Gastrointestinal Dysmotility

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The principles of management of any gastrointestinal motility disorder include restoration of hydration and nutrition by the oral, enteral, or parenteral route, suppression of bacterial overgrowth, use of prokinetic agents or stimulating laxatives, and resection of localized disease.

Bowel Hypomotility. The first line of treatment of bowel hypomotility is to increase dietary fiber as well as water intake and exercise. Psyllium or methylcellulose with a concomitant increase in fluid intake may be used to further increase stool bulk. Some caution is required in diabetic patients, in whom high fiber may pose a risk of distention, cramping, and potential bezoar formation in the presence of gastroparesis. If these measures are ineffective, stool softeners (e.g., docusate sodium) or lubricants (e.g., mineral oil) together with an osmotic agent (e.g., milk of magnesia or lactulose) may be used. Glycerine suppositories or sodium phosphate enemas promote fluid retention in the rectum and thus stimulate evacuation. Contact cathartics such as diphenylmetane derivatives (e.g., phenolphthalein, bisacodyl) or antraquinones (e.g., senna and cascara) should be used sparingly because these agents may damage the myenteric plexus, producing a "cathartic bowel."

This regimen can be used in conjunction with the prokinetic agents, which include the following: metoclopramide, which has antiemetic effects due to blockade of central dopaminergic D2 receptors and indirect prokinetic effects through cholinergic mechanisms; cisapride, which increases the release of acetylcholine from neurons of the myenteric plexus; erythromycin, which mimics the prokinetic actions of motilin, a gastrointestinal polypeptide; and misoprostol, a synthetic prostaglandin E1 analog. Patients who do not respond to medical therapy may require colonic surgery.

Bowel Hypermotility. Diarrhea may result from bacterial overgrowth in patients with intestinal hypomotility. A trial with tetracycline or metronidazole is generally conducted in patients with unexplained chronic diarrhea, particularly if steatorrhea is present. Prokinetic agents may paradoxically improve diarrhea in this situation. If these measures fail, synthetic opioid agonists such as loperamide or diphenoxylate can be used. Opioid agonists decrease peristalsis and increase rectal sphincter tone. Clonidine, an alpha-2 agonist, has been used to treat diarrhea associated with diabetic dysautonomia.

Idiopathic fecal incontinence may be associated with delayed conduction in the pudendal nerves and denervation changes in the sphincter muscles. High-fiber bulking agents may be beneficial because semi-formed stools are easier to control than liquid feces. Fecal disimpaction is indicated in some patients. Daily tap water enemas aid in clearing the residue from the rectum between evacuations and may improve continence. Biofeedback may be successful in some cases. Patients who undergo surgical sphincter repair may gain some continence for solid stool, although the presence of pudendal neuropathy is associated with a poor outcome. Other surgical treatments include colostomy, artificial anal sphincters, and creation of a neosphincter with muscle grafts.

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Constipation Prescription

Constipation Prescription

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