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Gastrointestinal Motility Disorders

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr.

Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

Abstract

The muscles of the gastrointestinal (GI) tract perform an important job. The

GI tract peristalsis, or contractions, mix the contents of the stomach and

propel contents throughout the entire GI tract until they exit as waste. When

these muscles underperform or fail to perform, it can create serious and

painful consequences, diagnosed as GI motility disorders. Although these

disorders are rarely fatal, they can cause physical and emotional effects that

negatively impact a patient's quality of life. However, there are many

options for treatment of GI motility disorders available to healthcare

professionals. Treatment is discussed in context of the current research and

trends to develop new criteria to diagnose and clinically manage care.


Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 7 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 1 hour.

Statement of Learning Need

Clinical criteria to treat patients diagnosed with a gastrointestinal motility

disorder have developed options for primary and acute care clinicians

involved in managing treatment. Research in the area of

neurogastroenterolgy is focused on primary care to access new criteria to

diagnose and guidelines to treat.

Course Purpose

To provide health clinicians with knowledge of gastrointestinal motility

disorders diagnosis, treatment and interventions to support improved quality

of life.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.


1. Ninety percent of absorption of nutrients occurs in the

a. stomach. b. duodenum. c. small intestine. d. large intestine.

2. True or False: The small intestine is referred to as “small”

because it is the shortest segment of the GI tract.

a. True b. False

3. The junction between the small intestines and the colon is the

a. ileocecal valve. b. cecum. c. pyloric sphincter. d. duodenum.

4. When disorders of motility occur in the small intestine, the

affected patient may suffer from

a. malnutrition. b. fluid and electrolyte imbalances. c. overgrowth of intestinal bacteria. d. All of the above

5. True or False: An opioid analgesic, a drug used to manage

moderate-to-severe pain, may cause side effects, such as nausea, vomiting, and constipation.

a. True b. False


Introduction

The gastrointestinal (GI) tract serves a multitude of important functions to

keep the body healthy and active. Much of the work of the GI tract goes on

behind the scenes within the body and is beyond physical or voluntary

control. Gastrointestinal motility describes the process of food, fluids, and

other secretions moving through the GI tract. The intestinal tract normally

carries out a certain number of contractions that advance food and liquids

through the gastrointestinal system as part of digestion and absorption of

nutrients. When disorders of motility occur, the GI tract is said to have some

sort of abnormal amount of motility; it may be working too fast, pushing

food and fluids through at an abnormal rate, resulting in dumping syndrome

or diarrhea. Alternatively, GI motility may be sluggish and working at a rate

much slower than normal or, in the case of aperistalsis, not at all.

The muscles that move and transition food and waste through the GI tract

are involuntary and cannot be physically controlled. The work of the GI

musculature continues at a set pace that makes up part of a complex system

of digestion, absorption of nutrients, and excretion of waste. If the pace of

GI motility is abnormally fast or slow, the affected person will experience

symptoms that can cause discomfort and that could lead to illness. Whether

GI motility problems occur as a result of chronic disease, damage to the

intestinal tract, or short-term illness, the affected patient typically suffers

the effects when normally routine motility and transfer of food goes awry.

The Gastrointestinal Tract

A pathway that extends throughout the body from the upper portion in the

face and head to its terminal location below the pelvis, the gastrointestinal

tract, is between 23 and 26 feet long, beginning with the mouth and ending

with the anus. Instead of being one complete organ, the GI tract consists of


a number of different organs throughout the length of the system. Together

these organs are designed to carry out the processes of digestion but each

organ has its specific purpose and function.

The various organs include those of the upper GI tract, which consists of the

structures of the mouth and throat, the esophagus, the stomach, and the

duodenum of the small intestine. The lower GI tract is comprised of most of

the small intestine and the colon, including the distal portions of the large

intestine containing the sigmoid colon, the rectum, and the anus. Accessory

organs of the gastrointestinal tract are those that are not technically

considered gastrointestinal organs; however, they do play important roles in

the process of digestion and in supporting the work of the GI tract.

Accessory organs include the tongue, salivary glands, the liver, gall bladder,

and pancreas. This course will focus primarily on the main organs of the GI

tract, their functions and disorders of motility.

Esophagus

The esophagus, also referred to as the alimentary canal, is a hollow tube

found in the upper GI tract that is vertically located at approximately the

level of the chest. It is about 10 inches long and connected to the pharynx at

the back of the throat on one end and the stomach at the other end. The

esophagus runs through an opening in the diaphragm known as the

diaphragmatic hiatus before connecting with the stomach.

The process of digestion actually begins before food reaches the esophagus.

It starts in the mouth as a person chews his or her food. The enzymes in

saliva interact with food and start to break food down before it is even

swallowed. As an individual chews and prepares to swallow, ptyalin, the

main enzyme within saliva, works to break down starches and carbohydrates


in foods. Chewing involves using the teeth to break down food until it is in

small enough pieces that it can enter the esophagus; the tongue then

pushes the food toward the back of the mouth so that it can be swallowed.

When swallowing, the food passes through the pharynx and enters the

esophagus as it travels toward the stomach. Despite being a hollow tube

that stretches from the neck to the abdomen, the esophagus does not

simply act as a chute for food to slide from the mouth to the stomach.

Instead, the esophagus contains three layers of tissue where each has a

different function: the interior layer lining or the inner lumen of the

esophagus, a mucosal layer that secretes mucus to provide lubrication for

food as it moves through the esophagus, and, the layer underneath the

mucosal layer, which contains smooth muscles that contract in sequence to

propel food along the tract. The esophageal muscles work in sequence to

control the food’s movement instead of letting it slide toward the stomach by

gravity. The muscles are arranged circumferentially around the esophagus

and also longitudinally along the length of the esophageal lumen.

Toward the top of the esophagus, near the pharynx, the muscles work

voluntarily. When swallowing, a person has more control over muscular

processes used in this area and can better manage the passage of food. As

food gets closer to the stomach at the lower end of the esophagus, the

muscles are smooth and the work of the esophageal musculature is

involuntary; the person eating food does not control the muscular

movements in this area.3 The process of the muscles moving the food

throughout the esophageal tube is known as peristalsis and it occurs

whether or not the person is eating while standing up, sitting, or lying down.


At the base of the esophagus is the lower esophageal sphincter (LES), a

muscle that forms the connection between the esophagus and the stomach.

As food is propelled through the esophagus, the LES relaxes and opens

slightly, which allows the food to pass into the stomach. As soon as the food

enters the stomach, the LES then closes tightly again. It remains closed

when the individual is not eating or swallowing, which prevents stomach acid

and food from being regurgitated and backing up into the esophagus again.

The main function of the esophagus is to transport the food between the

mouth and the stomach. There is very little digestion that occurs within the

esophageal lumen; whatever was first broken down in the mouth and

partially digested is transferred to the stomach to further the digestive

process. Alternatively, some foods are not broken down for digestion until

they reach the stomach. The esophagus therefore plays a very important

role in transferring food from one area to the next so that the body can

digest food, absorb nutrients, and gain energy.

Stomach

The stomach is a curved, hollow organ at the base of the esophagus, and it

consists of four different sections: the cardia, fundus, body, and pylorus.

Food enters the stomach after passing through the esophagus and the lower

esophageal sphincter where it is then partially digested as well as broken

down into smaller pieces so that it can continue to move along the

gastrointestinal tract. The stomach is able to expand and contract,

depending on the volume of food eaten.

The stomach is lined with millions of gastric glands that are made up of

various types of cells that secrete different substances, such as hydrochloric

acid, digestive enzymes, intrinsic factor, and certain hormones. After food


passes through the esophagus, it enters the gastric cardia, which is the first

portion of the stomach. Gastric juices are created in the cardia of the

stomach; these juices contain mucus, hydrochloric acid, and enzymes that

work to break down the food as it enters the stomach. Hydrochloric acid,

while often well known as a component of gastric juice, is only one product

excreted in the stomach that contributes to the breakdown of food during

digestion. Hydrochloric acid has a pH between 1 and 2, which facilitates food

breakdown and kills most types of bacteria that may be present in food.

The fundus is the next portion of the stomach after the cardia. Food is

temporarily stored in the fundus, and this is the point where food is churned

and broken down when it is mixed with enzymes. The chief cells of the


stomach secrete pepsinogen, which converts to form pepsin, an enzyme

needed for protein digestion. The parietal cells lining the stomach secrete

gastrin, a hormone that stimulates production of gastric juice and all of its

components. Intrinsic factor is a type of protein that allows the body to take

in vitamin B12 by combining with the nutrient so that it can be absorbed in

the small intestine.

Food digestion continues in the body of the stomach, which is the largest

portion. Digestion occurs as the stomach secretes gastric juices to break

down food particles. In addition to secretion of gastrin, which stimulates

production of gastric juices, there are other factors that may increase or

decrease the rate of digestion because of how much gastric juice is released.

For example, as food enters the stomach, the walls of the stomach stretch,

stimulating certain receptors that promote the release of gastric juice.

Release of gastric juice may also occur when a person smells or sees food;

this process is known as the cephalic phase of digestion.

The body of the stomach is where most of the enzymatic breakdown of food

occurs and it is considered the primary area of digestion. Like the

esophagus, the stomach is lined with several layers, one of which contains

muscles that contract in different directions to move the food around and to

churn it within the stomach cavity. After spending time in the body of the

stomach, food reaches the antrum, which is the last portion of the stomach

before the small intestine. Similar to the esophagus, the stomach also has

peristaltic waves that propel food toward the small intestine. The word

antrum actually means ‘cave’ and it is in this location that food is slowly

released into the duodenum in small amounts to avoid dumping it into the

next section all at once.4


The length of time that food remains within the stomach varies between 30

minutes to several hours, depending on how much food was eaten and the

composition of the meal, but the average amount of time food spends in the

stomach is four hours.4 As food is broken down and partially digested, it

turns into a semifluid mass known as chyme as it travels through the rest of

the GI tract. The sphincter separating the stomach from the small intestine

is known as the pyloric sphincter. Large food particles cannot pass through

the pyloric sphincter, so if food is not broken down well enough as it

approaches the small intestine, it is churned back within the body of the

stomach to break it down further. As with the LES, the pyloric sphincter is

also a muscle that opens to allow small amounts of chyme to enter the small

intestine at a time and then closes tightly again to keep stomach contents

within the pouch.

As part of the GI tract, the stomach plays an important role in digestion and

motility of food. The stomach can develop its own issues of motility that are

separate from other sections of the GI tract; when this organ develops

motility problems, the affected patient may suffer from a number of

symptoms, depending on whether food is being moved too quickly, too

slowly, or is being regurgitated in the wrong direction. Any of these

symptoms can wreak havoc on other parts of the body, so regulation of

stomach motility is essential for normal GI function.

Small Intestine

Although it is referred to as “small,” the small intestine is actually the

longest segment of the GI tract. Its description as being small refers to its

diameter, which is less than that of the nearby colon. The small intestine is

connected to the base of the stomach; and, the muscular sphincter between

the two structures is known as the pyloric sphincter, which is responsible for


controlling the rate of chyme, or partially digested food, entering the small

intestine from the stomach. The small intestine makes up approximately

two-thirds of the total length of the GI tract, but it remains within a compact

cavity by winding around in loops and coils within the area.

The small intestine consists of three main segments, each of which has its

own purposes and activities as part of digestion. The first section is the

duodenum, which is proximal to the stomach and first receives chyme as it

enters the small intestine. The duodenum is where much of digestion occurs

that finishes what was started in the stomach. Accessory digestive organs,

including the pancreas and gall bladder secrete substances into the

duodenum to aid in digestion. Following this segment is the middle portion

of the small intestine, called the jejunum, which has various folds within its

interior layer. These folds increase the overall surface area of this portion of

the small intestine; consequently, the jejunum is the section of the small

intestine where much of the absorption of nutrients takes place. The distal

section of the small intestine is the ileum, the end of which connects to the

large intestine at the ileocecal valve. This valve is actually another sphincter

found along the GI tract that controls the amount of partially digested food

as it enters the colon.

The small intestine moves chyme throughout its tract by two different

actions: intestinal peristalsis and segmentation. The presence of chyme

within the small intestine stimulates peristalsis, which is the movement of

the smooth muscles to propel the food forward as it moves along the tract.

Segmentation refers to intestinal contractions that create small waves that

churn the chyme as it moves through peristalsis.


Digestion occurs within the stomach of

the GI tract. The stomach begins

absorption of nutrients, and, the small

intestine completes the process of food

digestion and absorbs many nutrients

as the chyme passes through it. The

pancreas and gall bladder, both located

next to the small intestine, secrete

digestive enzymes, including amylase

and lipase into the duodenum to

stimulate further digestion of food.

Once food enters the duodenum, this

action stimulates other areas to

secrete other substances as well, such

as bile from the liver, which work

together to facilitate food digestion and the breakdown of fats, starches, and

other substances in the chyme. The rate of motility of the small intestine is

regulated by secretion of hormones and neuroregulators found within

intestinal secretions.

Chyme travels through the small intestine during an average time of 3 to 6

hours. Absorption occurs because of the microscopic projections on the

surface of the small intestine; these projections, known as villi, are located

on the mucosal surface and are where absorption takes place. Ninety

percent of absorption occurs in the small intestine along its full length. Water

enters and is reabsorbed in the small intestine as well. Each villous is

connected to a tiny capillary network that allows for absorption of nutrients

such as carbohydrates, vitamins, and fatty acids directly into the

bloodstream.


Absorption begins in the jejunum of the small intestine as nutrients pass

from the villi and are diffused through the intestinal wall into the capillary

network. Absorption continues in the ileum of the small intestine, with

specific nutrients being absorbed in certain locations throughout; for

instance, sodium and chloride are absorbed in the jejunum, while vitamin

B12 and bile salts are absorbed in the ileum.1 Most of the nutrients are

absorbed in the small intestine. The remaining substances move into the

colon. The substances first move into an area known as the terminal ileum,

which is the very end of the small intestine, and then pass through the

ileocecal valve. What is left is indigestible and will travel through the colon

where a certain amount of fluid is absorbed before the matter finally exits

the body.

The extraordinary length of the small intestine means that food and chyme

spends a significant amount of time moving through this organ of the

digestive tract. When the small intestine develops a motility disorder, food

can move through this organ much more quickly and may spend very little

time in the small intestine. Because the small intestine is responsible for

much of the absorption that takes place in the GI tract, when motility

disorders occur, the affected patient may then suffer consequences

associated with malabsorption, including malnutrition, fluid and electrolyte

imbalances, and overgrowth of intestinal bacteria.

Colon

Also referred to as the large intestine, the colon is shorter than the small

intestine but its diameter is much larger in size. The colon is divided into

three areas, based on its position in the abdominal cavity. The ascending

colon is connected to the small intestine at the ileocecal valve and is located

on the right side of the body; undigested material travels through this


portion of the colon first. The large intestine turns and then becomes the

transverse colon, which extends from the right to the left side of the

abdomen. At this point, the intestine turns again to become the descending

colon that travels down the left side of the body. The terminal portion of the

descending colon is the sigmoid colon, the S-shaped final portion that

connects to the rectum, and finally, the anus.

The end of the small intestine and the

junction between the small and large

intestines contains the ileocecal valve,

which connects the small intestine to

the colon. Each wave of peristalsis of

the small intestine opens the ileocecal

valve briefly to allow a small amount of

material to pass into the colon. Near

the ileocecal valve is the cecum, which

is a pouch that absorbs some fluid and

salts from undigested food. Next to the

cecum is the appendix, a finger-like

projection that may serve as a reservoir for beneficial bacteria in the gut.

Undigested materials enter the colon from the small intestine and travel

through its segments over the course of several hours; the average amount

of time that these materials stay in the colon is approximately 24 hours.4

The colon has a segmented appearance and contains layers of tissue that

are similar to the small intestine; however, the interior layer of tissue in the

large intestine does not contain villi needed for nutrient absorption. The

mass of material is moved through the colon in peristaltic waves that occur

on an intermittent basis, typically from stimulation by secreted hormones


that are released after another meal is eaten. In other words, food from the

last meal may move through the digestive tract and, once it reaches the

large intestine, it is further stimulated to move through this organ when the

person eats the next meal.

