Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies

Disorders of gastrointestinal (GI) transit and motility are common, and cause either delayed or accelerated transit through the stomach, small intestine or colon, and affect one or more regions. Assessment of regional and/or whole gut transit times can provide direct measurements and diagnostic information to explain the cause of symptoms, and plan therapy.Recently, several newer diagnostic tools have become available. The American and European Neurogastroenterology and Motility Societies undertook this review to provide guidelines on the indications and optimal methods for the use of transit measurements in clinical practice. This was based on evidence of validation including performance characteristics, clinical significance, and strengths of various techniques. The tests include measurements of: gastric emptying with scintigraphy, wireless motility capsule, and 13 C breath tests; small bowel transit with breath tests, scintigraphy, and wireless motility capsule; and colonic transit with radioopaque markers, wireless motility capsule, and scintigraphy. Based on the evidence, consensus recommendations are provided for each technique and for the evaluations of regional and whole gut transit. In summary, tests of gastrointestinal transit are available and useful in the evaluation of patients with symptoms suggestive of gastrointestinal dysmotility, since they can provide objective diagnosis and a rational approach to patient management.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79321/1/j.1365-2982.2010.01612.x.pd

COLONIC MOTILITY IN HEALTH AND IN SLOW TRANSIT CONSTIPATION

PhDIntroduction Our knowledge of normal human colonic motility remains incomplete. Historically, this has been due to the relative inaccessibility of this organ for study, and the lack of standardisation of methods used to investigate it. Recent device development has provided us with advanced tools by which to assess colonic motility, namely pancolonic manometry, and the wireless motility capsule (WMC). Using traditional diagnostic tests, a subgroup of patients presenting with severe intractable symptoms, but without organic disease, are found to have slow transit constipation (STC). This is believed to be primarily due to colonic dysmotility, although colonic motor functions remain poorly understood in this group also. Aims The principal aims of this thesis were to: (1) explore the effect of pancolonic manometric recording technique on colonic motility; (2) describe pancolonic motility in STC, compared to healthy control subjects; (3) using the wireless motility capsule (WMC), validate the precise location of the pH fall around the ileo-caecal junction as a landmark for measuring colonic motility; (4) obtain normative data for colonic motility (transit and contractility) and intraluminal pH in a large cohort of healthy volunteers using the WMC, and compare this to patients with STC. Methods The following methods were used: (1) prolonged pancolonic manometry in healthy volunteers and patients with STC; (2) a dual scintigraphic technique, involving radioactive-labelling of the WMC in healthy volunteers; (3) wireless motility capsule studies of colonic motility in healthy volunteers and in patients with STC. Results Colonic manometric recording technique (bowel preparation or not, and different catheter types) significantly influences some characteristics of propagating sequence (PS) activity, including frequency, amplitude, polarity, relationship between consecutive PSs, and circadian rhythm. Patients with STC display dysregulated colonic motor function represented by disorganised spatiotemporal patterning and loss of ‘regional linkage’ among PSs. The fall in pH measured by the WMC was confirmed to be either in the caecum, ascending colon, or as the capsule moved from the caecum to the ascending colon. Using the WMC, the upper limit of normal colonic transit time (CTT) was found to be 51 h; however, CTT is not a continuous variable and exhibits peaks every 24 h. CTT is significantly prolonged in females and affected by the study protocol employed. In patients with STC, colonic contractility (motility index) is increased in comparison with healthy controls, and intraluminal pH is more acidic in the proximal colon, and more alkaline in the distal colon. Conclusions The method of pancolonic manometry requires standardisation. However, novel metrics derived from prolonged pancolonic recordings have improved our understanding of the physiology of colonic motor function in health, and also pathophysiology in constipation. The WMC provides an alternative, less invasive method to investigate colonic motility; this technique also requires standardisation, but early results in patients with STC complement those from manometry, and also reveal alterations in intraluminal pH that may be of pathophysiological significance.SmartPill Corporatio

Enhancing our understanding of small bowel function using modern imaging techniques

Small intestinal function is critical to digestive health and patients believe an abnormal reaction to food is responsible for many of their symptoms. Despite this, our ability to assess disturbed function in clinical practice has been limited, particularly after ingestion of the complex nutrients which make up normal food. Recent advances in both wireless capsules and magnetic resonance imaging have provided new insights. This review will briefly describe the limitations of past techniques and focus on how these newer techniques are changing our understanding, particularly of how patients’ gastrointestinal tracts respond to food

Update on the management of constipation in the elderly: new treatment options

Constipation disproportionately affects older adults, with a prevalences of 50% in community-dwelling elderly and 74% in nursing-home residents. Loss of mobility, medications, underlying diseases, impaired anorectal sensation, and ignoring calls to defecate are as important as dyssynergic defecation or irritable bowel syndrome in causing constipation. Detailed medical history on medications and co-morbid problems, and meticulous digital rectal examination may help identify causes of constipation. Likewise, blood tests and colonoscopy may identify organic causes such as colon cancer. Physiological tests such as colonic transit study with radio-opaque markers or wireless motility capsule, anorectal manometry, and balloon expulsion tests can identify disorders of colonic and anorectal function. However, in the elderly, there is usually more than one mechanism, requiring an individualized but multifactorial treatment approach. The management of constipation continues to evolve. Although osmotic laxatives such as polyethylene glycol remain mainstay, several new agents that target different mechanisms appear promising such as chloride-channel activator (lubiprostone), guanylate cyclase agonist (linaclotide), 5HT4 agonist (prucalopride), and peripherally acting μ-opioid receptor antagonists (alvimopan and methylnaltrexone) for opioid-induced constipation. Biofeedback therapy is efficacious for treating dyssynergic defecation and fecal impaction with soiling. However, data on efficacy and safety of drugs in elderly are limited and urgently needed

