Table Of Content

A Guide to Gastrointestinal Motility Disorders Albert J. Bredenoord André Smout Jan Tack 123 A Guide to Gastrointestinal Motility Disorders Albert J. Bredenoord (cid:129) André Smout Jan Tack A Guide to Gastrointestinal Motility Disorders Albert J. Bredenoord Jan Tack Gastroenterology and Hepatology Gastroenterology and Hepatology Academic Medical Centre UZ Leuven Amsterdam , The Netherlands Leuven , Belgium André Smout Gastroenterology and Hepatology Academic Medical Centre Amsterdam , The Netherlands The work was fi rst published in 2010 by Bohn Stafl eu 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 ISBN 978-3-319-26938-2 (eBook) DOI 10.1007/978-3-319-26938-2 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, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms 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 specifi c 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 Classifi cation 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 1 3 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 Refl ux Disease . . . . . . . . . . . . . . . . . . . . . . . 47 4.8 Pathophysiology of GERD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 4.8.1 Defense Against Refl ux . . . . . . . . . . . . . . . . . . . . . . . . . 48 4.8.2 Factors Promoting Refl ux . . . . . . . . . . . . . . . . . . . . . . . 49 4.8.3 Hypersensitivity of the Esophagus . . . . . . . . . . . . . . . . . 50 4.8.4 Refl ux Esophagitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 4.9 Diagnosis of Gastroesophageal Refl ux Disease . . . . . . . . . . . . . 51 4.9.1 PPI Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4.9.2 Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4.9.3 Ambulatory Refl ux Monitoring . . . . . . . . . . . . . . . . . . . 52 4.9.4 Manometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 4.10 Treatment of GERD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 4.10.1 Medical Treatment of GERD . . . . . . . . . . . . . . . . . . . . . 54 4.10.2 Antirefl ux 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 Signifi cance . . . . . . . . 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 1 Functional Anatomy and Physiology 1.1 Introduction 1.2.1 The Mucosa T he gastrointestinal tract can be regarded as a hol- The mucosa forms the barrier between the lumi- low tube divided into several compartments. Each nal content and the internal environment. The compartment has its own structure, related to its mucosa consists of the epithelium, a thin muscu- function. We distinguish the esophagus, stomach, lar layer of smooth muscle (muscularis muco- small bowel, and large bowel or colon. Glands pro- sae), and in between the connective tissue of the duce juices that play an important role in digestion, lamina propria. the salivary glands produce saliva, the stomach secretes hydrochloric acid and pepsin, the liver produces bile, and the pancreas produces amylase, 1.2.2 The Submucosa lipase, and tryptase. The various compartments dif- fer in diameter and are delimited by sphincters that The submucosa mainly consists of fi brous tissue. open and close at the correct moments (Fig. 1 .1 ). In this layer a network of nerve cells is found, the This allows the partly digested food or feces to submucosal plexus. be expelled in the right direction. The wall of the compartments of the gastrointestinal tract is dif- ferent for each compartment; however, the basic 1.2.3 The Muscularis Propria structure is similar. T he muscularis propria surrounds the submu- cosa. The muscularis propria consists of an inner 1.2 The Basic Structure longitudinal muscular layer and an outer circular muscular layer. In between the two muscular lay- The wall consists of several layers (Fig. 1 .2 ). ers, a nervous network exists called the myenteric From the inner to the outer layers, there is the plexus that plays an important role in regulation mucosa, submucosa, muscularis propria, and and coordination of the contractions of these serosa (Fig. 1 .3 ). muscular layers. © Springer International Publishing Switzerland 2016 1 A.J. Bredenoord et al., A Guide to Gastrointestinal Motility Disorders, DOI 10.1007/978-3-319-26938-2_1

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