The remainder of material that enters the colon is further broken down, as it

becomes waste products that will eventually be evacuated from the body as

stool. This process occurs in the colon through intestinal secretions and the

work of bacteria, which are always present within the large intestine. The

intestinal secretions lubricate the fecal mass as it moves through the colon;

and, the bacteria break down any other nutrients that are present at this

point. The mass moves through the colon much more slowly when compared

to the small intestine. During transit, extra water and electrolytes are

absorbed so that the material eventually forms the fecal mass that becomes

stool.

When the fecal mass reaches the rectum, it distends to contain the stool.

This fecal matter is mostly fluid with some solid material. It contains

indigestible particles of food and bacteria. As the stool stretches the rectum,

it stimulates the autonomic nervous system that controls the internal

sphincter near the anus. The anal opening contains both an internal and an

external sphincter to control passage of stool out of the body. Normally, the

external sphincter stays contracted and closed until the point when

defecation occurs, and it then relaxes to allow stool to pass. The work of the

colon is largely involuntary until stool reaches the rectum and the anus; at

this point, some control of the external anal sphincter is voluntary, allowing

the individual to control defecation.


A significant portion of the colon’s purpose is to absorb fluid and prepare

waste for evacuation, which is healthy and necessary to rid the body of

waste products and those materials that cannot be used by the body. This

last portion of the GI tract is necessary to complete the digestive process, to

eliminate stool and materials that the body does not need, to regulate fluid

and electrolyte levels, and to maintain overall health of the body.

Etiology Of Gastrointestinal Motility Disorders

There are multiple factors that contribute to motility disorders. Because

dysmotility may be manifested in different ways, for instance, as delayed

motility that results in too slow of transit or increased motility that prevents

proper nutrient absorption, there are also various causes of dysmotility.

Some factors may be related to patient health, such as, a decline in overall

health as a result of aging or chronic disease, which can affect the

gastrointestinal system and its rate of motility. Alternatively, there are some

elements in the environment that also affect gastrointestinal function, such

as with drug use. Understanding the potential etiologies of motility problems

may better assist healthcare providers with diagnosing these conditions

when patients present for care.

Degenerative Disorders

The motility of food and materials through the digestive tract is a complex

process that involves stimulation of the muscles and tissues of the

esophagus, stomach, and intestines to propel food through the tract using

peristalsis. Factors such as hormones, enzymes, blood flow, nerve activity,

and intestinal secretions all impact the rate of food transit and digested

materials. Because degenerative disorders can affect many of these factors,

people who suffer from these illnesses may be more likely to develop

disorders of motility within the gastrointestinal tract.


Chronic Intestinal Pseudo-Obstruction

Chronic intestinal pseudo-obstruction (CIP) develops as a disorder that

results in poor intestinal motility. The patient may suffer from signs or

symptoms that would occur with an intestinal obstruction but there is

actually no evidence of any sort of blockage or barrier upon exam. The

condition may develop because of various factors, including surgical trauma

or chronic disease, as well as various nerve and muscle disorders, including

scleroderma, Parkinson’s disease, and lupus.

A person who develops CIP will often suffer from symptoms characteristic of

intestinal obstruction, including abdominal distention and pain, nausea and

vomiting, and either constipation or diarrhea. The patient actually presents

with symptoms that lead the healthcare provider to believe, upon initial

assessment, that some sort of intestinal obstruction is present. However,

after diagnostic testing, the patient is then found to have no lesions or

occlusions in the intestinal tract that would cause the symptoms.57,85

Diagnosis of CIP requires a physical

exam and diagnostic testing, which

typically involves imaging studies. The

patient most often needs an abdominal

X-ray, a CT scan of the abdomen, or

even endoscopy to verify what is

causing the symptoms or to rule out

any other cause, such as an actual

intestinal obstruction. Chronic intestinal

pseudo-obstruction affects GI motility

because the condition affects intestinal

peristalsis, including causing delayed


gastric emptying or rapid transit of digestive substances.

Management of CIP is usually not curative and the best approach is to treat

the patient’s symptoms and to prevent complications, such as malnutrition

or dehydration that may develop from the condition. The patient often needs

nutritional guidance and to be counseled about food intake, as weight loss is

common. In some cases, the symptoms are so severe that the patient

requires a feeding tube to ensure that he or she is getting enough nutrients.

A feeding tube can ensure that the patient continues to gain nutrition

because CIP tends to affect how the food moves through the intestinal tract

but does not necessarily cause changes in the intestinal lining that would

otherwise affect nutrient absorption.

The medications required as part of management of CIP are also prescribed

to control symptoms and to reduce complications. If the patient primarily

suffers from delayed gastric emptying and constipation, then drugs such as

stool softeners, laxatives, and antiemetics may be necessary. Alternatively,

if the condition leads to frequent diarrhea, then antidiarrheal medications

would be required. If the CIP is caused by an infection, the provider can

prescribe antimicrobial drugs to contain the infection and to control

symptoms.

Ideally, CIP is managed by controlling the condition that is causing it;

however, when it develops because of chronic disease that has no cure, such

as lupus or scleroderma, CIP management becomes symptomatic only. The

patient may then continue to take medications and undergo treatments to

control his or her chronic illness while simultaneously managing GI

dysmotility. If symptoms are severe or are unresponsive to medication, the

patient may need surgical treatment. Treatments involved also prevent


complications and may include decompression of the gas that has

accumulated in the intestinal tract, removal of excess stool and waste in the

large intestine, or surgically manipulating intestinal sphincters to improve

muscular control.

Swallowing and Esophageal Disorders

Gastrointestinal motility problems may develop within various segments of

the GI tract. When motility issues occur in the upper gastrointestinal tract

and affect a person’s ability to swallow or transport food to the stomach, the

person is at risk of complications such as dehydration, malnutrition, and

electrolyte imbalance because he or she may have greater difficulties with

getting enough to eat and drink. Motility problems in this portion of the GI

tract are typically classified as swallowing problems or esophageal motility

disorders.

Dysphagia describes difficulty with swallowing; when a person develops

dysphagia, he or she has trouble transitioning food from the back of the

mouth and into the esophagus. Dysphagia can develop as a consequence of

a number of conditions, including physical disabilities, stroke, and

carcinoma, and, it may also develop because of difficulties related to certain

types of degenerative disorders. The problem not only causes issues with GI

motility and food transport, it can lead to other complications, such as

malnutrition, dehydration, and aspiration if food or liquid accidentally enters

the lungs instead of the esophagus.

Degenerative disorders can cause swallowing problems when the nerves that

impact a person’s ability to coordinate swallowing become damaged or

injured as a result of the disease process. Many degenerative conditions

cause loss of neurons in the brain and spinal cord, which further affect


movement and coordination in the GI tract. Degenerative diseases are

typically progressive and are often incurable, with treatment focusing on

management of symptoms and maintaining quality of life. Examples of

degenerative diseases that affect neurological function and swallowing

include such conditions as Huntington’s disease, dementia, or Creutzfeldt-

Jakob disease.

Dysphagia causes motility problems in that an affected person is unable to

adequately coordinate how to transition food from the mouth into the

esophagus so that it can travel to the stomach. The process of swallowing

requires sequencing of various muscles, including those of the face, neck,

mouth, and esophagus; it also requires recognition of the sensations needed

to move the muscles to pass the food along, enough muscle strength to

coordinate movement of the food, and intact reflexes in the pharynx and the

larynx.7 When considering that swallowing is something that most people do

multiple times per day, and that it is a mostly voluntary action, the act of

swallowing is surprisingly complex.

Degenerative changes can also further complicate dysphagia with advancing

age and with other factors that affect cognitive ability, including reduced

cognition because of a decline in the number of neurons in the brain, poor

dentition, decreased salivary production, poor oral hygiene, and decreased

mobility. Strategies to increase quality of life can help to maintain an

affected person’s ability to swallow, despite progression of the disease. This

may involve thickening liquids to make them easier to swallow or choosing

soft and moist foods that are not sticky or hard, making them easier to pass

and less likely to be aspirated.


According to Walse in the Journal of Gastroenterology and Hepatology, the

mode of dysphagia can vary depending on the type of degenerative

condition present. For instance, a person with Alzheimer’s disease may have

difficulty with sensing that food is in the back of the mouth to be swallowed,

while a person with vascular dementia may have difficulty with chewing.7

Because dysphagia is so complex of a process, each patient who suffers from

a medical condition that affects swallowing may have differences in abilities

to contend with when compared to another patient who is also classified as

having dysphagia.

Interventions for people who struggle with dysphagia are centered on

preventing complications associated with the condition and improving overall

wellbeing. Eating is such a social activity that a person’s inability to swallow

normally may further impair the person’s ability to enjoy a meal and to eat

with others. This potentially leads to social isolation and feelings of

loneliness. It is therefore important to consider that dysphagia can deeply

impact quality of life for the affected patient, and improving the ability to

swallow may then increase quality of life for those involved.

The healthcare provider who works with a patient with dysphagia may

provide some interventions that would facilitate easier swallowing. As

mentioned, this may involve thickening liquids and otherwise modifying food

textures and consistencies. The provider may also help the patient to

straighten or move the neck or posture to make swallowing easier and to

reduce the risk of obstruction. Some forms of rehabilitation utilize adaptive

utensils and other methods that make eating easier for the patient.

Further interventions are aimed at preventing aspiration pneumonia, a

potentially serious complication that can develop when the patient aspirates


food into the lung tissue because he does not have control over food and

liquids while swallowing. Silent aspiration occurs when the person swallows

incorrectly and the food or liquid enters the lungs but there is no physical

response from the individual, such as with coughing or choking. Silent

aspiration can be one of the more dangerous complications of dysphagia

because it can be difficult to detect and control, and yet can lead to

pneumonia and breathing difficulties.

Pharmacological and surgical interventions can be helpful for some people

who have difficulties with swallowing, but in most cases, they are not terribly

effective and only help with some of the symptoms.7 For instance, if drooling

is a problem, drug administration may help to control the amount of saliva

production. In many cases, palliative care is often the only management

strategy after attempts at helping the patient to achieve normal swallowing

have been exhausted. Administration of enteral feedings through a feeding

tube may be necessary for some patients who are no longer able to swallow

and who are at risk of malnutrition and dehydration from an inability to pass

food and liquids from the mouth to the esophagus. Caregivers who

determine when and what type of enteral feedings are needed must consider

numerous factors related to the patient’s health, age, living situation, and

prognosis, as changing to this form of feeding may involve a certain amount

of ethical decision making on the part of the healthcare provider. However, it

can continue to provide nutrients and fluid to a patient who is otherwise

unable to adequately swallow.

Achalasia describes a condition that affects how food is transitioned between

the mouth and the stomach. Achalasia develops after damage to the nerves

of the esophagus, causing aperistalsis, in which the esophagus is unable to

propel food and liquids because it lacks the muscular action. The condition


also causes weakening and incomplete closing of the lower esophageal

sphincter, leading to acid reflux and difficulty swallowing. Over time, the

patient with achalasia develops greater difficulties with eating and drinking,

and may suffer from severe gastroesophageal reflux, all of which could

potentially lead to weight loss and malnutrition.

The exact reason why achalasia develops in some people is not entirely

clear, but there are some theories. One common opinion is that the nerves

that control the esophagus become damaged because of an autoimmune

disorder, in which the body attacks its own nerve cells, rendering them

useless for maintaining normal motility in the esophagus.6 The nerve cells

within the muscles of the esophagus slowly degenerate until they are almost

non-functional. Achalasia typically does not develop all at once; instead,

symptoms progressively worsen over time as the patient loses more ability

to drink liquids and to eat solid food. The condition may initially cause

symptoms of mild reflux that can eventually develop into severe pain any

time that the individual tries to eat.

Unfortunately, achalasia is a progressive condition in that the nerve cells

continue to degenerate and the condition continues to worsen. Achalasia can

be managed, though, and depending on the type of treatment, the affected

patient may go for months to years without further symptoms. Treatment

with medication includes administration of botulinum toxin injection into the

LES, which paralyzes the sphincter and allows for food to pass into the

stomach. Surgical myomectomy is another option for treatment that involves

cutting the muscles around the LES, which allows for food to pass into the

stomach.


Stomach and Small Intestine Disorders

Some disorders affect the body’s ability to transition food through areas of

the GI tract; food may have reached a certain point within the

gastrointestinal system but because of some degenerative conditions, the

patient’s body may have enough motility difficulties that it has problems

with further movement. Disorders that affect the nerves of the stomach and

small intestine can cause delayed gastric emptying, dumping syndrome, or

difficulties with absorbing food properly.

Polymyositis degenerative disorder is a relatively rare condition that causes

inflammation of connective tissues. It is characterized by muscle

inflammation, weakness, and elevated serum muscle enzymes, as well as

patient fatigue, shortness of breath, and dysphagia or speaking difficulties.8,9

The exact cause of the condition remains unknown, but it is thought that the

muscle inflammation develops as an autoimmune condition. Most people

with the condition develop pain and inflammation in the muscles of the

upper body, including the neck, shoulders, upper back, and upper

extremities, however, GI symptoms and motility problems are also common

with this condition.

Polymyositis has been known to be responsible for a number of GI conditions

that affect anything from swallowing to lower esophageal sphincter tone.

One condition that may be more likely to develop with polymyositis is

delayed gastric emptying, also called gastroparesis, which occurs when food

moves too slowly from the stomach and into the small intestine. The

condition can often cause gastroesophageal reflux, abdominal pain and

bloating, and anorexia in affected individuals and can lead to an increase of

bacterial proliferation within the stomach and painful lumps of undigested


food in the stomach that are difficult to break down and pass into the small

intestine.

Patients with polymyositis have also developed GI symptoms of diarrhea or

constipation, colonic dilatation, GI bleeding, and pseudodiverticula, which

occur as small projections of the mucosal layer of the intestine into the

muscular wall. All of these symptoms can cause significant discomfort for the

affected patient, potentially resulting in malnutrition and anorexia if the

patient is unable to eat or digest food properly and if the patient struggles

with painful symptoms when eating. Treatment involves administration of

corticosteroids to reduce inflammation and symptom management to control

gastrointestinal motility problems, such as through modifying food textures

to facilitate easier chewing and swallowing, increasing fluid intake, and

eating smaller but more frequent meals.

Another type of disorder that causes too rapid intestinal motility from the

stomach to the small intestine is known as dumping syndrome. The

condition often develops following certain surgical procedures when the

muscles and nerves have been damaged or changed and no longer work

correctly to control gastric motility. Dumping syndrome is said to affect up to

50 percent of patients who have undergone gastric surgery.66 It occurs when

food moves too quickly out of the stomach and into the duodenum of the

small intestine. The condition is actually a collection of symptoms that

develop with the increased movement of food through the intestine; it is

classified as being early phase or late-phase dumping syndrome according to

the timing of symptoms.

Early phase dumping syndrome occurs within 30 to 60 minutes after a meal.

The affected patient may develop abdominal pain and cramping and may


start to sweat or feel flushed and lightheaded. Other symptoms include a

distinct feeling of fullness in the abdomen, nausea, vomiting, diarrhea, and a

rapid heart rate. Up to three hours after a meal, late dumping syndrome

may develop, which causes symptoms of flushing, sweating, fatigue, tremor,

dizziness, tachycardia, and mental confusion.67

Dumping syndrome is said to develop because of changes in the size of the

intestinal tract during digestion, the release of certain hormones after eating

that can affect blood pressure, rapid swings in blood glucose levels after

eating, and increased fluid absorption from the bloodstream and into the

small intestine.66 When a patient has bariatric surgery, such as with gastric

bypass, the patient may also develop dumping syndrome because the

procedure may affect innervation of the stomach muscles. If the nerves

controlling the muscles are cut during surgery or are otherwise damaged,

the patient may then lose control over stomach contractions, leading to

dumping syndrome.

Dumping syndrome is best managed with changes in dietary practices,

including avoiding anything that would overstimulate the muscles of the

stomach and cause it to contract too quickly. For instance, the patient

should be advised to slow down while eating and to eat small meals,

chewing every bit thoroughly before swallowing. A patient may also be

instructed to avoid drinking large volumes of liquid before, during, or after

meals, and may need to increase fiber intake while decreasing intake of

sugar, alcohol, and caffeine.