First translational consensus on terminology and definitions of colonic motility in animals and humans studied by manometric and other techniques

Alterations in colonic motility are implicated in the pathophysiology of bowel disorders, but high-resolution manometry of human colonic motor function has revealed that our knowledge of normal motor patterns is limited. Furthermore, various terminologies and definitions have been used to describe colonic motor patterns in children, adults and animals. An example is the distinction between the high-amplitude propagating contractions in humans and giant contractions in animals. Harmonized terminology and definitions are required that are applicable to the study of colonic motility performed by basic scientists and clinicians, as well as adult and paediatric gastroenterologists. As clinical studies increasingly require adequate animal models to develop and test new therapies, there is a need for rational use of terminology to describe those motor patterns that are equivalent between animals and humans. This Consensus Statement provides the first harmonized interpretation of commonly used terminology to describe colonic motor function and delineates possible similarities between motor patterns observed in animal models and humans in vitro (ex vivo) and in vivo. The consolidated terminology can be an impetus for new research that will considerably improve our understanding of colonic motor function and will facilitate the development and testing of new therapies for colonic motility disorders. This Consensus Statement provides a conceptual and methodological framework to expand research on colonic motility in experimental animals and humans. The work is intended to facilitate the development of new drugs for common colonic motility disorders and of appropriate diagnostic and therapeutic algorithms for the management of paediatric and adult patients

Wireless pH-motility capsule for colonic transit: prospective comparison with radiopaque markers in chronic constipation

Colon transit (CT) measurements are used in the management of significant constipation. The radiopaque marker (ROM) method provides limited information.We proposed to validate wireless motility capsule (WMC), that measures pH, pressure and temperature, to ROM measurement of CT in patients with symptomatic constipation evaluated at multiple centers. Of 208 patients recruited, 158 eligible patients underwent simultaneous measurement of colonic transit time (CTT) using ROM (Metcalf method, cut off for delay >67 h), and WMC (cutoff for delay >59 h). The study was designed to demonstrate substantial equivalence, defined as diagnostic agreement >65% for patients who had normal or delayed ROM transit.Fifty-nine of 157 patients had delayed ROM CT. Transit results by the two methods differed: ROM median 55.0 h [IQR 31.0–85.0] and WMC (43.5 h [21.7–70.3], P  < 0.001. The positive percent agreement between WMC and ROM for delayed transit was ∼80%; positive agreement in 47 by WMC/59 by ROM or 0.796 (95% CI = 0.67–0.98); agreement vs null hypothesis (65%) P  = 0.01. The negative percent agreement (normal transit) was ∼91%: 89 by WMC/98 by ROM or 0.908 (95% CI = 0.83–0.96); agreement vs null hypothesis (65%), P  = 0.00001. Overall device agreement was 87%. There were significant correlations ( P  < 0.001) between ROM and WMC transit (CTT [ r  = 0.707] and between ROM and combined small and large bowel transit [ r  = 0.704]). There were no significant adverse events.The 87% overall agreement (positive and negative) validates WMC relative to ROM in differentiating slow vs normal CT in a multicenter clinical study of constipation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79053/1/j.1365-2982.2010.01517.x.pd

Imaging Measurement of Whole Gut Transit Time in Paediatric and Adult Functional Gastrointestinal Disorders: A Systematic Review and Narrative Synthesis

Background: functional gastrointestinal disorders (FGID) are common conditions in children and adults, often associated with abnormalities of whole gut transit. Currently, transit tests can be performed using several imaging methods including tracking of radiopaque markers, gamma scintigraphy with the use of radioisotopes, magnetic tracking methods, tracking of movement of Wireless Motility Capsules and emerging Magnetic Resonance Imaging (MRI) approaches. Objectives: to review recent literature on diagnostic imaging techniques used to investigate whole gut transit in FGIDs. Methods: a systematic review was carried out. The different techniques are described briefly, with particular emphasis on contemporary literature and new developments, particularly in the field of MRI. Conclusions: emerging MRI capsule marker methods are promising new tools to study whole gut transit in FGIDs

Assessment of Gastrointestinal Autonomic Dysfunction:Present and Future Perspectives

The autonomic nervous system delicately regulates the function of several target organs, including the gastrointestinal tract. Thus, nerve lesions or other nerve pathologies may cause autonomic dysfunction (AD). Some of the most common causes of AD are diabetes mellitus and α-synucleinopathies such as Parkinson’s disease. Widespread dysmotility throughout the gastrointestinal tract is a common finding in AD, but no commercially available method exists for direct verification of enteric dysfunction. Thus, assessing segmental enteric physiological function is recommended to aid diagnostics and guide treatment. Several established assessment methods exist, but disadvantages such as lack of standardization, exposure to radiation, advanced data interpretation, or high cost, limit their utility. Emerging methods, including high-resolution colonic manometry, 3D-transit, advanced imaging methods, analysis of gut biopsies, and microbiota, may all assist in the evaluation of gastroenteropathy related to AD. This review provides an overview of established and emerging assessment methods of physiological function within the gut and assessment methods of autonomic neuropathy outside the gut, especially in regards to clinical performance, strengths, and limitations for each method