Small intestine motility disorders: Chronic intestinal pseudo-obstruction.

Chronic intestinal pseudo-obstruction (CIPO) is a syndrome associating chronic or recurrent obstructive symptoms with intestinal dilation on imaging but without organic obstruction in the digestive tract. It is a rare disease with varying severity whose diagnosis is very complex. The diagnosis is based on clinical and paraclinical arguments in the context of repetitive occlusive syndromes when no mechanical obstruction of the digestive lumen is observed. Abdomino-pelvic computerized tomography (CT) must be performed to rule out a mechanical obstruction. An additional reference examination is trans-duodenal manometry of the small intestine, which is almost never normal in CIPO, but the test is rarely systematically performed. CIPO can be primary (acquired or congenital) or secondary to a systemic pathology (neurological, metabolic, etc.) resulting in neuromuscular damage to the intestinal tract. There are familial forms associated with genetic mutations. The majority of CIPO cases are idiopathic. Symptoms of the CIPO syndrome should be investigated with a complete assessment, guided by questioning and clinical examination that should also focus on urinary, neurological and cardiac involvement. Pathological tissue analysis is interesting for the etiological classification but is difficult to obtain. CIPO must be distinguished from non-CIPO intestinal dysmotility. Management must be carried out in an expert center with multidisciplinary care involving gastroenterologists, nutritionists, psychologists, radiologists, pathologists and digestive surgeons. It is essentially based on symptomatic management (especially with pro-kinetic agents and analgesics), nutritional support, as well as psychological support in view of its impact on quality of life. Surgical management is sometimes necessary.

Medical and surgical management of short bowel syndrome.

Short bowel syndrome (SBS) is a rare disease, resulting from extensive resection of the small intestine. Depending on the severity of malabsorption, it will lead to intestinal failure, defined as the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, resulting in a situation where intravenous supplementation is required. The risk of developing intestinal failure is related to the remaining length of small intestine and the anatomy of the remnant bowel. SBS incidence has been estimated to range from 5 to 10 patients per year per million population. The main consequence of SBS is a marked reduction of intestinal absorption surface and its main complication is undernutrition and hydro-electrolytic abnormalities. Parenteral nutrition (PN), the major treatment of intestinal failure, has long-term complications. In case of PN dependency, treatment with trophic factors can be proposed. Glucagon-like peptide-2 (GLP-2) analogs allow significant reduction of PN dependency and improve quality of life. Rehabilitative surgery should always be proposed, with the primary goal of restoring digestive continuity. Sometimes, an additional surgical procedure, such as an antiperistaltic reversal of a small bowel segment, is performed when restoring digestive continuity in patients with insufficient length of remnant small intestine to enhance the possibility of PN withdrawal. Intestinal transplantation is proposed as a last resort.