For some patients, dumping syndrome is only managed through medications

or surgery if it does not respond to lifestyle changes. Antidiarrheal

medications can help to control some of the abdominal pain, flatulence, and


diarrhea that often develop because of dumping syndrome. In severe cases,

surgery to alter the muscles of the pyloric sphincter can best manage

dumping syndrome in order to control the rate at which food passes between

the stomach and the small intestine.

Muscular dystrophy is another type of degenerative disease that may cause

GI motility problems throughout the entire GI tract; however, many

symptoms of motility disorders can be concentrated within the stomach or

small intestine regions with this disorder. Muscular dystrophy is actually a

group of more than 30 degenerative diseases that involve breakdown of

muscle tissue, affecting movement and coordination. Muscular dystrophy has

no treatment, and management is focused on physical therapy and use of

assistive devices to maintain quality of life and to offset some of the muscle

weakness experienced by the patient.

In addition to the symptoms affecting

various skeletal muscles of affected

patients, muscular dystrophy can also

cause gastrointestinal changes that affect

motility; the most frequently cited

symptoms include dysphagia, dyspepsia,

gastroesophageal reflux, and vomiting.10

Other symptoms may also include

constipation or diarrhea, early satiety,

delayed gastric emptying, abdominal pain,

and bloating. The extent of symptoms

experienced by the patient is typically not

correlated with the extent of the disease,

as muscular dystrophy affects skeletal muscles and not necessarily the


smooth muscles of the GI tract. Still, those who have more advanced forms

of muscular dystrophy have been shown to also struggle with more severe

gastrointestinal symptoms, suggesting that motility problems seem to

worsen over time.

The progressive muscle weakness that develops from muscular dystrophy is

related to skeletal muscles; those that are used for physical movement and

functioning and are voluntarily controlled. While some of the gastrointestinal

tract utilizes the work of voluntary muscles, much of the peristalsis and

transit of food and chyme is done through involuntary control of the smooth

muscles lining the GI tract. Experts are not sure why patients with muscular

dystrophy then develop gastrointestinal disturbances, but many believe that

it is due to an alteration in gastrointestinal secretions and changes in nerve

function associated with the disease.10

Because of the potential for altered nutrition due to gastrointestinal motility

problems in patients with muscular dystrophy, healthcare providers often

include interventions designed to improve motility, increase appetite, and

assist the patient with eating and digesting food properly, despite the

condition. This may mean administering medications that increase bowel

motility and to treat diarrhea, and dietary modifications to facilitate easier

chewing and swallowing. As with some other progressive degenerative

diseases that affect gastrointestinal motility, tube feedings may be

necessary to maintain adequate nutrition once the patient’s condition has

advanced.

Disorders of the Large Intestine

Although degenerative disorders can affect motility at any point along the

digestive tract, the areas of concern are most often within the colon and the


rectum. In the large intestine, extra water is absorbed and stool is stored

until the individual can evacuate stool voluntarily. When a degenerative

disease develops, it can impact a person’s ability to control stool evacuation

or to sense the need to defecate. Consequently, patients diagnosed with

degenerative disorders often suffer from motility problems, including

constipation, fecal incontinence, or fecal impaction.

Degenerative neurological disease can affect nervous pathways leading to

the large intestine, causing potential complications for a patient diagnosed

with this type of disease. Degenerative conditions such as multiple sclerosis,

Parkinson’s disease, and spinal cord lesions have all been shown to impact

nervous system pathways to the large intestine, leading to dysregulation of

intestinal smooth muscle and difficulties with peristalsis and transit.5

The greater risk of complications tends to occur with further progression of

the degenerative disease. In other words, the more advanced the stage of

the neurodegenerative disorder, the more likely the patient will be affected

with gastrointestinal motility problems. A report by Wald of the International

Foundation for Functional Gastrointestinal Disorders stated that among

patients with multiple sclerosis (MS) analyzed in a large research study,

about two-thirds struggled with constipation or fecal incontinence, and, most

were considered to have moderate or severe disability associated with MS.5

It should be noted that patients who are considered to have even mild forms

of some degenerative disease may still suffer from intestinal motility

problems.

Degenerative diseases may also contribute to muscle weakness that impact

the body’s abilities to control sphincter muscle tone. Patients who have

diabetes mellitus may experience muscle weakness and may have an


inability to control the external anal sphincter muscle that normally tightens

and relaxes to control defecation. When the patient is unable to control the

external anal sphincter because of muscle weakness, he or she is at higher

risk of fecal incontinence because of an inability to control stool and

defecation. Patients who suffer from some neurodegenerative disorders may

be more likely to struggle with constipation from decreased motility rather

than diarrhea. If there is a risk of fecal incontinence because of muscle

weakness and poor anal sphincter control, the healthcare provider should

carefully consider management of constipation as aggressive treatment

could not only reverse the condition, but could also cause diarrhea that

would be difficult to control with muscle weakness.5

Hirschsprung’s disease, also called congenital intestinal aganglionosis, occurs

as a type of birth defect in which a person is missing some of the nerve cells

that control the GI tract. It typically affects the large intestine. Normally, the

nerve ganglia develop between muscle layers that line the colon; and, these

nerve bundles are usually present throughout the length of the large

intestine. With Hirschsprung’s disease, nerve growth is incomplete and, in

some areas, nerve bundles fail to form at all, which results in aganglionosis.

The length of aganglionosis may vary between individuals; some people are

born with aganglia only in the sigmoid colon and the rectum, while others

may have absent nerve bundles extending to proximal portions of the large

intestine. Approximately 80 percent of patients have aganglionosis within

the recto-sigmoid portion of the colon.11 This affected area is also classified

as short-segment disease.

Because Hirschsprung’s disease is a congenital condition, symptoms start to

appear during infancy. Symptoms are typically manifested as an inability to

pass stool in a normal manner, including difficulties with passing first


meconium after birth among some infants. Other symptoms include frequent

emesis, chronic constipation, and abdominal pain and distention. As the

person grows, he or she may suffer from long-term problems with

constipation, flatulence, and fatigue.

Unfortunately, patients with Hirschsprung’s disease are at risk of intestinal

infection because of poor motility. Stool tends to back up within the colon,

causing intestinal distention and the potential for bacterial growth, which can

lead to enterocolitis. The backup of stool in the colon also causes intestinal

obstruction so that the patient has difficulties with passing stool at all. The

intestinal walls could become overly distended thereby increasing the risk of

intestinal perforation.

The most common type of treatment for Hirschsprung’s disease is surgical

resection of the affected areas of the colon where aganglionosis is present.

For patients who have short-segment disease, this may mean removal of the

diseased portion and placement of a colostomy. If longer sections of the

bowel are affected, the patient may need an ileostomy to pass stool after a

significant section of the bowel has been removed. Other interventions that

are often necessary involve monitoring food intake, including high-fiber

foods, to reduce the risk of constipation, increasing fluid intake and physical

activity, and possible administration of laxative medications to stimulate gut

peristalsis.

Endocrine Disorders

Endocrine disorders develop from dysfunction of the endocrine glands that

result in either over- or underproduction of hormones. Endocrine dysfunction

can lead to long-term problems and symptoms that affect the entire body,

including the gastrointestinal tract. Gastrointestinal motility disorders may


develop in some patients with endocrine dysfunction, even if the endocrine

disorder seems otherwise unrelated to the GI condition.

Diabetic Gastroparesis

Defined as delayed gastric emptying, gastroparesis occurs when a person’s

ability to transport food from the stomach to the small intestine slows down,

despite a lack of obstruction. The condition is more often associated with

diabetic patients, although it can develop among those who do not have

diabetes. Gastroparesis more commonly occurs among diabetic patients

because uncontrolled blood glucose levels can damage the vagus nerve,

which controls the rate of stomach emptying. As a result, food tends to stay

in the stomach longer and is slower to transition to the small intestine for

further digestion and absorption.

Gastroparesis can lead to multiple uncomfortable symptoms related to

delayed gastric emptying. The most common symptom typically includes

nausea, vomiting, abdominal bloating, early satiety, and epigastric fullness.

The patient is more likely to suffer from poor quality of life because of

symptoms and may eventually develop malnutrition and weight loss when

food cannot be transitioned normally in the GI tract. Furthermore, some

patients with gastroparesis are unable to absorb oral medications in a

normal manner, making this route of medication administration ineffective;

these groups of people may then need to utilize other methods of drug

administration to control symptoms. The vomiting and anorexia associated

with gastroparesis can also significantly impact the diabetic patient’s blood

glucose levels.

Diabetes mellitus is an endocrine disorder that impacts how the body uses

glucose for energy. It is a complex disease that is divided into types 1 and 2.


Type 1 diabetes develops when the pancreas, the main organ responsible for

secreting insulin to get glucose into the cells for energy, is damaged or

otherwise unable to secrete enough of the insulin hormone to control how

much glucose enters the bloodstream. Type 2 diabetes tends to develop

because of insulin resistance, in which the cells are unaffected by insulin and

thereby become unable to take on enough glucose for energy. Without

treatment, both types of diabetes result in elevated levels of glucose in the

bloodstream, which can be damaging to blood vessels and to the nerves that

serve various organs throughout the body. For this reason, diabetes has

been known to cause many different types of health conditions, such as

circulatory and peripheral vascular disease, as well as blindness.

Diabetes is also closely linked to gastrointestinal motility problems. As food

is absorbed in the digestive tract, it is transformed into glucose so that the

body can use it for energy; however, when there are GI motility problems

that affect absorption, the body may be unable to take up enough nutrients

to provide glucose for energy. Alternatively, too much glucose in the

bloodstream that circulates without being used for energy damages parts of

the GI system, including the nerves that serve the intestinal tract, which

may lead to severe GI motility disturbances.

Between 5 and 12 percent of patients with diabetes report symptoms of

gastroparesis.12 Gastroparesis is not necessarily a condition that develops

early on after a diabetes diagnosis, instead, it is more likely to occur later in

the course of the disease, after the patient has had diabetes for several

years and may more likely suffer from concurrent conditions that have also

developed as a result of diabetes, including nephropathy, neuropathy, or

retinopathy.


Normally, the stomach uses muscular contractions to churn and propel food

within it, and the stomach’s peristaltic waves then move the food,

coordinated with the opening and closing of the pyloric sphincter (between

the stomach and duodenal (small intestine) bulb, to push it into the first

portion of the small intestine. Once damage has occurred to the vagus nerve

that controls this process, there is no cure for the condition. The patient is at

risk of several complications, including malnutrition and dehydration when

food and liquids cannot be processed normally. A bezoar may develop, which

is a hard mass of undigested food that sits in the stomach and cannot be

passed into the small intestine. The patient typically develops nausea and

may vomit when a bezoar is present; and, it can eventually be dangerous for

the patient if it blocks the pyloric sphincter and prevents other food from

passing into the small intestine.

Management of gastroparesis involves controlling the underlying condition

and taking steps to improve the rate of gastric emptying. For the patient

with diabetes, the damage to the vagus nerve that causes gastroparesis is

typically irreversible, even with later blood glucose management. However,

it is still important to help the patient to control blood glucose levels to

better prevent other complications of the condition and to inhibit the

potential for gastroparesis symptoms to affect blood glucose levels.

Gastroparesis is also managed through dietary changes that help the patient

to eat foods that are easier to digest. The patient may need to chew food

very thoroughly so that bites are very small and easier to pass through the

stomach. Other dietary interventions often include increasing fluid intake

and avoiding certain foods; those foods that are very fibrous or that contain

hard particles, such as nuts and seeds, may be more difficult to digest and

can complicate symptoms of gastroparesis. Some medications may stimulate


stomach contractions to help with the passage of food. Metoclopramide

(Reglan®) may be given to improve the rate of gastric emptying; and,

erythromycin is another drug that has been shown to be successful.

Erythromycin stimulates the smooth muscles in the stomach and the

duodenum of the small intestine to increase gastric motility.12

Electrical stimulation may also be used as part of treatment for

gastroparesis. The process uses a permanent implanted device, inserted

surgically, that stimulates the lower gastric nerves of the stomach, which

helps the stomach to contract. The most common device is called Enterra™

and it is used when the clinician laparoscopically inserts the electrodes into

the patient’s stomach to deliver the electrical current. A study published in

the Journal of Minimal Access Surgery demonstrated that a permanently

implanted device such as Enterra to deliver electrical stimulation improved

symptoms in 70 percent of patients with severe gastroparesis who had

participated in the study.13 Once implanted, the Enterra device stays in place

for the long-term and provides permanent stimulation to control

gastroparesis and prevent it from worsening; and, it is typically reserved for

patients with delayed gastric emptying who have not otherwise responded to

other therapies.

Because there is no cure for diabetes, the patient who is diagnosed must be

educated about the damaging effects of the disease and the need for control

of blood glucose levels to prevent complications. Gastroparesis that develops

as a result of diabetes is also a permanent condition that will require lifelong

management once it occurs. If possible, it is better to prevent the condition

from developing instead of trying to manage it after it has already occurred.


Thyroid Disorders

Over-activity or underactivity of certain glands causes endocrine problems

and potentially debilitating symptoms that can lead to gastrointestinal

issues. The thyroid gland, which releases hormones that regulate body

metabolism, temperature, and heart rate, may not function properly if there

are complications associated with the gland itself or with the portion of the

brain that stimulates its release of hormones. Hyperthyroidism develops

when the thyroid is overactive and produces too many hormones; it

normally results in a rapid heart rate, increased appetite, shakiness, and

anxiety, but it can also lead to motility problems.

A commonly seen gastrointestinal motility disorder associated with

hyperthyroidism is diarrhea, as the transit times in the intestine are

increased due to the effects of the hormones. Diarrhea may also be more

likely to develop in hyperthyroid patients when there are abnormal rates of

intestinal secretions, whether because they are secreted in too high of

quantities or if there are not enough.9 Patients with hyperthyroidism may

suffer from other gastrointestinal symptoms as well, including steatorrhea,

which describes increased amounts of fat within the stool, epigastric pain,

abdominal fullness, and dyspepsia.

In contrast to hyperthyroidism, low levels of thyroid hormone result in

hypothyroidism, which has also been shown to cause gastrointestinal

motility disorders. Hypothyroidism is associated with slowing of many

metabolic processes, and affected patients often struggle with symptoms of

weight gain, fatigue, muscle and joint pain, depression, and increased

sensitivity to cold. One of the most common GI complaints among patients

with hypothyroidism is constipation, as colonic motility slows with a decrease

in thyroid hormone production. Hypothyroidism is also responsible for a


number of other GI symptoms, which may include delayed gastric emptying

and bezoar formation, reflux esophagitis, and abdominal distention.

The gastrointestinal changes that develop as a result of hypothyroidism

often occur because the bowel wall becomes thickened and sometimes

dilated. There may also be cellular changes that occur in the bowel mucosa,

including an increase in mucopolysaccharides, which can affect metabolism.

This may relate to an explanation of why the patient with hypothyroidism is

more likely to have slower gut motility and constipation.

Treatment of gastrointestinal motility problems in relation to hyper- or

hypothyroidism involves controlling these underlying conditions. The initial

goal is to achieve normal levels of thyroid hormone, typically through

medications or procedures, in order to regulate metabolic processes within

the body and to diminish symptoms. Hyperthyroidism is often controlled

through radioactive iodine, which damages some of the thyroid cells so that

they stop overproducing thyroid hormones, or surgery to remove part of the

thyroid gland. Alternatively, hypothyroidism is most often controlled through

prescription synthetic thyroid hormone replacement to bring hormone levels

back to within normal limits. Often, prescription medication is administered

lifelong, as discontinuing the drugs will usually cause the body to revert back

to a state of hypothyroidism and continued problems with low hormone

levels.

Patients who suffer from thyroid abnormalities may not initially develop

gastrointestinal motility problems. These difficulties may occur later in the

course of thyroid disease, particularly when there is poor control over

thyroid hormone secretion and poor management of thyroid disease. It is

therefore important to be aware of the gastrointestinal effects that can


develop as a result of abnormal thyroid production so that when symptoms

of motility problems do develop, the healthcare provider and the patient can

be prepared for a possible diagnosis and for treatment of the condition.

Adrenal Gland Disorders

The adrenal glands are another set

of endocrine glands that can cause

various health problems when they

are not functioning appropriately.

The adrenal glands sit on top of the

kidneys in the lower back and are

responsible for secreting hormones

that help the body respond to stress.

