A Guide to Gastrointestinal Motility Disorders

A Guide to Gastrointestinal Motility Disorders

Albert J. Bredenoord André Smout Jan Tack A Guide to Gastrointestinal Motility Disorders

Albert J. Bredenoord Gastroenterology and Hepatology Academic Medical Centre Amsterdam, The Netherlands Jan Tack Gastroenterology and Hepatology UZ Leuven Leuven, Belgium André Smout Gastroenterology and Hepatology Academic Medical Centre Amsterdam, The Netherlands The work was first published in 2010 by Bohn Stafleu van Loghum with the following title: Functiestoornissen van het maag-darmkanaal by Arjan Bredenoord, Jan Tack, André Smout - ISBN print: 978-90-313-7839-5 ISBN 978-3-319-26936-8 DOI 10.1007/978-3-319-26938-2 ISBN 978-3-319-26938-2 (ebook) Library of Congress Control Number: 2016930027 Springer Cham Heidelberg New York Dordrecht London Springer International Publishing Switzerland 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com)

Contents 1 Functional Anatomy and Physiology...................... 1 1.1 Introduction........................................ 1 1.2 The Basic Structure.................................. 1 1.2.1 The Mucosa.................................. 1 1.2.2 The Submucosa............................... 1 1.2.3 The Muscularis Propria......................... 1 1.2.4 The Serosa................................... 3 1.3 The Esophagus...................................... 3 1.4 The Stomach....................................... 5 1.5 The Small Bowel.................................... 5 1.6 The Colon.......................................... 5 1.7 The Anorectum..................................... 5 1.8 The Gallbladder and Bile Ducts......................... 6 1.9 Nerves............................................ 6 1.9.1 The Enteric Nervous System..................... 6 1.9.2 The Role of the Autonomous Nervous System....... 8 1.9.3 The Role of Nerves under Voluntary Control........ 8 1.9.4 The Role of Hormones.......................... 8 1.9.5 Separation into Compartments.................... 8 1.10 Contractility and Motility of the Gastrointestinal Tract....... 9 1.10.1 The Rhythm of the Stomach and Intestines.......... 9 1.10.2 From Contraction to Peristalsis................... 9 1.10.3 Tonic Contractions............................. 10 1.10.4 Digestion.................................... 10 1.10.5 The Intestines Between Meals.................... 11 1.11 Functional Disorders of the Gastrointestinal Tract.......... 11 1.11.1 Classification of Functional Disorders: The Road to Rome............................. 12 2 Diagnostic Techniques................................. 15 2.1 Introduction....................................... 15 2.2 Manometry........................................ 15 2.2.1 Perfused versus Solid-State Manometry........... 15 2.2.2 High-Resolution Manometry.................... 17 2.3 ph Recording...................................... 17 2.4 Impedance Monitoring............................... 20 2.5 SmartPill......................................... 21 v

vi Contents 2.6 Radiographic Examination............................ 21 2.6.1 Timed Barium Esophagogram................... 22 2.6.2 Defecography................................ 22 2.6.3 Pellet Transit Test............................. 23 2.6.4 Plain Abdominal Radiograph..................... 24 2.7 Scintigraphy........................................ 24 2.7.1 Gastric Emptying Test.......................... 24 2.7.2 Measurement of Small Intestinal and Colonic Transit Time.................................. 25 2.7.3 HIDA Scintigraphy............................ 25 2.8 Ultrasonography..................................... 25 2.9 Electromyography................................... 27 2.10 Electrogastrography.................................. 27 2.11 Breath Tests........................................ 28 2.11.1 Hydrogen Breath Test.......................... 28 2.11.2 13 C Breath Test................................ 28 2.11.3 Barostat Technique............................. 29 2.12 Impedance Planimetry................................ 30 3 Principles of Drug Therapy for Disorders of Gastrointestinal Function............................................. 31 3.1 Introduction....................................... 31 3.2 Drugs That Enhance Contractility of the Gastrointestinal Tract................................ 31 3.2.1 Direct Stimulation of Gastrointestinal Smooth Muscle 31 3.2.2 Stimulation of Contractions through Intrinsic Excitatory Nerves............................. 32 3.3 Drugs That Inhibit Contractility of the Gastrointestinal Tract. 33 3.3.1 Direct Inhibition of Smooth Muscle.............. 33 3.3.2 Inhibition of Contractions through Intrinsic Inhibitory Nerves............................. 33 3.4 Medications That Change the Content of the Gastrointestinal Tract................................ 34 3.4.1 Inhibition of Gastric Acid Secretion.............. 34 3.4.2 Stool Softeners............................... 34 3.4.3 Intestinal Secretagogues........................ 34 3.4.4 Bile Salt Sequestration......................... 35 3.4.5 Alterations in the Intestinal Microbiome........... 35 3.5 Medications That Alter the Sensitivity of the Gastrointestinal Tract............................................. 36 4 The Esophagus....................................... 39 4.1 Anatomy of the Esophagus........................... 39 4.2 Swallowing and Esophageal Peristalsis.................. 39 4.3 Belches........................................... 41 4.4 Motility Disorders of the Esophagus.................... 41 4.5 Primary Esophageal Motility Disorders.................. 41 4.5.1 Oropharyngeal Dysphagia...................... 41 4.5.2 Esophageal Dysphagia......................... 43

