI
motility disorders. These two common symptoms are most
frequently seen with GI dysmotility conditions such as
gastroparesis, intestinal pseudo-obstruction, and dumping
syndrome.”
96. Antiemetics can ____________ messages to the brain that
stimulate the sense of nausea.
a. block
“Prescription antiemetics may work in a manner similar to nonprescription drugs in that they can block messages to the brain that
stimulate the sense of nausea.”
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97. Antiemetics may be administered as
a.
b.
c.
d.
rectal suppositories.
transdermal patches.
intramuscular/intravenous injections.
All of the above [correct answer]
“In addition to oral preparations, antiemetics may be administered
as rectal suppositories, transdermal patches, intramuscular
injections, or as intravenous injections.”
98. True or False: Cholinergic agonists are drugs that act in a
manner opposite to the neurotransmitter acetylcholine.
b. False
“Cholinergic agonists are drugs that act in a manner similar to the
neurotransmitter acetylcholine.”
99. Prokinetic medications can be administered to __________ the
speed of GI motility.
c. increase
“Prokinetic medications can be administered to increase the speed
of GI motility to move food through the intestinal tract at a faster
rate.”
100. _______________ is a growing medical field with working
committees to develop improved algorithms to diagnose and
treat GI motility disorders.
c. Neurogastroenterology
“The field of neurogastroenterology has increasingly developed into
multi-dimensional working committees of clinical researchers
organized to develop improved therapeutic options for the wide
spectrum of individuals suffering from functional gut disorders.”
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2.
3.
4.
5.
6.
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8.
9.
10.
11.
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Wald, A. (2009). Bowel problems associated with neurologic diseases.
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