There are various types of adrenal

gland disorders, most of which

produce varying symptoms, and

gastrointestinal motility problems

may be included in some of these symptoms. Some of the more common

types of adrenal disorders include Cushing’s syndrome, pituitary tumors,

pheochromocytoma, and Addison’s disease.

Patients with Addison’s disease tend to develop gastrointestinal symptoms

related to nausea, vomiting, and anorexia; the symptoms seem to worsen as

the condition progresses. Addison’s disease is most often caused by an

autoimmune disorder in which the body attacks its own tissues and causes

the adrenal glands to work inappropriately. Eventually, the damage from the

autoimmune system destroys the adrenal cortex, which is the outer

protective covering to the adrenal glands. The patient is no longer able to

secrete sufficient amounts of cortisol and aldosterone needed to regulate


various body functions, including weight control, the ability to fight infection,

and control of heart rate and blood pressure. For this reason, Addison’s

disease is also known as hypocortisolism.

Addison’s disease is difficult to diagnose because many of the symptoms,

whether they are gastrointestinal in nature or not, are non-specific and could

be attributed to any number of medical conditions. General symptoms of

Addison’s disease include hyperpigmentation of the skin and mucous

membranes, weakness, fatigue, poor appetite, and weight loss, as well as

joint pain, a heightened sense of smell, hypoglycemia, myalgia, and muscle

paralysis. Addison’s disease typically develops as a result of autoimmune

adrenocortical insufficiency; and, because over 80 percent of cases are

related to autoimmune adrenal damage, Addison’s may be seen in

association with some other types of autoimmune diseases that affect the GI

tract, including celiac disease, type 1 diabetes, Hashimoto thyroiditis,

pernicious anemia, and biliary cirrhosis.14

Management of Addison’s disease improves the likelihood of controlling GI

motility problems that develop as a result of the condition. Treatment

involves correcting the levels of hormones through hormone replacement

therapy; this includes administration of corticosteroids and androgen

replacement therapy, if necessary. Treatment with corticosteroids may

resolve some of the GI symptoms as well as many of the other symptoms of

the condition. Symptoms develop due to hormonal imbalance; the hormones

secreted by the adrenal glands are involved with regulation of the body’s

inflammatory responses, proper balance of electrolytes, and sexual

development. With hormone replacement and medications, the affected

patient may find relief from many symptoms where hormone imbalance is

the root cause. For example, a patient with an imbalance in sodium levels in


the body may struggle with symptoms of diarrhea and dyspepsia. By

replacing mineralocorticoid levels that would otherwise be out of balance

with Addison’s disease, the body would be more likely to regulate sodium

and potassium levels, potentially diminishing the risk of diarrhea from the

condition.

Another endocrine condition that affects the adrenal glands and that is

sometimes confused with Addison’s disease is Cushing syndrome. Cushing

syndrome, also called hypercortisolism, develops when the adrenal glands

create too much cortisol; one of the most common causes of this condition is

when an individual takes in too many steroid medications, however, it can

also develop from such conditions as adrenal tumors or excess production of

adrenocorticotropin hormone (ACTH), which normally stimulates the adrenal

glands to produce cortisol.15

Excess cortisol production can have a number of effects on the

gastrointestinal system. Cortisol is sometimes referred to as the “stress

hormone” in that the body may produce greater amounts in response to

stress. Cortisol can also impact an individual’s nutritional status, as it

normally regulates energy by selecting the correct amount of carbohydrates,

fats, or proteins to meet the physiological needs of the body.16 Elevated

levels of cortisol, as seen with Cushing syndrome, can lead to elevated blood

glucose levels, weight gain, increased appetite, and cravings for high-calorie

foods. Elevated cortisol levels also affect the sympathetic nervous system,

which can affect GI function and can cause uncomfortable symptoms in the

patient with Cushing syndrome. When the person eats a meal, his or her GI

system responds poorly due to elevated cortisol levels and is more likely to

lead to suffering from problems with digestion, nausea, vomiting,

indigestion, and mucosal inflammation.


Control of gastrointestinal motility symptoms associated with Cushing

syndrome is achieved by managing the symptoms when they occur and by

treating the syndrome to regulate cortisol levels. The type of treatment

needed depends on the cause of Cushing syndrome; for instance, if it

develops from excess corticosteroid use, the patient should be assisted to

decrease or eliminate use of this drug to avoid further deleterious effects.

Nursing interventions are focused on helping the patient to perform self-care

measures, keeping the patient safe when symptoms develop, and helping

the patient to control stress levels.

Irritable Bowel Syndrome

One of the more common functional gastrointestinal motility disorders,

irritable bowel syndrome (IBS) is thought to affect up to 10 percent of the

population of the United States.17 Irritable bowel syndrome is considered a

functional gastrointestinal disorder because its symptoms develop from

abnormal functioning of the GI tract. Diagnosis of IBS can be difficult and

clinicians are sometimes perplexed by its expression and manifestations, as

imaging studies and laboratory results tend to be completely normal in

affected patients.

A patient with IBS may suffer from severe symptoms but upon examination,

there is no sign of disease or any change in the colon. Experts have

determined that there are several factors that play a role in the development

of IBS, and control of some of these factors may help to control the negative

symptoms associated with this complex condition. Irritable bowel syndrome

has also been referred to as colitis, spastic colon, and functional bowel

disease,18 although these terms are often designated by the general public

and are not entirely accurate to the disease process that occurs with IBS.


The exact cause of IBS is unclear, but those who develop the disorder often

have several risk factors in common, including increased levels of stress, a

low-fiber diet, recent history of infectious diarrhea, and a history of physical

or sexual abuse. The condition is seen much more often in women when

compared to men, with a 50 percent greater incidence; it is also much more

common among young- and middle-age adults, with most diagnosed cases

occurring before the age of 50 years.19

Irritable bowel syndrome can cause symptoms that predominantly involve

diarrhea or constipation, although some patients suffer from both. It is

classified according to the predominant forms of stool that occur with

symptoms, and may be considered IBS with constipation (IBS-C), IBS with

diarrhea (IBS-D), IBS mixed (IBS-M), or IBS unsubtyped (IBS-U) in which

the stool consistency does not meet the criteria for the other forms of the

condition. The affected patient may also have abdominal bloating, cramping

pain, flatulence, mucus in the stool, and the feeling of incomplete emptying

after having a bowel movement.

In addition to GI symptoms, IBS often causes other symptoms that seem

unrelated to gastrointestinal functioning, including anxiety, depression,

headache, and fatigue. The severity of symptoms may range between mild

gastrointestinal disturbances to severe enough symptoms that impact the

patient’s ability to participate in normal activities and thereby affects his or

her overall quality of life.

There are various theories as to the potential cause of IBS; experts have

proposed that IBS symptoms develop due to altered levels of serotonin in

the GI tract, increased release of inflammatory mediators, abnormal muscle

contractions in the GI tract, visceral hypersensitivity, and brain-gut


dysfunction.18,19 Some patients with IBS may have sensitivities to

stimulation in which the muscles of the large intestine react abnormally and

either increase peristalsis to propel stool through the colon more quickly, or

to slow it down to cause constipation. Visceral hypersensitivity refers to a

situation in which the nerves of the intestinal tract are very easily stimulated

and can send pain messages to the brain in response to potentially mild

environmental triggers. When this occurs, the body may further stimulate

the involuntary muscles of the GI tract to increase peristalsis; the patient

may also be more likely to experience abdominal pain and discomfort in

response to triggers.

Brain-gut dysfunction describes a condition in which a patient may

experience gastrointestinal symptoms in response to emotions and

psychological distress. Feelings of distress may trigger further symptoms of

IBS, causing greater intensity of GI symptoms if the patient is suffering from

psychological symptoms. Unfortunately for some, there are certain

environmental triggers that are more likely to cause symptom exacerbation

in IBS. Persons with IBS have stated that they have been more likely to

experience symptoms after eating a meal containing certain foods, such as

greasy, fried, or spicy foods; and, after drinking alcohol or beverages

containing caffeine, or when experiencing distressing situations or feeling

stress because of traumatic events. Many women with IBS say that they are

more likely to experience symptoms during the days surrounding their

menstrual periods.

Irritable bowel syndrome may be diagnosed after consideration of the Rome

III Diagnostic Criteria, a set of measurements developed by research teams

of neurogastroenterolgy specialists affiliated with the Rome Foundation for

the diagnosis of functional gastrointestinal disorders. According to the Rome


III Criteria, IBS is diagnosed when a patient has had symptoms for at least

three months with symptoms involving recurrent abdominal pain and either

improvement in pain after defecation, change in stool frequency at onset, or

change in stool appearance at onset. These symptoms must have occurred

for at least three days per month.19

Other tests are important when diagnosing IBS, as the condition could be

related to another gastrointestinal illness. Irritable bowel syndrome is not

associated with a greater risk of colon cancer, nor does it cause intestinal

bleeding. If a patient has symptoms of intestinal obstruction, bleeding, or

has a fever or significant weight loss, the patient most likely has another GI

illness that is not irritable bowel syndrome. In addition to utilizing the Rome

Criteria, the clinician may check a stool sample, perform a rectal exam, and

check a blood count. There are no specific biomarkers for IBS that would

appear in a stool or serum sample and that would specifically identify IBS

based on physical data alone. Instead, these tests are performed to rule out

other conditions that may be the cause of the patient’s symptoms. A

thorough medical history is also important to determine how long the patient

has been experiencing symptoms and whether the symptoms are triggered

by outside events.

Because it is not entirely clear what causes IBS, treatments may vary; they

are usually based on controlling symptoms and preventing patient

complications that can develop as a result of chronic IBS, including

malnutrition, chronic pain, social isolation, dehydration, and electrolyte

imbalance. Drug therapy is a common method of treatment and may include

administration of medications to relieve cramping pain and increased

peristalsis that causes diarrhea, including antidiarrheal medications, anti-gas

formulations, fiber supplements, and anticholinergic drugs that relax the


smooth muscles of the intestines. Alternatively, a patient who struggles with

IBS-C type may need medications and diet therapy that manages and

prevents hard stools from forming, such as osmotic laxatives, stool

softeners, and bulking agents. The type of drug administered is based on the

patient’s predominant form of IBS.

There are also two different drugs that have been approved specifically for

the management of IBS. Lubiprostone (Amitiza®) is used for IBS that

involves predominant symptoms of constipation; it improves symptoms by

increasing fluid to the colon where it would otherwise be absorbed.

Increased fluid in the large intestine prevents the formation of hard stools

that are difficult to pass, as associated with constipation. Lubiprostone is

only approved for use in women. Alosetron (Lotronex®) is a second drug

that has been approved specifically for IBS treatment. This drug is more

commonly prescribed for patients who suffer from IBS with predominant

diarrhea symptoms; it works by slowing peristalsis in the large intestine by

relaxing the intestinal tract. This ultimately slows the passage of stool to

prevent diarrhea and to enhance normal stool formation and excretion.17

For some patients, it has been thought that IBS is caused by food allergies

in which the patient develops severe gastrointestinal symptoms as a type of

allergic response. When food allergies are suspected, the patient may need

to follow an elimination diet in which the potential allergen is avoided for a

certain period of time to see if symptoms abate. An elimination diet may

take quite a while for results, as the patient may need to eliminate more

than one kind of food, avoid it for several weeks to see if symptoms change,

and then reintroduce the food slowly. If there is no change, the patient then

eliminates another potential source of allergy and starts the process again.


For many, following a healthy diet and eating small meals is enough to

control symptoms. Other lifestyle interventions that the nurse could promote

include recognizing potential triggers and avoiding them, controlling stress

and overly taxing activities, increasing activity levels, and participating in

exercise.

Antidepressants have been shown to be beneficial for patients with IBS when

they are used off label to manage symptoms. Antidepressants are helpful

among patients with IBS that is otherwise unresponsive to other medications

and lifestyle interventions. Tricyclic antidepressants (TCAs) and selective

serotonin reuptake inhibitors (SSRIs) are the most common types of

antidepressants prescribed in these situations. Because IBS has been

associated with greater levels of anxiety and depression among some

patients who develop the condition, prescription antidepressants can help to

control many psychological symptoms that develop as a result. When further

considering the brain-gut dysfunction theory, management of emotional

stressors and depression could also physically alter the body’s

gastrointestinal response to psychological factors.

Tricyclic antidepressants have also been shown to decrease transit times in

the gastrointestinal tract, which could potentially control symptoms of

diarrhea. They are also somewhat effective in relieving abdominal pain

associated with IBS. Some types of TCAs that may be prescribed include

desipramine (Norpramin®) and nortriptyline (Pamelor®). Selective

serotonin reuptake inhibitors are more likely to increase GI motility and may

be more appropriate for patients who suffer from predominant constipation.

Some types of SSRIs that are prescribed in these cases include fluoxetine

(Prozac®) and citalopram (Celexa®).19


Patients with IBS have also been helped with controlling stress through

nonpharmacological interventions, including cognitive-behavioral therapy

(CBT) and gut-directed hypnotherapy. These interventions and others,

including stress management techniques of relaxation therapy,

aromatherapy, massage, and yoga may be included as part of treatment for

IBS. Because the symptoms of IBS have been associated with some

psychological manifestations as well, it is important to not only manage the

physical GI symptoms that develop with this condition, but to also consider

the mental health of the patient.

Fecal Incontinence

Although less common than urinary incontinence, fecal incontinence is

thought to affect up to 20 percent of older adults living in the community

and up to 50 percent of long-term care residents.26 Fecal incontinence is

described as the unintentional loss of solid or liquid stool. Involuntary loss of

gas or liquid stool is known as minor incontinence whereas loss of solid stool

is referred to as major incontinence. The condition most often occurs due to

loss of control of the anal sphincter, which is normally responsible for

tightening the sphincter and maintaining stool within the rectum until the

person is ready to defecate. Without adequate sphincter control, the

individual may have little to no control over stool evacuation. Loss of anal

sphincter control may occur due to trauma or injury to the pelvis, from

medical conditions that affect nerve function in the area, or due to chronic

GI conditions that affect stool characteristics and bowel frequency, such as

Crohn’s disease.

Furthermore, fecal incontinence could develop through other conditions that

are unrelated to damage to the anal sphincter. Instead, the affected patient

could develop difficulties with controlling sphincter tone to keep it closed in


enough time to retain stool. Neurologic damage from some chronic

conditions causes the patient to lose the normal awareness of needing to

defecate and may lead to incontinence of stool because of decreased

sensation. Examples of conditions that may lead to this damage include

uncontrolled diabetes or multiple sclerosis.28 Alternatively, fecal impaction

that develops from constipation could also contribute to fecal incontinence in

a condition known as overflow incontinence. If the patient develops a stool

impaction in the lower GI tract, he or she may actually leak stool around the

impaction when the anal sphincter relaxes to the point that stool can escape.

Fecal incontinence may be considered either an acute or chronic condition. A

person may lose control of defecation during times of acute illness, leading

to incontinence of stool that is often diarrhea. This may or may not occur

more than once and may be settled when the illness or current condition is

resolved. For example, a patient who suffers from a viral infection affecting

the gastrointestinal tract may develop severe and explosive diarrhea and

may suddenly experience cramping that indicates that a bowel movement is

going to occur. The patient may experience fecal incontinence if he or she is

unable to get to the bathroom in time to defecate, but once the viral illness

has resolved and the patient’s stools have returned to normal, he or she

may resume a normal pattern of bowel movements without incontinence.

Alternatively, when a chronic condition develops, the patient may struggle

with fecal incontinence and involuntary loss of stool on an ongoing basis.

The patient may or may not be incontinent of feces with each bowel

movement, but may have a condition that causes incontinence of stool over

a longer period of time that is not resolved despite ongoing medical

management. The patient with chronic incontinence is also at higher risk of

complications associated with involuntary loss of stool, including skin


irritation and breakdown from repeated contact between the feces and the

skin.

Fecal incontinence is also embarrassing for the affected patient. Uncontrolled

fecal incontinence can lead to feelings of depression and anxiety and the

patient may be more likely to suffer from social isolation if he or she is afraid

to leave the house or attend social functions because of an inability to

control defecation. Although there are statistics about how many people

suffer from fecal incontinence, the actual numbers may be higher since

many who struggle with this condition avoid talking about it and bringing it

to the attention of their healthcare provider because they are too

embarrassed. Management of fecal incontinence depends on whether the

condition is acute or chronic and on the underlying situation that leads to

loss of control. Treatment of the condition typically is through medication

and non-pharmacological measures, surgery, or biofeedback.

