Dysmotility

Dysmotility

Ariel Rodgers, PGY-4

TWIS 12/30/2020

Multiple Choice

A 56-year-old woman undergoes a total colectomy with ileorectal anastomosis for colon cancer. On POD 3, the patient reports abdominal pain despite a morphine PCA and emesis. Her bowel sounds are reduced with abdominal distention without rebound tenderness. Her vital signs and electrolytes are within normal limits. A KUB shows uniform distention of the stomach, small bowel, and colon. What is the next step in management?

• Oral Milk of Magnesia

• Endoscopic decompression

• NGT and multimodality pain control

• Erythromycin

• IV neostigmine

C. NGT and multimodality pain control

This patient most likely has postoperative functional ileus, so NPO, NGT placement, and multimodal pain management are the best next steps. Her risk factors include abdominal surgery and narcotic use as she does not have electrolyte abnormalities or signs of infection. Her x-ray is consistent with uniform distention from stomach to colon, which steers the diagnosis away from obstruction. NPO, nasogastric tube placement for decompression, electrolyte repletion, and a reduction in narcotic and anticholinergic use is the initial management for the first 2 to 4 days. If these measures fail, a CT scan should be ordered to look for other causes. Neostigmine, cholecystokinin, and erythromycin are ineffective in managing paralytic ileus.

Multiple Choice

Which of the following is suggestive of paralytic ileus rather than small bowel obstruction?

• Crampy abdominal pain

• Abdominal distension

• Air fluid levels on imaging

• Uniform bowel distension on imaging

• Nausea and vomiting

D. Uniform bowel distension on imaging

SBO and paralytic ileus have a lot of the same symptoms and it is sometimes hard to tell the difference between the two. SBO usually has crampy abdominal pain whereas ileus may not have pain as a symptom. Both SBO and ileus can have abdominal distension, nausea and vomiting and air fluid levels on imaging. Uniform distension between the stomach, small bowel, and large bowel is more indicative of ileus than SBO as SBO more likely to have a transition point.

Multiple Choice

A 51-year-old man is scheduled for a left colectomy for cancer just distal to the splenic flexure. Which of the following is most likely to reduce his risk of postoperative ileus?

• Analgesia via PCA

• Alvimopan (Entereg)

• Metoclopramide

• Early postoperative feeding

• Administration of neostigmine

B. Alvimopan (Entereg)

Alvimopan is an opioid antagonist that is peripherally acting and does not cross the blood brain barrier. In several studies, it has been demonstrated to decrease time to resumption of bowel function described as flatus, bowel movement, or toleration of regular diet by 15-24 hours. It has been approved by the FDA for perioperative use after partial large or small bowel resections with primary anastomosis. All other interventions listed have never been shown in large scale studies to decrease the risk of postoperative ileus.

Multiple Choice

An 18-year-old inmate is brought to the ED after an episode of unknown foreign body ingestion. He has been on your service several times in the last year under similar circumstances and required laparotomy for a jejunal perforation. Today, his abdomen is benign and his vital signs are stable. A radiograph reveals multiple foreign bodies throughout the small intestine, including coins and bolts. What is the next step in management?

• Emergent laparotomy for foreign body removal

• Admit and daily KUBs to evaluate progress

• Endoscopic retrieval

• Discharge since he is not in immediate danger and wait until he comes back (which is inevitable)

B. Admit and daily KUBs to evaluate progression

Intentional FBI is commonly seen in adult patients with underlying psychiatric disorders. Often, repeat offenders are subsequently discovered to have factitious disorder/Munchausen syndrome, with attention-seeking behavior or self-mutilation. Radiographs are the cheapest and fastest way to diagnose foreign body ingestion. If the foreign body is not radiopaque or unidentified on plain imaging, CT should be considered. Approximately 80% to 90% of foreign bodies will pass without intervention; 10% to 20% require endoscopic removal; and 1% need surgery. Symptomatic patients who have a button battery localized to the stomach, even if symptoms are minor, warrant emergent endoscopic battery removal. Observation alone with daily radiographs is best in this asymptomatic patient with blunt objects in his GI tract. Emergency exploratory laparotomy is not warranted as there are no signs of perforation or obstruction. Endoscopic retrieval should be tried first for sharp objects such as toothpicks, fish bones, straight pins, and paper clips within the stomach that cause perforation in 15% to 35% of cases. These require urgent endoscopic removal after radiologic examination.