Contents vii 4.6 Secondary Esophageal Motility Disorders................ 47 4.7 Gastroesophageal Reflux Disease....................... 47 4.8 Pathophysiology of GERD............................. 48 4.8.1 Defense Against Reflux......................... 48 4.8.2 Factors Promoting Reflux....................... 49 4.8.3 Hypersensitivity of the Esophagus................. 50 4.8.4 Reflux Esophagitis............................. 50 4.9 Diagnosis of Gastroesophageal Reflux Disease............. 51 4.9.1 PPI Test..................................... 51 4.9.2 Endoscopy................................... 51 4.9.3 Ambulatory Reflux Monitoring................... 52 4.9.4 Manometry................................... 53 4.10 Treatment of GERD.................................. 53 4.10.1 Medical Treatment of GERD..................... 54 4.10.2 Antireflux Surgery............................. 55 4.11 Eosinophilic Esophagitis.............................. 56 4.12 Rumination Syndrome................................ 56 4.13 Excessive Belching.................................. 57 5 Gastric Motility....................................... 59 5.1 Normal Gastric Function............................. 59 5.1.1 Control of Gastric Motility..................... 59 5.1.2 Fasting or Interdigestive Motility................ 60 5.1.3 Postprandial Motility.......................... 60 5.1.4 Control of Gastric Emptying.................... 61 5.2 Gastric Motility Disorders............................ 61 5.2.1 Symptoms.................................. 61 5.2.2 Gastroparesis................................ 61 5.2.3 Functional Dyspepsia.......................... 65 5.2.4 Dumping Syndrome........................... 66 6 Small Bowel.......................................... 69 6.1 Small Bowel Motility................................ 69 6.2 Disorders of Small Bowel Motility..................... 69 6.2.1 Frequently Occurring Disorders of Small Bowel Motility of Uncertain Pathophysiological Significance........ 69 6.2.2 Chronic Intestinal Pseudo-obstruction............. 70 6.2.3 Small Intestinal Bacterial Overgrowth............. 72 6.2.4 Mechanical Sub-occlusion and Intestinal Motility... 72 7 Colon............................................... 75 7.1 Introduction....................................... 75 7.2 Anatomy and Innervation............................. 75 7.3 Colonic Motility.................................... 75 7.3.1 Haustrating Contractions....................... 78 7.3.2 Mass Contractions............................ 78 7.4 Postprandial versus Interdigestive Activity............... 79 7.5 Symptoms of Disordered Colonic Motility and Perception... 79 7.5.1 Constipation................................. 79

viii Contents 7.5.2 Diarrhea.................................... 79 7.5.3 Distended Abdomen........................... 80 7.5.4 Abdominal Pain.............................. 80 7.6 Causes of Constipation.............................. 81 7.6.1 Irritable Bowel Syndrome...................... 82 7.6.2 Functional Constipation......................... 85 7.6.3 Ogilvie s Syndrome............................ 87 7.7 Treatment of Irritable Bowel Syndrome and Functional Constipation........................................ 87 7.7.1 Treatment of Irritable Bowel Syndrome............ 87 7.7.2 Treatment of Functional Constipation.............. 88 8 Anorectum........................................... 91 8.1 Introduction....................................... 91 8.2 Anatomy.......................................... 91 8.3 Anorectal Constipation.............................. 93 8.3.1 How to Recognize Constipation Caused by an Anorectal Disorder......................... 93 8.3.2 Functional and Structural Causes................. 93 8.4 Constipation Caused by Disordered Anorectal Function..... 93 8.4.1 Dyssynergic Defecation........................ 93 8.4.2 Diagnosis................................... 94 8.4.3 Treatment................................... 95 8.4.4 Hirschsprung s Disease........................ 95 8.5 Constipation Caused by Structural Abnormalities in the Anorectal Region................................ 97 8.6 Fecal Incontinence.................................. 98 8.6.1 Investigations in Incontinence................... 98 8.6.2 Causes and Treatment of Fecal Incontinence....... 98 8.7 Perianal and Rectoanal Pain........................... 100 8.7.1 Coccygodynia............................... 100 8.7.2 Levator Ani Syndrome......................... 100 8.7.3 Proctalgia Fugax............................. 100 9 Biliary System....................................... 103 9.1 Introduction...................................... 103 9.2 Anatomy......................................... 103 9.3 Bile............................................. 103 9.4 Gallbladder....................................... 104 9.5 Sphincter of Oddi.................................. 105 9.6 Regulation of Bile Flow into the Duodenum............. 105 9.7 Regulation of Flow of Pancreatic Juice into the Duodenum. 105 9.8 Motility Disorders of the Bile Ducts and Gallbladder...... 106 9.8.1 Gallstones.................................. 106 9.8.2 Gallbladder Dysfunction...................... 106 9.8.3 Sphincter of Oddi Dysfunction................. 107 Index..................................................... 109