When diarrhea is a major cause of incontinence, medications that increase

stool bulk can reduce the risk of leaking liquid stool. Bulking agents,

including fiber supplements, such as methylcellulose or psyllium, are often

used for management of constipation but can be helpful for fecal

incontinence as well. Bulking agents prevent diarrhea and, by adding more

bulk to the stool, they may help the patient to retain formed stool within the

rectum until there is a chance to voluntarily pass it. Increasing dietary fiber

will have a similar affect. The nurse may ask patients about their diet history

and calculate daily fiber intake, counseling patients to increase fiber slowly,

day-by-day to reach a high-fiber diet. The soluble and insoluble fiber in

some foods also provides bulk for stools, potentially reducing instances of

diarrhea and fecal incontinence.


Some medications that are given to control diarrhea may also be helpful in

cases of fecal incontinence. These are available without a prescription, but

the affected patient should consult with a healthcare provider before using

them to determine the best course of action for control of incontinence.

Antidiarrheal medications available without a prescription are either

loperamide (Lomotil®), which works by slowing down the rate of intestinal

motility, or bismuth subsalicylate (Pepto Bismol®), which alters fluid levels

in the intestine to prevent liquid stool.29 These medications are

recommended for short-term use and should not be used for someone with

chronic incontinence as the main form of treatment. They can, however, be

taken when someone experiences occasional stool incontinence on a short-

term basis, such as when suffering from a viral illness that causes diarrhea.

When overflow incontinence develops, as when the patient has fecal

impaction and leaks stool, he or she may benefit from laxatives or stool

softeners. These drugs should be used with caution, however, as they could

worsen diarrhea, and the patient may be even less likely to control stool.

There are various types of laxatives and stool softeners available, which are

designed to change fluid content in the large intestine or the consistency of

stool to make it easier to pass. Normally reserved for cases of constipation,

these drugs can be helpful for some patients with incontinence but a

healthcare provider should direct drug use.

Other non-pharmacological interventions may also be employed that either

prevent diarrhea and stool incontinence or that manage stool incontinence

when it occurs. Examples of changes that could be made to manage stool

incontinence include the use of fecal collection devices, such as pouches, and

bowel retraining programs. A pouch may be placed around the anal opening,

and secured to the skin by an adhesive, to collect stool that leaks


involuntarily. The pouch is a good idea for patients who are frequently

incontinent of stool, as it saves them from repeated accidents and stool loss.

Alternatively, if a patient is very active and involved in many activities, may

the pouch may not be preferred since it can be bulky and difficult to contain

within clothing. The end of the pouch often has an opening that allows the

stool to be drained out without changing the bag. A person who is immobile

and cannot use a collection device may utilize disposable underpads and

undergarments designed for adults to collect stool, which can be changed

quickly and replaced with a clean, dry garment to promote skin integrity.

Bowel retraining programs are behavioral programs that are designed for

those who have difficulties with fecal incontinence. These types of programs

are developed to help affected persons re-establish control over their bowel

habits. A bowel-training program may not work for everyone but it can help

to develop a routine that some people may benefit from related to building

on necessary skills to recognize the need to defecate and to control their

bowel movements to avoid being incontinent of stool.

A bowel-retraining program first addresses stool consistency. If the patient

is suffering from diarrhea or overflow incontinence because of constipation

and bowel impaction, he or she may need medication to change stool

consistency and to provide bulk.29 After this has been addressed, the

program then focuses on establishing a schedule for elimination in which the

patient attempts to defecate at certain times on a schedule. Finally, part of

bowel retraining includes understanding how to stimulate the rectum to

empty of stool. This may be done through interventions such as laxatives or

enemas; however, the method typically varies between patients depending

on their conditions and success to eliminate stool.


Biofeedback is a second method of controlling fecal incontinence. With

biofeedback, the patient learns to consciously contract the muscles of the

rectum that control defecation. The healthcare provider may perform

biofeedback during a procedure known as anorectal manometry, which

involves insertion of a balloon past the anal sphincter and inflating the

balloon inside the rectal vault while a manometer records the sphincter’s

response. The patient then learns through this method of biofeedback how

much pressure is needed to apply to the sphincter muscles to retain stool

within the rectum and to avoid incontinence. Biofeedback is a non-invasive

method of re-training some of the muscles in the lower pelvis to control

stool elimination; however, it has not been shown to be successful for

everyone who has difficulties with stool incontinence.

Whether or not to choose biofeedback, as a method of controlling

incontinence, is decided on a case-by-case basis, depending on the patient’s

condition. Studies have shown, though, that when used in combination with

other methods of managing fecal incontinence, biofeedback can be very

helpful for some patients. A study in the Scandinavian Journal of

Gastroenterology showed that women who combined biofeedback therapy

with use of loperamide and stool-bulking agents showed symptom

improvement in terms of fecal consistency, reduced urgency, and increased

rectal sensory thresholds.31 If possible, the provider working with the patient

in this condition may need to explore more than one idea about the best

method of controlling incontinence, even combining more than one method

to provide adequate treatment.

Surgery may be particularly helpful for people who suffer from fecal

incontinence when the cause is from damage to the anal sphincter. Surgical

procedures have been shown to be successful in up to 80 percent of cases of


fecal incontinence among women who have suffered damage to the anal

sphincter from torn tissue during childbirth.30 Surgery in these cases

involves using a piece of a muscle from another part of the body and

connecting it to the rectum to replace the muscle of the anal sphincter.

Alternatively, a synthetic option is to replace the anal sphincter with a cuff

that can be inflated and deflated as needed to have a bowel movement.

When a patient continues to suffer from fecal incontinence and is unable to

control bowel movements, and the condition is unable to be corrected by

surgical muscle replacement, a colostomy may be yet another option for

management of the condition. A colostomy involves surgically attaching the

end of the colon to the abdominal wall so that feces are collected in a bag

outside of the body instead of being routed through the rectum and

eliminated through the anus. Surgery for colostomy placement is a

complicated procedure and this type of surgery is typically only reserved for

those that have not responded to any other therapy or treatment.

Constipation

Constipation is a common problem that may develop after use of various

drugs, it may occur with fluid loss or after eating certain foods, or it can be a

chronic condition that develops as a result of increasing age or chronic

disease. Constipation describes a situation in which a person has difficulty

with defecation because stool in the large intestine has become dry or

colonic motility has slowed to the point that it takes much longer for feces to

reach the rectum. As stool passes through the colon, it is eventually held in

the rectum before being eliminated. When stool remains in the rectum for a

longer period, the person can develop constipation, which makes feces

difficult to pass due to it being hard and dry.


Constipation is classified as being either a primary or secondary condition.

Primary constipation is also referred to as functional constipation in that

symptoms are typically ongoing and are frequently a routine part of the

person’s life. Alternatively, secondary constipation develops as a result of a

condition or illness that affects the person’s ability to form stool and pass it

in a normal manner. Primary constipation is further divided into three sub-

groups: 24

1. Normal transit constipation, in which the person is able to pass

stool at a normal rate, but stools are very hard and difficult to pass.

2. Slow transit constipation, in which the rate at which a person

passes stool is abnormally long, as it takes much longer for the

stool to pass through the large intestine and into the rectum for

defecation.

3. Pelvic floor dysfunction, which affects the person’s ability to pass

stool at all, regardless of transit time or stool consistency. Stool is

more likely to be retained in the rectum, causing feelings of fullness

and incomplete evacuation.

Assessment of the patient involves taking the medical history information

about current or previous illnesses, changes in dietary and lifestyle habits,

and changes noted with the toileting routine. The nurse should consider

whether the patient has noted changes in bowel habits and how long such

changes have been happening, and, if the patient has had to utilize manual

maneuvers to eliminate stool, pain with defecation, and fecal incontinence.

There may be psychosocial factors present that could also contribute to the

patient’s constipation through changes in diet and lifestyle; and,

psychosocial symptoms to consider include the existence of depression,

anxiety, or cognitive changes.


According to the Rome III Criteria for Functional Gastrointestinal Disorders,

a diagnosis of functional constipation is made when a patient experiences

two or more of the following:

• Straining with at least 25 percent of defecations

• Passing lumpy or hard stools with each defecation at least 25

percent of the time

• Experiencing the feeling of incomplete evacuation for at least 25

percent of the time

• Sensing an obstruction or blockage that prevents the passage of

stool for at least 25 percent of evacuations

• Using manual maneuvers, such as pelvic floor support, in at least

25 percent of defecations

• Having fewer than three defecations per week

Although the diagnostic criteria include defecations fewer than three times

per week, there is great variation with what is considered to be a normal

number of defecations for the average person.23 Some healthcare providers

consider whether the patient has experienced fewer defecations than is

normal for the patient when considering constipation, instead of attaching a

specific number to what is considered normal for the general population.

Secondary constipation can develop from a number of situations; the rate of

stool passage, the length of time stool remains in the rectum, and the

amount of water absorbed can all be affected by situations related to a

medical illness, use of certain medications, or psychological distress that

further contribute to constipation. Common conditions that typically lead to

constipation include:22


• Pain in the rectum or the anus:

Hemorrhoids and anal fissures can cause pain while having a bowel

movement. The patient may avoid passing stool for as long as

possible to avoid the pain. This actually further aggravates the

situation, as the stool becomes hard and dry from holding it in,

which makes it even more difficult and painful to pass.

• Medications:

Certain drugs, particularly opioid medications, contribute to

constipation by decreasing motility of the colon.

• Dietary influence:

A diet low in fiber and fluids may contribute to constipation when

there is less bulk and stools become dry.

• Medical conditions:

Injuries or illnesses that affect the patient’s ability to sense the

need for a bowel movement, such as diabetes or spinal injury, can

delay defecation and the stool remains in the rectum longer than

needed.

• Advancing age:

As a person ages, there is more likelihood to develop constipation

because of impaired mobility, muscle weakness, an increase in the

average number of medications that can affect bowel motility, and

dietary changes that affect stool bulk. Despite the increase in cases

of constipation among older adults, constipation is not considered a

normal part of aging.


• Obstruction:

At times, partial obstruction of the large intestine, such as through

polyps or colon cancer, can make passage of feces difficult and the

stool becomes hard and dry.

Upon assessment of the patient with constipation, the healthcare provider

should note any abdominal distention or the appearance of abdominal

masses, rectal hemorrhoids, signs of dehydration or anemia, and

characteristics of bowel sounds. The nurse should also assess for any other

factors in the patient’s life that may contribute to bowel changes and the

development of constipation, including checking a list of the patient’s current

medications, noting whether the patient has a history of a medical illness

that could contribute to slowed GI motility, determining if the patient has a

history of any other GI disorders, and assessing for any other clinical

manifestations that could cause bowel obstruction and prevent the patient

from passing normal stools.

Because constipation can develop from so many different situations, the

condition is not simply isolated to those with certain medical illnesses or with

predisposing conditions. Instead, constipation can be a widespread problem

that affects people with illness and healthy people alike; it can occur in older

adults, young- or middle-age adults, and children. In addition to difficulty

with passing stools, the patient with constipation may also suffer from

abdominal pain, bloating and distention, a feeling of fullness in the

abdomen, a feeling of pressure in the rectum, and the sensation of

incomplete emptying after defecation. Some people with constipation also

develop other symptoms such as headache, nausea, fever, pain in the

urinary tract, and decreased appetite.


While pain is often associated with constipation and may be a factor

determined through the patient’s assessment, pain is not always a

characteristic of constipation and should not be held as a deciding factor

during the diagnostic process. A technical review by the American

Gastroenterological Association in the journal Gastroenterology stated that

abdominal pain with constipation is more often associated with a more

significant disorder, such as in the case of irritable bowel syndrome,

predominant type. In contrast to IBS, a patient with constipation related to

other factors will have symptoms of hard, dry stools that are difficult to

pass, but will not necessarily have abdominal pain.88 This is an important

distinction to make when taking a health history with the patient and

performing a physical exam because the information may assist the

healthcare provider with making a more accurate diagnosis of IBS that

involves predominant constipation versus constipation caused by another

situation or condition that could be remedied.

A patient who suffers from constipation is at risk of certain complications

associated with an inability to pass stool in a timely manner. A patient who

already has a condition that affects the cardiac or respiratory systems could

develop complications from constipation if he or she has to strain to have a

bowel movement. Straining to defecate typically involves the Valsalva

maneuver, which entails exhaling against a closed airway, increasing

pressure and force. The maneuver temporarily decreases venous return to

the heart and increases peripheral venous pressure. If a patient has a

history of certain cardiac illnesses such as heart failure, or has previously

suffered a myocardial infarction, repeated episodes of performing the

Valsalva maneuver could put the patient at risk of cardiac rupture or

death.22


Constipation has the potential to cause various other complications in

affected patients. A patient who suffers from this condition may also be at

risk of fecal impaction when the mass of stool becomes so dry that it cannot

be passed. If stool obstructs the colon, but the person continues to digest

and absorb food, he or she may be unable to pass more stool around the

obstruction. At times, the patient may be incontinent of liquid stool that

leaks around the site of obstruction. This diarrhea that flows past the

obstruction is known as overflow incontinence.

The treatment for constipation is typically related to the cause of the

condition. Management of constipation may be utilized through non-

pharmacological interventions or through medications. Non-pharmacological

interventions involve making dietary changes, encouraging activity, and

helping the patient to develop a normal toileting routine. Constipation that

develops from poor diet could be remedied by lifestyle changes alone, in

which the patient increases fiber intake through foods or supplements to

improve stool bulk. The individual in this case would benefit from increasing

fluid intake as well, which will make stool easier to pass and prevent feces

from becoming hard and dry. As a patient increases dietary fiber intake, he

or she should be counseled to increase fluid intake accordingly.

Significantly increasing fiber intake without adjusting fluid intake can cause

symptoms to worsen and the patient may suffer from abdominal pain,

bloating, and flatulence. The patient should also be counseled to slowly

increase fiber intake each day, rather than suddenly jumping up in total

daily fiber. For example, a person who normally consumes 15 g of fiber daily

and who suffers from constipation should not start eating fiber-rich foods to

increase daily fiber to 60 g per day all at once. Instead, the patient should


be counseled to increase fiber intake by 5 g to 10 g each day to achieve

appropriate amounts and to avoid uncomfortable side effects.

The patient should include a mixture of foods in the diet that contain soluble

and insoluble fiber, both of which can increase stool bulk; additionally,

insoluble fiber helps to prevent excess water absorption in the colon that can

result in stool becoming too dry. Foods that are good sources of soluble

fibers include cereal, nuts, seeds, and fruits. Items that can be included to

increase insoluble fiber include wheat bran, vegetables, and legumes.24

If possible, the patient should increase physical activity to best prevent

constipation. Exercise helps food to move more quickly through the

intestine, preventing slow motility and its associated problems. It is

important to remind patients that if they are increasing activity levels,

particularly when taking on an exercise routine, they should continue to

drink fluids and increase fluid intake around the time of activity, as increased

exercise could lead to fluid loss through sweat and could further perpetuate

constipation.

It may be helpful for some patients with constipation to develop a toileting

routine and to maintain good habits when using the bathroom. The person

should be taught to try to defecate as soon as the urge is felt, rather than

trying to hold stool in the rectum, which can further contribute to uptake of

water in the colon and dry stools. The patient may also be taught pelvic floor

exercises to strengthen the muscles used for defecation and to sit in a

position that facilitates easier defecation. If the patient has an issue with

using a toilet or does not want to try to eliminate stool because of pain or

discomfort, the nurse may need to help the patient find strategies to

increase efforts at elimination. For example, a patient may avoid trying to


defecate because of hemorrhoids; and, the nurse may help the patient by

treating the hemorrhoids to alleviate discomfort so that the patient will not

feel the need to avoid defecation because of pain.

Pharmacological interventions for the treatment of constipation include

medications designed to stimulate bowel motility and to relieve the patient’s

constipation through the passage of stool. Medications administered for

constipation are often given if the non-pharmacological interventions have

been unsuccessful or if the patient has a condition that prevents an ability to

pass stool, leading to further risk of constipation. Pharmacological

interventions include medications such as laxatives, stool softeners, enemas,

and oral medications that alter fluid absorption in the large intestine to

manage constipation.