Multiple Choice

A 39-year-old man with a longstanding history of gastric motility disorder presents with a 3-month history of vague abdominal pain, early satiety and occasional nausea. Workup reveals a large, dark brown amorphous ball in the fundus on endoscopy. Samples taken show the ball is made up of vegetable matter. The most appropriate next step in management includes:

• Activated charcoal

• Dissolution with Coca-Cola

• Endoscopic removal

• Metoclopramide

• Gastrotomy and removal

B. Dissolution with Coca-Cola

Gastric bezoars result from the accumulation of foreign ingested material in the form of masses. Major types are phytobezoars (most common), trichobezoars and pharmacobezoars. To diagnose, use EGD and attempt chemical dissolution then move to endoscopic retrieval. Surgery if endoscopic removal fails.

Activated charcoal - pharmacobezoars along with EGD unless illicit drugs, then go to surgical removal

Metoclopramide is used as an adjunct but never has a sole therapy

Multiple Choice

You are consulted regarding an 8-year-old mentally disabled boy who swallowed an unknown number of small refrigerator magnets 2 hours ago. His vital signs are stable, his abdominal examination is unremarkable, and his mother confirms his behavior is at baseline. What is the next best step in the management of this patient?

• A single anterior/posterior view plain radiograph is sufficient for diagnosis and evaluation.

• The patient should be taken for computed tomography of the abdomen.

• If the stomach is found to contain a single magnet, urgent endoscopic retrieval is indicated.

• If the stomach is found to contain multiple magnets, urgent endoscopic retrieval is indicated.

• If stomach is found to contain multiple magnets, observation is indicated if patient remains asymptomatic.

D. If the stomach is found to contain multiple magnets, urgent endoscopic retrieval is indicated.

If multiple magnets, or a magnet and another metallic object are ingested, they can entrap tissue and cause perforation. This situation requires emergent endoscopic retrieval.

It is necessary to obtain anterior/posterior (A/P) as well as lateral radiographic films when evaluating magnets. Management of magnets changes depending on how many were ingested. A single magnet does not pose a risk to the patient and can be allowed to pass naturally. However, if multiple magnets are involved, there is a risk that they may entrap gastric tissue and cause perforation. With a single A/P view, multiple magnets may clump together and appear to be a single magnet. A lateral view film provides an additional perspective and allows the clinician to better determine the number of magnets present. Observation is not an option in this scenario.

Multiple Choice

A 69-year-old woman who underwent a hemiarthroplasty 5 days ago develops abdominal distension. The nurse reports she has not had a bowel movement in 3 days. A KUB demonstrates a cecum measuring 8 cm in diameter. The patient is hemodynamically stable. What is the appropriate first step in management?

• NGT and gastrograffin enema

• Milk of Magnesia

• Endoscopic decompression

• Cecostomy

A. NGT and gastrograffin enema

This patient has signs of acute colonic pseudo-obstruction (ACPO, also known as Ogilvie syndrome). This disorder of bowel motility is thought to be related to increased sympathetic activity or reduced parasympathetic tone. It most often occurs in older, hospitalized, or institutionalized patients with severe comorbid conditions or infections or in patients recovering from surgery or traumatic injuries. To accurately diagnose ACPO, clinicians should exclude the presence of a mechanical large-bowel obstruction with an abdominal CT scan or a water-soluble contrast enema, and therefore this should be the first step in management. Therapeutic interventions for ACPO include supportive measures, pharmacologic therapy with neostigmine, colonoscopic decompression, and occasionally, operative intervention. Laxatives should only be given once obstruction has been ruled out.

Multiple Choice

What is NOT a part of the Rome IV criteria for IBS?