Whether it is an acute case of constipation that is easily resolved with

medications or whether a patient suffers from chronic constipation as a

result of illness or disease, constipation can be difficult to manage and to

accept for some people. The potential for complications associated with this

condition make it even more important of a situation to be remedied to help

the affected patient achieve normal defecation once again. Fortunately,

because constipation is so prevalent, there are many options for treatment

and healthcare providers have discovered numerous ways to prevent

constipation and to manage it if it does occur.

Genetic Factors

The role of genetics may be overlooked when considering some

gastrointestinal motility problems. When dysmotility can be explained by a

chronic illness or its development occurs as a result of medication use or

lifestyle factors, healthcare providers may be less likely to consider whether


the condition is supported by any genetic factors. There are some cases,

however, when it is not entirely clear how or why a patient develops a GI

motility problem, which may cause clinicians and researchers to dig deeper

into genetic factors that contribute to development of the disease.

There is evidence that suggests there are some genetic factors that

contribute to functional gastrointestinal disorders. These disorders are

classified as conditions in which symptoms are recurring and persistent, and

they typically develop because of abnormal functioning in the GI tract.

However, functional GI disorders can vary extensively in terms of their

causes and manifestations. For instance, irritable bowel syndrome,

functional dyspepsia, and globus (the sensation of something being stuck in

the back of the throat) are all functional GI disorders, yet they have various

characteristics and symptoms. Because of the differences in the types of GI

motility disorders, and of functional motility disorders in particular, they may

be categorized according to the section of the GI tract most commonly

affected.

Esophageal Disorders

Functional gastrointestinal disorders of motility that affect the pharynx and

esophagus include globus, functional chest pain (which is pain that is most

likely caused by esophageal damage and not cardiac problems), functional

heartburn (which is similar to that experienced with gastroesophageal reflux

but without evidence of esophageal sphincter problems), and functional

dysphagia.89

Achalasia, as described earlier, is a motility disorder of the esophagus. It is

characterized by weak or absent esophageal peristalsis, which leads to

difficulties during swallowing with transferring food from the back of the


throat to the stomach for digestion. Idiopathic achalasia has an unknown

etiology and is also characterized by weakening of the lower esophageal

sphincter (LES), regurgitation of gastric secretions, and non-cardiac chest

pain from heartburn. Achalasia is an example of an upper gastroesophageal

motility disorder that may stem from genetic factors.

It is known that achalasia develops when the affected patient loses neurons

that provide sensation and motor function to the esophagus; the loss of

nerves typically begins in the lower portion of the esophagus and is thought

to be related to nerve cell neurodegeneration.90 Although there is some

understanding about the damage or loss of neurons in the esophagus that

occurs with achalasia, researchers still do not entirely understand why this

occurs and other causes, including genetic factors, continue to be

investigated.

Achalasia has been shown to have familial tendencies in that people who

develop the condition are more likely to have a family member who also

suffers from achalasia. There have been some twin studies that have

examined the incidences of achalasia development between twin siblings,

but these results are still inconclusive. Still, research has confirmed that

there is some amount of familial connection in the development of achalasia

and that affected patients should be aware of the possibility that the

condition may also develop among family members. Furthermore, there are

some genetic syndromes in which achalasia is more likely to develop among

affected patients, for example, persons with Down syndrome are more likely

to have achalasia than the general public; and, the swallowing disorder is

typically manifested just after birth in these situations.90


Sarnelli, et al., in their work published in the World Journal of

Gastrointestinal Pathophysiology, investigated specific genes that may

contribute to the development of achalasia among certain patients.

Inflammatory-based neurodegeneration of nerve cells affecting the

esophagus is more prevalent among neurons that contain nitric oxide (NO).

Nitric oxide is produced in the body, and, it is a molecule that allows for

greater communication through the nervous system and between tissues.

The production of nitric oxide is genetically regulated. The researchers in the

study determined that achalasia may be more likely to occur in some

patients who express the longer form of a certain gene, as this gene may be

involved in greater amounts of nitric oxide production.90 This concept could

more likely explain some of the breakdown of certain nerves in the lower

esophageal tract associated with the condition.

Clearly, it is important that research continue to find genetic influences and

those other factors that contribute to development of certain conditions such

as achalasia. While it is important to understand familial influences in the

development of the condition in order to better prepare affected patients,

more research is needed to find the connection as to why certain neurons

are destroyed in this condition.

Stomach and Small Intestine Disorders

Disorders of motility affecting the stomach and small intestine can include

any number of conditions, including gastroparesis, functional dyspepsia,

functional vomiting, and aerophagia. As with disorders affecting the pharynx

and esophagus, it is difficult to define the exact etiology of why some of

these conditions occur. Although damage to the nerves or muscles of the GI

tract is typically involved, there may also be familial or genetic factors that

predispose some people to increased risks of developing these conditions.


Functional dyspepsia is an example of a gastrointestinal motility disorder

that causes recurrent pain and epigastric discomfort, as well as abdominal

distention and a feeling of fullness in the abdomen. It may develop from a

number of acute or chronic conditions, including Helicobacter pylori infection

in the gut, increased pain sensitivity; or psychological factors, such as

increased anxiety or depression.91 Unlike simple indigestion that follows a

meal, symptoms of functional dyspepsia are recurrent and often require

lifestyle changes and medication to control the symptoms.

Another potential cause of functional dyspepsia is damage or other problems

with the nerves and muscles that control the GI tract. When damage occurs

to these structures, the affected person is more likely to experience nausea,

vomiting, and abdominal fullness if the stomach empties more slowly than

normal. The damage done to muscles and nerves of the stomach and small

intestine that causes functional dyspepsia could be related to chronic illness,

such as in cases of diabetes; however, there are some conditions where the

patient may suffer from symptoms of dyspepsia but the cause is unknown.

Researchers continue to look for genetic factors that may explain why

damage sometimes occurs in this area.

There is some evidence that indicates that functional dyspepsia may be an

inherited trait and is more likely to occur within families. Studies have shown

that patients with functional dyspepsia are more likely to have family

members also affected by the condition. A review by Yarandi and Christie in

Gastroenterology Research and Practice discussed the impact of genetic

factors on the development of functional dyspepsia, stating that certain

genes that are more likely to activate G-proteins in the GI system may lead

to dysfunction of the motor neurons in the intestinal tract. G-proteins are

cellular membrane receptors; if they do not work properly, there is potential


for some communication breakdown between nerve signals. Some people

have certain genes that activate these G-proteins, which can ultimately

cause dysfunction of receptors that control the muscles and nerves of the GI

tract.92

While research continues to investigate the probability of specific genes that

contribute to damage in the GI tract and cause functional motility disorders,

there are well-known factors that also can cause symptoms of dyspepsia.

While most people are unaware if they have a specific gene that contributes

to dyspepsia symptoms, they can still learn more about the symptoms of GI

dysfunction and understand whether family members are affected by similar

symptoms, which may be a better predictor of health.

Large Intestine Disorders

Functional disorders affecting the large intestine can vary from irritable

bowel syndrome, functional constipation, functional diarrhea, and fecal

incontinence to those that are more often associated with disorders of the

rectum and anus, including functional anorectal pain and dyssynergic

defecation.89 There are some genetic factors that play a role in the

development of fecal incontinence. A person with a parent who suffers from

fecal incontinence is at higher risk of developing the condition. Twin studies

have shown similar results in that someone who has a twin who suffers from

fecal incontinence is at greater risk of developing fecal incontinence as well.

Rates are higher between monozygotic twins when compared to dizygotic

twins.93

Similar to other types of functional motility disorders, conditions affecting

the colon and rectum that cause changes in how the GI tract functions can

have obvious causes or their sources may be more obscure. Fecal


incontinence may often be associated with chronic constipation, resulting in

overflow incontinence when stool leaks out of the rectum around a fecal

impaction in the lower bowel.

There are a number of risk factors that increase the probability that a person

will develop difficulties with retaining stool. Known risk factors for fecal

incontinence include advancing age, female gender, physical disabilities, and

injury to the nerves affecting the anal sphincter, such as through childbirth.

Some risk factors are environmental and could be prevented while others,

including age and gender, are uncontrollable.

There are some genetic conditions that can also contribute to fecal

incontinence. These conditions may be listed as the cause of stool

incontinence itself and they develop because of genetic factors, thereby

indirectly affecting the risk of fecal incontinence. For example, structural

abnormalities may be present in the rectum because of a congenital

condition present at birth. As a result, the patient may suffer from fecal

incontinence because of an inability to properly retain stool within the

rectum. Additionally, a GI condition such as inflammatory bowel disease, can

also contribute to fecal incontinence because of abnormalities in the anal

sphincter. A person who has a close relative with inflammatory bowel

disease is at higher risk of developing the condition as well because of

familial tendencies.

At times, the cause of colonic motility disorders may be obvious, while in

other cases further research and education is needed to fully understand the

risks and causes of these complex conditions. In some cases, genetic factors

do not play a role in whether a patient will develop symptoms of a disorder;


alternatively, genes and familial tendencies are a large part of whether

certain patients are at high risk of GI motility problems.

Classification Of Gastrointestinal Motility Disorders

It is well known that there are numerous conditions that can be classified as

being gastrointestinal motility disorders. They may affect various portions of

the GI tract and can cause multiple symptoms that range in severity from

mild discomfort to potentially life-threatening complications. In addition to

the different areas affected and their manifestations, GI motility disorders

may also be classified according to the entities that individually demonstrate

abnormalities within one or more areas of the GI tract and that may be

associated with systemic conditions as contributors to the clinical condition.

Charles Knowles and Professor Joanne Martin, in their work studying slow

transit constipation, defined a classification system of gastrointestinal

motility disorders that categorizes the various causative conditions into

different entities.57,58 A classification system to categorize GI motility

disorders based on demonstrated abnormalities and associated clinical

conditions is a sensible approach to performing diagnostic measures when

managing a patient who suffers from dysmotility symptoms. To classify

motility conditions based on certain entities can further assist the clinician

with identifying a diagnosis and providing appropriate treatment for the

patient’s condition.

Motility of the GI tract is more than muscle movements that propel digestive

tissue through the expanse of the system. Instead, motility is described as a

combination of muscular movements that are controlled by specific nerves;

furthermore, innervation of the GI tract can actually be classified as being

motor innervation and sensory innervation.56 If one type of nerve system is


damaged, it can impact the other; for example, if a person suffers from

illness that damages sensory innervation of the GI tract, he or she may also

suffer from problems with motor movements because the two types of

nerves that control the gut are closely intertwined.

Knowles-Martin Classification System

Motor disorders that affect motility, whether by producing increased motility

that leads to uncontrollable stool output and abdominal pain, or delayed

motility that slows colonic movement and results in constipation and

bloating, can be classified according to the regions affected, such as the

esophagus, small intestine, or large intestine; and, the clinical condition that

causes each entity and any associated disorder involved that would be

causing symptoms. According to the Knowles-Martin classification system,

entities are grouped into different categories, including well-defined entities

(those that are understood and straightforward), variable dysfunction-

symptom relationship entities, questionable entities, and entities related to

behavioral disorders (those impacted by the individual’s habits and actions).

Well-Defined Entities

Well-defined entities may be further broken down into sub-classifications

that affect the different regions of the GI tract, including the esophagus, the

stomach, the small intestine, and the bowel. Within the esophagus, well-

defined entities include excessive acid exposure, esophageal spasms, and

achalasia. Excessive acid exposure is often associated with gastroesophageal

reflux disease (GERD), which is most often diagnosed according to the

pattern of damage it causes to the lining of the esophagus. However, GERD

can also be identified because of its causative conditions, such as poor

control in the lower esophageal sphincter, which leads to subsequent acid

reflux and tissue damage.


Achalasia, which results in poor motility within the esophagus or even lack of

peristalsis entirely, is another example of a well-defined esophageal entity.

The associated motility problems with achalasia also can lead to

regurgitation of food and liquids from the stomach and damage to the tissue

lining of the esophagus. Both achalasia and GERD can occur from damage to

the nerves that affect the esophagus, leading to poor motor control and

dysmotility. Systemic diseases often contribute to nerve damage that

ultimately affects motility; for example, damage from scleroderma may

contribute to loss of muscle tone in the intestinal tract. Scleroderma is a

connective tissue disorder that results in deposits of collagen building up

between smooth muscle fibers.68 According to the Scleroderma Foundation,

the esophagus is the area where most patients with scleroderma suffer from

intestinal motility problems, including symptoms of GERD, and weakening of

esophageal muscles that result in poor peristalsis and increased damage

from regurgitation.59 Other systemic diseases that may contribute to

conditions classified as well-defined entities of the esophagus include

diabetes, enteric neuropathy, and Chagas disease, which is caused by

parasitic infection.

Well-defined abnormalities that specifically impact the stomach and small

intestine involve accelerated gastric emptying and abnormal contractile

activity.56 These occurrences are most often demonstrated as clinical entities

of dumping syndrome and intestinal pseudo-obstruction. As previously

stated, dumping syndrome is defined as rapid gastric emptying, in which

food leaves the stomach at a faster rate than normal and is quickly

deposited into the small intestine. The patient often suffers from symptoms

such as diarrhea, flushing, sweating, heart palpitations, and abdominal

cramping within a few minutes after a meal. Dumping syndrome is not the

same as dyspepsia or indigestion; it is classified as an actual disorder of the


stomach related to changes in hormone secretion and gastric mucosal

secretions.

Pseudo-obstruction often causes symptoms of intestinal obstruction without

identification of any specific blockage. Both pseudo-obstruction and dumping

syndrome can develop from defects in innervation to the stomach and small

intestine, which ultimately affect the rate of food transition between these

areas during the digestive process. Systemic conditions that often lead to

these clinical entities affecting the stomach include surgical procedures to

treat obesity; these include gastric bypass surgery, as well as vagotomy

surgery (which reduces gastric secretions) when part of the vagus nerve is

cut. Other systemic conditions include enteric neuropathy, and in some

cases, scleroderma.

Within the large intestine, well-defined entities include dilated colon with or

without small bowel involvement, absent rectoanal inhibitory reflex, and

delayed colonic transit.56,57 Dilated portions of the colon may be caused by

such conditions as Ogilvie syndrome or megacolon where the affected areas

of bowel may be localized to one region or may be found throughout the

entire large intestine. Ogilvie syndrome is the same condition as pseudo-

obstruction of the intestine; it develops when the patient suffers from

symptoms of bowel obstruction but there are no lesions present.

Megacolon

There are various types of megacolon that could be the cause of significantly

dilated portions of the bowel, including acute or toxic megacolon, as well as

the chronic form of the condition. Chronic megacolon may be used as a term

to describe the condition when it is congenital, although it can be later

acquired because of illness or toxicity. Megacolon occurs with dilated


sections of bowel that are not caused by obstruction. Because the lumen of

the colon is enlarged, the body is unable to carry out normal colonic transit

and to pass stool in the usual manner. Megacolon can develop due to

different reasons, which depend on the type present; however, it may be

associated with damage to the nerves that serve the large intestine and the

rectum in that they are inhibited or do not activate the colon to work in a

normal fashion. Systemic conditions associated with both Ogilvie syndrome

and megacolon include enteric neuropathy and enteric myopathy.

Hirschsprung disease is another clinical entity that affects the large intestine.

It too often occurs due to damage of the nerves that serve the colon, which

causes difficulties for the patient to have normal defecation. Hirschsprung

disease is related to a poor or even absent rectoanal inhibitory reflex, which

is the reflex that controls the anal sphincter to retain stool within the rectum

or to pass stool when defecating. The reasons why some people are born

with this type of nerve damage in the large intestine are not clearly known.

Constipation is a well-defined entity affecting the large intestine; slow-transit

constipation (STC) leads to a long period of time for stool to pass through

the colon. The affected patient often has stools that are hard to pass and are

dry, as well as abdominal pain and, at times, fecal incontinence. As with

other entities defined in this section, slow transit constipation is thought to

occur due to damage to the nerves that serve the large intestine. People

with STC may have abnormal amounts of neurotransmitters in the muscular

layer of the colon, which affects the movements and transit of stool through

the large intestine. Other nerve cells affecting the colon may also be

abnormal in their appearance or there may be too few cells, ultimately

affecting the rate of colonic transit.69


Variable Dysfunction-Symptom Relationship

Entities classified as having variability in the relationship between

dysfunction and symptoms are those in which the connection between the

abnormalities of the clinical entity present and its associated symptoms may

be inconsistent. The basis for whether certain entities are classified in this

category is not entirely clear, but associated entities within the classification

are often related to increased or decreased muscle pressure within the

intestinal tract as well as delays in intestinal transit rates.

Variable dysfunction-symptom entities found in the esophagus include high

and low amplitude peristalsis, low LES pressure, and incomplete relaxation

of the LES.56 All of these conditions result in abnormalities in how the

esophagus or LES function when compared to normal motility. Whether

esophageal peristalsis is of high amplitude or low amplitude often depends

on the type of innervation affected, whether it is inhibitory or excitatory.

Inhibitory innervation of the nerves affecting the esophagus causes

problems with low amplitude peristalsis and low LES pressure.68 These

conditions can further lead to gastroesophageal reflux when the esophagus

is unable to adequately propel food toward the stomach and when the

muscle tone of the LES is sporadic. Stomach acid and undigested food is

then more likely to reflux back into the esophagus, causing damage to the

esophageal mucosa or interior lining.

Within the stomach, delayed gastric emptying occurs as a type of entity

described as having variable dysfunction-symptom relationship. This most

often occurs as a result of gastroparesis associated with diabetes, however,

there are many other systemic conditions that also contribute to the

situation, including scleroderma, enteric neuropathy, a post-vagotomy state,

and enteric myopathy. Abnormalities within the stomach may also lead to


impaired gastric relaxation, which often develops in conjunction with

esophageal achalasia and results in the dumping of food into the antrum of

the stomach instead of the fundus where it accumulates. Affected patients

typically suffer from symptoms of dyspepsia and indigestion.

The term enteric dysmotility is used to describe motility disorders of the

small intestine. Enteric dysmotility is also a clinical entity included as an

example of the variable dysfunction-symptom relationship in the small

intestine. It is demonstrated as abnormal contractions in the intestinal tract

that typically lead to delays in the transport of food through the small

intestine. There are a number of systemic conditions that can cause enteric

dysmotility within this section of the GI tract. Some examples include

intestinal neuropathy, as with what occurs through poorly controlled

diabetes, as well as Parkinson’s disease, scleroderma, and spinal injury.56

Within the large intestine, low levels of pressure within the anal canal can

lead to fecal incontinence. When pressure is low in this area, the affected

person is unable to control stool output, often because of muscular

weakness. Fecal incontinence results when low pressures in the anal canal

prevent the individual from retaining stool within the rectum and it passes

through the anus with little to no control. The condition may be caused by

spinal injury when the patient suffers a lack of motor control or sensation in

the lower body, or because of nerve damage due to diabetes and

uncontrolled blood glucose levels. Some women who have endured

traumatic childbirth and had nerve injuries due to tearing of perianal tissue

may also suffer from fecal incontinence and low pressure in the anal canal,

causing difficulties with normal defecation and poor control of stool output.


Questionable Entities

Conditions classified as questionable entities within the gastrointestinal tract

can vary but often seem to be related to accelerated transit of food and fecal

material through the GI system. This may be due to high pressures found in

the GI tract as well as overstimulation of the nerves that affect the GI

system.

An example of a questionable entity associated with the esophagus is

increased pressure found within the lower esophageal sphincter. The

condition may be referred to as hypertensive LES, in which it maintains high

contraction pressures when it opens and closes. Similar to other disorders of

the LES, hypertensive LES occurs when there are changes to the nerves

affecting the esophagus. In this case, there is increased function of the

excitatory nerves feeding the esophagus, such that the neurons are working

at a faster pace and are causing increased muscle contractions within the

LES.68 Hypertensive LES can cause dysphagia, heartburn, non-cardiac chest

pain, and symptoms of GERD.

Tachygastria is a condition that causes high-frequency electrical activity

within the stomach during digestion. The condition most often occurs

because of motion sickness or as nausea during the first trimester of

pregnancy. The motility of the stomach is somewhat controlled through

myoelectrical activity, typically generated by the antrum portion of the

stomach cavity.56 High frequencies of electrical activity in the stomach lead

to tachygastria, which generally causes feelings of nausea, dyspepsia, and

indigestion.

Within the small intestine, food and undigested materials may be

transitioned too quickly through the GI tract because of intestinal hurry,


which describes the intestine pushing food through at an accelerated rate.

Intestinal hurry may be a type of malabsorption disorder, in which the

affected person is unable to adequately absorb food because it moves too

quickly through the small intestine. The condition most often occurs

following vagotomy surgery that is done to control gastric secretions.

Finally, questionable entities found within the large intestine involve colonic

hurry and accelerated transit of food and fecal matter through this portion of

the GI tract. Colonic hurry is similar to intestinal hurry in that materials

move through the colon too quickly and there is potential for malabsorption

of electrolytes and fluid. The patient may suffer from diarrhea and watery

stools if too little fluid is absorbed during this section of the GI tract. Colonic

hurry can develop because of electrolyte imbalances, certain metabolic

disorders, and following colon surgery that results in short bowel

syndrome.56

Entities Related to Behavioral Disorders

Psychological symptoms and manifestations of mental illness may impact

gastrointestinal motility and function. Although there are often fewer cases

of behavioral disorders that lead to symptoms when compared to some other

well-known clinical entities, it is still important to consider how behavioral

disorders can impact GI function. The behaviors performed that lead to

problems with motility may appear purposeful in that it would seem the

affected patient is choosing to continue in the behaviors; however, when the

disordered behavior occurs as a result of mental illness, the patient may be

unable to control his or her actions.

Behavioral disorders related to the esophagus include rumination and

aerophagia.56 Rumination refers to swallowing food and then regurgitating it;


the patient may then repeatedly swallow the food or may vomit it. The

condition is most often seen among people who suffer from eating disorders

such as bulimia as a method of purging food to avoid weight gain after

eating or bingeing. Aerophagia is a rare type of disorder in which a person

swallows large amounts of air. The air passes through the esophagus and

enters the stomach but is then regurgitated, causing frequent belching. The

air may also pass into the intestinal tract, where it causes abdominal

bloating and increased flatulence. Some of the symptoms of aerophagia may

be related to GERD; however, the two conditions are distinct due to their

causes.

Wingate, et al. produced a working party report in the Journal of

Gastroenterology and Hepatology that effectively describes the various

entities found within the Knowles-Martin classification system. As part of this

classification, the authors do not identify any entities associated with

behavioral disorders that directly affect the stomach or small intestine.56

Alternatively, there are two conditions that exist as behavioral entities that

affect the large intestine, including impaired pelvic floor relaxation and

avoidance of defecation.

Anismus is a condition in which the patient is unable to control pelvic floor

muscles normally in order to defecate. Normal defecation requires the

patient to relax the muscles of the pelvic floor to expel fecal contents from

the rectum. However, when the patient does not relax these muscles, or

even contracts them instead while trying to defecate, he or she will be

unsuccessful and will end up retaining stool within the rectum.

Additionally, purposely retaining stool within the rectum is a behavioral

activity done to avoid defecation. The reasons behind why a person would


deliberately keep stool in the body instead of excreting it are varied. Some

people may avoid defecation because of pain while passing stool, such as

when hemorrhoids are present; alternatively, some people choose to avoid

defecation because of muscle weakness with straining, discomfort with the

act of having a bowel movement, or the feeling of an obstruction in the

rectum or the anus. Regardless of the reason, the purposeful holding of stool

within the body leads to constipation when excess fluid is absorbed from

feces held in the rectum. This paradoxically can lead to an even more

difficult time with having a bowel movement if the original reason for

avoiding defecation is because of the effort it takes to pass stool. The clinical

entity in these situations is known as functional fecal retention; it is the

most common behavioral disorder that causes motility problems in the large

intestine, rectum, and anus.56

Diagnosis Of A Gastrointestinal Motility Disorder

Correct diagnosis of a gastrointestinal motility disorder is essential to avoid

unintentionally missing a potentially life-threatening condition or

complication affecting the GI tract. The healthcare provider has several tools

that can be used to identify and analyze problems of dysmotility. Using

imaging studies, laboratory measures, and other forms of diagnostic testing

along with an accurate medical history from the patient, the healthcare

provider is more likely to formulate a diagnosis of a GI motility disorder and

its contributing factors.

Medical History

With the increase in diagnostic capabilities in the form of surgical practices,

imaging techniques, and laboratory measurements, the patient’s account of

his or her health may seem unnecessary as part of diagnosis. However,

taking a patient’s medical history, particularly as it relates to the patient’s


current symptoms of gastrointestinal motility problems is still important, as

the patient is aware of his or her signs and symptoms and medical condition.

Furthermore, many causes of GI motility disorders have microscopic

sources; for example, when nerve damage causes delays in motility and

problems with intestinal motor function, the exact cause of the condition

cannot be observed without specialized equipment that is able to visualize

affected tissues at the microscopic level. This then requires in-depth

examination and testing to fully diagnose the cause of the patient’s

symptoms.

The patient’s history is therefore important to begin to narrow down the

mechanisms that may be causing GI motility problems, what the individual

has done or not done to manage the condition, and if there are any other

factors affecting the particular situation that can be changed to best control

uncomfortable symptoms. GI motility disorders can produce a number of

symptoms that can range from mild and intermittent to those severe

symptoms significantly affecting bowel function and decreasing the patient’s

quality of life. It cannot be overemphasized that a thorough patient history

at the beginning of the provider-patient relationship, and again periodically

over the course of care as the patient’s condition changes, is very important.

The healthcare provider should obtain information about the patient’s

current condition, including how long the patient has been suffering from GI

motility problems, since the length of time a person has been experiencing

symptoms will help the provider to make a diagnosis. Other information to

gather from the patient may include the symptoms being experienced, and

whether the patient has had any other complications associated with a

condition.


Upon the initial meeting, the patient may present with symptoms that vary

according to the disorder present. Because the patient most likely will not

know the cause of his or her symptoms upon arrival, it is up to the

healthcare provider to make a diagnosis based on the information presented.

The nurse should ask questions that focus not only on symptoms affecting

the GI system, but also other symptoms that may be impacting different

areas of the body. Starting with the GI system, the nurse should question

the patient about symptoms, including history of pain, changes in stool

output, feelings of pressure or bloating in the abdomen and lower pelvis, and

any changes in toileting practices.

The nurse may also need to assess the patient's abdomen by performing a

focused physical examination. This involves inspection of the abdomen,

auscultation of bowel sounds to determine GI motility, and palpation to

assess for areas of tenderness or abnormalities, such as any abdominal

swelling or solid areas. The nurse should include an assessment of the

patient's dietary intake, including food and fluid consumption, to check for

possible electrolyte imbalance, dehydration, or malnutrition, all of which can

impact GI motility.

In addition to reviewing the patient’s current symptoms, the nurse should

also question the patient about any known GI disorders, such as

gastroesophageal reflux, dyspepsia, constipation, or diarrhea. The nurse

should include questions about any recent illness or injury that may have

affected the GI system. For example, the patient may have recently

recovered from a bout of food borne illness that caused vomiting and

diarrhea, from which he or she has since recovered. Although the patient

may no longer be suffering from acute symptoms of the illness, it could still

have an impact on the patient’s GI motility that leads to long-term


symptoms that are slower to resolve. Further questions regarding patient

history should include a history of chronic disease, food allergies, and

surgical procedures that would affect the intestine.

Following the gastrointestinal portion of the patient's history, the nurse

should question the patient about other previous illnesses or injuries that

could indirectly lead to GI motility problems. For instance, a patient with

diabetes who has uncontrolled blood glucose levels could develop

neuropathy and gastroparesis to the point that he or she is unable to detect

the need to have a bowel movement. Although it may seem that diabetes

would not directly affect GI motility, it is important to be aware of this

chronic disease as the change in blood glucose levels can cause nerve

damage.

Other conditions that should be included as part of the assessment and

patient history consist of metabolic disorders, a history of injury or infection

to the spinal cord or the central nervous system, history of drug or alcohol

abuse, autoimmune diseases or those affecting the muscles and nerves,

such as lupus or scleroderma; additionally, previous injuries or accidents

that have caused periods of immobility, previous head injuries that have

resulted in changes in level of consciousness, and any neurological or

neurodegenerative disorders, such as Alzheimer's disease, Parkinson's

disease, or multiple sclerosis should be considered.

Imaging Studies

Imaging studies create visual depictions of the internal organs and are very

useful as diagnostic procedures when assessing gastrointestinal motility

dysfunction. Most imaging studies are non-invasive for the patient and the

results can be obtained relatively quickly. Imaging studies may consist of


general examination of the abdomen to assess for global issues that affect

GI motility, or they could specifically analyze certain structures within the GI

tract. Most imaging studies involve various forms of radiology, such as X-

rays, ultrasound, computed tomography, or magnetic resonance imaging.

Endoscopic procedures have been included in this section as well, as they

often involve a combination of radiological imaging with technology to

visualize the interior structures of the GI tract through instruments placed

within the cavity.

Scintigraphy

Scintigraphy utilizes radiographic isotopes that are transferred into the

gastrointestinal tract to assess a patient’s motility and gastric emptying

time. The patient eats a meal, typically scrambled eggs, which contain the

isotopes needed for the study; the most common isotopes used are

technetium and iodine. After consuming the meal, the images are taken to

detect the food as it passes through the patient’s GI tract. The measuring

device that monitors food passage is a scintiscanner, which scans the

isotopes and can follow them through the body. This type of study is often

used when the provider suspects a disorder of GI motility affecting the

stomach and small intestine, including cases of gastroparesis and dumping

syndrome.

A similar form of scintigraphy is a colonic transit test, which checks the

motility of the large intestine. This test also uses radionuclide markers,

which are placed in a capsule that the patient swallows. The person then

goes through normal, everyday activities, including eating normal meals.

The capsule contains 20 radionuclide markers and the patient will have an

abdominal X-ray approximately every 24 hours until each of the markers has

been excreted. The process typically takes about five days.1 Each X-ray can


visualize the markers and determine at which points they are at in the

intestinal tract. The test analyzes how the markers move through the GI

tract and can determine their rate of motility and whether it is too fast or too

slow. According to the test, if after five days more than 20 percent of the

markers are still present in the patient’s body, the patient is said to have

delayed colonic transit times.47

X-Ray

Radiographic testing through an X-ray takes an image of the gastrointestinal

tract at one specific point in time. The X-ray machine sends energy beams

into the body, which form a picture of the structures inside. It allows the

medical provider to view what is happening in the GI tract through one

snapshot, such as with a single-view X-ray, or it could be more complex and

could involve taking images of the GI tract from various angles or while food

or liquid is passing through the intestines.

A radiographic procedure that looks at the upper portion of the GI tract,

including the esophagus, stomach, and small intestine, is the upper GI series

that can help to diagnose conditions possibly causing GI motility problems in

these segments of the GI tract. The procedure is often referred to as an

upper GI test. The upper GI test requires that the patient drink barium

contrast in order to visualize sections of the GI tract. As the patient drinks

the barium contrast, the medical provider monitors the passage of the fluid

through the esophagus, stomach, and small intestine, since the contrast will

show up on X-ray examination. The process involves taking several X-rays

over time to check where the barium is in the GI tract and how quickly it is

moving through.


An upper GI test is appropriate for diagnosing dysmotility conditions that

affect the upper gastrointestinal tract, including achalasia, gastroparesis, or

dumping syndrome. The test may also note whether there are obstructions

in the GI tract that can affect food passage; strictures or narrowing, such as

with pyloric stenosis, or whether inflammation is present, which can affect

the body’s ability to digest and absorb food.48 However, this test is not able

to detect certain other conditions that could cause GI motility problems,

such as small ulcers or infection with H. pylori, which could also cause

symptoms. Often, confirmation testing, such as through endoscopy, is

necessary to authenticate the results seen on the X-ray.

Enterography

A type of imaging test that uses a CT scan or MRI, enterography allows the

provider to visualize the small intestine and other areas of the abdomen. To

perform the exam, the patient drinks a liquid contrast medium or is

administered the contrast intravenously. The contrast then shows up in the

patient’s GI tract where the MRI can pick up images in the intestine and

check for abnormalities that may be causing GI motility problems, such as

obstructions, inflammation, or bleeding.