• Recurrent abdominal pain

• Pain related to diarrhea

• Change in stool appearance

• Change in stool frequency

Multiple Choice

A 24-year-old female with long-standing history of alternating constipation and diarrhea presents to clinic to discuss the findings of her extensive gastrointestinal workup. She has had multiple abdominal and pelvic CTs, ultrasounds, endoscopies, gynecologic evaluations, laboratory studies and stool analyses, all of which have been unrevealing. She denies pain that interferes with sleep, bloody stools, or weight loss. Her abdominal exam is unremarkable. Her only medication is loperamide. She insists she needs surgery. What is the next best step in management?

• Prescribe sertraline

• Increase dose of loperamide

• Psychiatric consultation

• Schedule loop ileostomy

C. Psychiatric Consultation

This patient has irritable bowel syndrome (IBS), which is a diagnosis of exclusion based on the Rome IV criteria. She has undergone the necessary workup for common gastrointestinal and gynecologic conditions that could overlap in terms of symptomatology. Patients with IBS have a higher incidence of panic disorder, depression, anxiety disorder, and hypochondriasis. A brief set of questions can help identify which patients need behavioral health or psychiatric referral.

Multiple Choice

A 38-year-old woman presents to your office because of irregular recurrent right upper quadrant pain, which lasts for an hour and disrupts her daily activities. She has a history of cholecystectomy 6 years ago. A physical examination is unremarkable. Laboratory tests performed during her attack of pain show elevated liver enzymes but normal amylase/lipase levels. Upper endoscopy is normal. MRCP reveals a common bile duct of 16 mm but no stones. The pancreas is normal. Sphincter manometry was attempted, but unable to be completed. What is the next step in management?

• Nitric Oxide

• ERCP and sphincterotomy

• Antidepressants

• Transduodenal sphincteroplasty

B. ERCP and sphincterotomy

This is a classic description of sphincter of Oddi dysfunction. Because the patient has both a dilated bile duct and elevated liver enzymes, she has organic stenosis—for which endoscopic sphincterotomy is highly successful. In cases where access to the duodenum is anatomically limited (such as prior bariatric surgery), a transduodenal sphincteroplasty may be necessary.

Numerous pharmacologic agents (such as nitric oxide, amitriptyline, nifedipine, octreotide, etc.) have been used to treat sphincter of Oddi dysfunction in small studies. No one agent has demonstrated enough consistent benefit to become the mainstay of pharmacologic therapy.

This patient has an anatomic source for her abdominal pain and therefore requires procedural intervention.

Multiple Choice

Reproduction of biliary colic with which of the following tests best identifies patients likely to benefit from transduodenal sphincteroplasty?

• Secretin stimulation test

• Morphine-neostigmine (Nardi) test

• Glucagon stimulation test

• Cholecystokinin (CCK) test

• Corticotropin stimulation test

B. Morphine-neostigmine (Nardi) test

Reproduction of pain with morphine (resulting in sphincter contraction) and neostigmine (resulting in biliary contraction) has been historically used to identify patients with sphincter of Oddi dysfunction that would benefit from transduodenal sphincterectomy.

Multiple Choice

A 40-year-old woman with diabetes mellitus and a body mass index of 45 kg/m² presents with recurrent right upper quadrant pain that typically lasts for 30 minutes and is occasionally postprandial. She denies any nausea or vomiting but reports she has experienced these episodes before. Her right upper quadrant ultrasound is unremarkable, so she undergoes a hepatobiliary iminodiacetic acid (HIDA) scan, which reveals an ejection fraction of 35%. Which of the following characteristics is necessary to diagnose functional gallbladder disease?

• Young age

• Female sex

• Obesity

• Biliary pain without gallstones or sludge

D. Biliary pain without gallstones or sludge

According to the Rome IV criteria, to be diagnosed with functional gallbladder disease, a patient must have biliary pain without gallstones, sludge, microlithiasis or any other structural pathology.

Biliary pain is defined as pain located in the epigastrium and/or RUQ and all of the following:

1. Builds up to a steady level and lasts 30 minutes or longer

2. Occurring at different intervals (not daily)

3. Severe enough to interrupt daily activities or lead to an emergency department visit

4. Not significantly (<20%) related to bowel movements or relieved by postural change or acid suppression

Thank you!

Any questions?