Enterography is beneficial because it is less invasive than endoscopic

procedures. The images produced through enterography are more complex

and can reach certain areas that an endoscopic tube would miss and the

type of study is sensitive to pick up small changes that can occur in the GI

tract that affect motility. A study by Menys, et al., in the journal Radiology

demonstrated that MRI enterography can detect changes with administration

of drugs to patients that will stimulate small bowel motility. The study

showed that the test was able to pick up the differences in GI motility

whether the participants were administered drugs that affected motility or


placebo.50 Because of the non-invasive process involved with this type of

study, and that it is sensitive enough to pick up changes in GI motility,

enterography is a viable option for diagnostic treatment among patients who

are suffering GI motility disturbances.

Endoscopy

Endoscopy is an umbrella term used to describe any test that involves

insertion of a tube into the gastrointestinal tract to visualize and take

pictures of the internal structures. Upper GI endoscopy involves testing of

the throat, esophagus, stomach, and small intestine, while lower GI

endoscopy involves testing of the large intestine, sigmoid colon, rectum, and

anus. Endoscopy differs slightly from other imaging studies in that contrast

medium is not always used and the GI endoscopist does not always utilize

radiographic images to make a diagnosis. However, endoscopy is a valuable

process that helps the endoscopist to visualize the internal segments of the

GI tract, which can better pinpoint a diagnosis when GI motility problems

are present.

Upper endoscopy, also called esophagogastroduodenoscopy or EGD, involves

insertion of a tube into the patient’s mouth and then advancing it down the

esophagus. Depending on the area of concern, the endoscopic tube insertion

may also need to be advanced into the stomach or the duodenum of the

small intestine. The patient’s mouth is sprayed with anesthetic to maintain

comfort during the procedure; in many cases, the patient is mildly sedated

for the procedure as well so that he or she will be relaxed.

The EGD is performed in an endoscopy suite where the patient can be

monitored closely before, during, and after the procedure. The process does

not require contrast media because it does not involve radiographic imaging,


but it does allow the endoscopist to look at images of the esophagus,

stomach, and a portion of the small intestine. The test is beneficial to look

for conditions that may be causing the patient’s symptoms of pain, nausea,

or vomiting, which may or may not be related to GI motility problems. It

may also be done to rule out another condition and narrow down the cause

of the motility issues.

The upper endoscopy is more accurate than traditional X-rays when looking

for certain issues within the gastrointestinal tract, such as inflammation.49

The endoscope can also be used to insert biopsy forceps through the channel

to remove small tissue samples from the GI tract if the endoscopist

determines its necessary to perform a tissue pathology test.

To examine the entire large intestine, a colonoscopy is typically performed,

which allows the endoscopist to visualize the colon. The colonoscopy is often

used as a cancer screening tool to initially assess and perform surveillance

exams for colon cancer, but it may also be utilized to assess for potential

obstructions in the large intestine, the presence of inflammation or polyps,

bleeding, diverticulosis, or whenever the patient is suffering symptoms and

is experiencing a change in bowel habits. A colonoscope, a flexible tube is

inserted into the anus and advanced through the large intestine all the way

from the left colon to the right colon and cecum. Prior to the procedure, the

patient must undergo a bowel cleanse as preparation in order to remove any

fecal matter in the intestine. This often requires a clear liquid diet for one

day before the procedure and administration of a laxative that will empty the

colon. During the procedure, the patient lies on a table, usually on the left

side, and is given a mild sedative to be comfortable. The procedure is

expected to last 30 to 60 minutes.


Because the colonoscopy is relatively invasive, there is another option to

visualize the bowel for some patients who would not tolerate a colonoscopy.

A procedure known as CT colonography, also referred to as virtual

colonoscopy, can be performed to assess for similar changes in the colon

that would be detected during a colonoscopy. The patient typically has to

undergo the same amount of bowel preparation, using a laxative and

changing the diet temporarily before the procedure. The patient will need to

drink a contrast medium and then lie on a table while the radiologist inserts

a tube into the anus and injects air into the rectum and the colon. This air

allows for better viewing during the procedure.

The colonography uses CT imaging to take pictures of the patient’s colon and

then demonstrate the results on a monitor to better visualize the interior of

the large intestine. Like the colonoscopy, the colonography test can detect

changes that can cause GI motility disorders and that lead to patient

symptoms; and, because it uses CT, it can identify areas of concern.

Alternatively, the colonography does not allow for biopsy sampling or direct

tissue examination as would be available through the colonoscopy, as there

is no endoscope being inserted into the large intestine to provide access to

tissue to biopsy.49

Endoscopic procedures of the anus, the rectum, and the sigmoid colon are

known as anoscopy, proctoscopy, and sigmoidoscopy, respectively. These

tests can be performed to assess GI motility and to determine if there are

obstructions within the descending colon and areas of the lower GI tract that

are preventing normal motility and slowing colonic transit, preventing

normal defecation. Some conditions that these tests may be used to

diagnose include fecal incontinence and chronic diarrhea.


Anoscopy is performed to look at the structures of the anus, the anal

sphincter, and the lower portion of the rectum. The medical provider may

perform a digital rectal exam before the procedure to ensure that there are

no blockages that would prevent passing the scope. The patient may also

need to take a laxative or have an enema prior to the procedure to clear the

bowel, particularly the sigmoid colon and the rectum, if stool is present in

these areas. Anoscopy is done by insertion of an anoscope, also called an

anal speculum, into the anal opening. The patient lies on a table but is

generally not sedated for the procedure. Instead, the insertion tube is

coated with an anesthetic cream that desensitizes the area to prevent much

discomfort.

The insertion tube has a light source and a camera, similar to other

equipment used for endoscopic procedures. The anoscope allows the

provider to view approximately 2 inches of the distal portion of the anal

canal. Anoscopy is most often performed to check for patient hemorrhoids or

polyps, which could be obstructing the anal opening, making stool passage

difficult. The test may also diagnose other conditions, such as inflammation

or anal fissures; although these conditions do not directly affect GI motility,

they can make it painful for the patient to defecate, potentially leading to

problems with constipation.

Proctoscopy involves examination of the rectum. The process is similar to

that of a colonoscopy or anoscopy in that the physician inserts a scope into

the patient’s anus and advances it to the rectum to visualize the internal

structures of this portion of the colon. The proctoscopy allows the physician

to visualize whether there are obstructions in the rectum that prevent the

passage of stool or whether any other abnormalities are present that would

affect gastrointestinal motility.


As with other endoscopic procedures, the patient may need to be in a fasting

state for several hours before the test and may need to use an enema or a

laxative to clear the rectum of stool. The medical provider may also perform

a digital rectal exam just before the procedure. The entire procedure takes

about 15 to 20 minutes, plus time before and after the procedure for

preparation and recovery. Because proctoscopy allows visualization of the

rectum, the main area where stool is stored before defecation, it is useful to

ability the patient’s ability to defecate normally and to diagnose conditions

that affect GI motility, such as fecal impaction or chronic constipation.

Furthermore, if there is inflammation or bleeding present in the rectum that

affects the patient’s ability to defecate, the proctoscopy can pick up on these

conditions as well. The patient may have polyps present in the rectum; by

utilizing a specialized snaring or biopsy tool, the physician can remove some

of the polyp tissue and send it for a pathology study.

Sigmoidoscopy examines the sigmoid colon, which is the lower portion of the

large intestine that connects the descending colon with the rectum. Because

the procedure involves further advancement of the sigmoidoscope as

compared to an anal or rectal exam, the patient may need to be lightly

sedated for the procedure. Sigmoidoscopy requires that the patient lie on a

table with the knees drawn toward the chest, and the physician generally

will perform a digital rectal exam to ensure there are no obstructions or

tenderness in the area. The physician will advance the sigmoidoscope past

the rectum and into the sigmoid colon; and, the scope is flexible so that it

can be navigated according to the shape of the intestinal tract.

During the sigmoidoscopy, air may be instilled into the bowel to help with

viewing the internal structures. The patient will pass this air back out of the

rectum following the test. The procedure typically only lasts a few minutes


and most patients tolerate it well without any pain. The sigmoidoscopy can

be used to assess for obstructions, such as polyps, found in the sigmoid

colon, the presence of stool or inflammation of the intestinal lining, or

whether any bleeding is present in this portion of the large intestine. If

polyps or other suspicious tissue is present, the physician can use

instruments that are inserted through the endoscope channel to extract

tissue for biopsy.

Barium Studies

Barium is a commonly used contrast medium for imaging studies. It is

radiopaque contrast used to coat the internal structures of the

gastrointestinal tract that can be seen during X-ray or CT scan. Barium

studies can be performed to assess the GI tract. By using barium, the

healthcare provider can assess for changes in the intestinal tract that could

contribute to GI motility problems. Barium studies can be performed to test

for upper GI tract disorders, often called barium swallows, or for lower GI

tract disorders in which the contrast is typically administered as a barium

enema.

The barium swallow is actually called an esophagography. It is referred to in

simpler terms as a barium swallow because the patient actually drinks

barium contrast that has been prepared as a mixture. When the patient

drinks the mixture, the clinician can take X-rays to follow the barium

contrast as it moves through the digestive tract. The barium can be seen

flowing down from the posterior pharynx where it was swallowed and the

physician may note how the esophagus propels the contrast toward the

lower esophageal sphincter and stomach, using peristaltic waves. The test

also examines patency of the lower esophageal sphincter as it opens to allow

the contrast to pass into the stomach.51


Although the barium swallow may demonstrate some factors that contribute

to the patient’s GI motility problems, they must typically be confirmed with

manometry or biopsy after the barium swallow. For example, if the physician

were to determine that the patient’s motility problems were the result of

lesions found in the intestinal lining, the condition could not actually be

diagnosed using the barium swallow results alone and would require biopsy

to do so.51 The barium swallow may be combined with an upper GI test to

identify a GI motility problem before other studies, such as biopsy, are

completed to confirm a diagnosis.

A barium enema is an examination of the lower gastrointestinal tract that

uses contrast medium, and it is administered rectally as an enema to allow

the medical provider to visualize the internal structures of the large intestine

when using imaging studies. The single-contrast technique describes

application of contrast through administration of barium enema alone, while

the double-contrast technique involves administration of a barium enema

and air into the large intestine. The colon expands slightly with the barium in

place and the contrast coats the inside of the intestinal tract. In this way,

the healthcare provider can see many details of the surface of the colon,

including whether obstructions are present or any other reason why the

patient may be experiencing changes in bowel habits. After enema

administration, the patient may lie on a table but be asked to change

positions occasionally while the healthcare provider visualizes the results

within the large intestine.

A further test that may use imaging of the large intestine is known as

defecography, which utilizes barium contrast and X-ray to take images while

the patient defecates. The test is done to determine how the stool moves

through the rectum and out of the body in situations where the patient


reports difficulties with colonic motility and stool evacuation. Barium paste is

inserted into the anal and rectal canals using a tube similar to an enema.

During the test, the patient sits on a specialized chair that can record the

movement of the contrast through defecation. The test then analyzes the

process of how the rectum empties itself of the barium paste. It can

determine whether there are problems associated with the rectal muscles

and the rectum’s ability to retain the contrast, motility problems with

passage of stool between the rectum and the anus, or whether there are

structural problems with the anus, such as poor sphincter control, that affect

the patient’s ability to evacuate stool.

Defecography is a useful test for identifying a number of GI motility

problems. Among others, it has been successfully used to identify and

diagnose patients who suffer from chronic functional constipation and

dyssynergic defecation. A study in the British Journal of Radiology showed

that magnetic resonance (MR) defecography can detect abnormal findings in

adults who suffer from dyssynergic defecation, which is defined as a

functional defecation disorder characterized by impaired pushing forces,

paradoxical contractions, or an inability to relax the anal sphincter muscle.52

The test has also been shown to be useful in identifying other disorders of GI

motility, including fecal incontinence and anismus, which occurs as

inappropriate spasms of the anal sphincter.

Capsule Endoscopy

Capsule endoscopy is a newer technique that allows the healthcare provider

to visualize the inside of the gastrointestinal tract when the patient swallows

a capsule that contains a tiny camera. The patient wears a recording device

during the test and the camera has its own light so that when it enters the


gastrointestinal tract, it can record data and send it wirelessly to the storage

device. The camera transmits the images over the course of approximately

eight hours. The test is beneficial because the capsule can reach certain

areas of the GI tract that could otherwise not be visualized through upper

endoscopy or colonoscopy.

Prior to the exam, the patient must have an empty stomach before

swallowing the capsule. If the patient takes medications that can cause

stomach irritation, such as NSAIDs, he or she may need to stop taking them

temporarily before swallowing the capsule. The recording device that

receives the information from the capsule is typically worn on the upper

body, where it keeps note of the images from the capsule throughout the

time of testing. At the end of the testing period, the patient will excrete the

capsule normally and it does not need to be retrieved from the intestine.

A drawback to capsule endoscopy is that if it detects a problem within the

gastrointestinal tract, it only takes pictures of it with the camera; the

healthcare provider must still follow up with further testing to diagnose a

condition or to obtain tissue samples. Because of the length of time the

capsule is able to function, it often does not examine areas past the small

intestine. There is also the small chance that the capsule could become stuck

in one of the loops of the intestine or at the junction between sections of the

GI tract, such as near one of the muscular sphincters. Despite these risks,

capsule endoscopy is generally safe to use for most patients and is a very

convenient method of visualizing the internal structures of the intestinal

tract for patients with GI disorders that may be co-occurring and/or

contributing to a problem of motility.


Electromyography

Electromyography (EMG) describes testing conducted to examine the

function of motor neurons, the nerves that control muscles. Normally, motor

neurons work by sending electrical signals to stimulate the muscle tissue. An

EMG is performed to monitor these signals to determine whether the motor

neurons are working at an appropriate amount. While EMG is often used as

part of diagnostic testing to analyze skeletal muscle tissue, it may also be

used to assess gastrointestinal function. The process tests the motor

neurons that stimulate the muscles that control intestinal tissue and checks

whether they are sending signals too quickly, or whether they are working at

a pace that is too slow.

The process of electromyography is one of the only diagnostic tests available

that can directly analyze specific muscle activity. Muscles are made up of

motor neurons as their basic units of function. When a nerve impulse arrives

at the junction of the muscle and the nerve, the body secretes acetylcholine

in response and the muscle contracts. The electrodes from the EMG gather

information from the surrounding muscle fibers and send a signal to an

amplifier where the information is displayed on a digital screen. The

information is also recorded so that it can be referred to later, if necessary.

Electromyography picks up the signals sent by motor neurons when

electrodes are positioned in specific locations in the muscles of the GI tract.

Contrary to the surface electrodes used as part of cardiac testing, electrodes

used with EMG are often special types of needles that are placed within the

muscle tissue. Electromyography is performed whenever there are potential

problems with different muscles and the organs and body systems that they

affect. For example, EMG may be utilized if there has been damage to the

spinal cord, which can impact muscle movement and nerve function, and to


determine the amount of damage to the muscles that has occurred from the

injury. If a patient suffers from a degenerative condition, EMG can be used

to analyze the extent of nerve damage and its effects on the muscles.

Electromyography recordings can be difficult to undertake when studying GI

function. For instance, when needle electrodes are used for measurement,

there are few people who wish to undergo intramuscular needle placement

into the jaw, pharynx, or esophagus. Likewise, it may be difficult to place

needle electrodes into locations such as sphincter muscles to obtain

measurements. However, it is possible that some patients could undergo

needle placement of electrodes for EMG monitoring as part of a surgical

process; the testing could be performed during a surgical procedure, even if

the procedure is not intended for surgical diagnosis or correction of a GI

disorder.114

A study published in the Journal of Investigative Surgery utilized EMG to test

for LES function in persons with reflux. The study examined patients who

were undergoing surgical procedures and who underwent simultaneous EMG

recordings of the lower esophageal sphincter during the process. At the end

of the surgical procedure, the patients were stimulated to cough by

manipulation of the endotracheal tube and researchers examined the

differences between the amount of pressure and muscle activity of the

esophageal sphincter on the EMG with coughing as compared to time at rest.

The results showed higher-level pressures during induced coughing, which

suggests that the LES is less likely to function normally during periods of

straining or coughing, which may contribute to weakened musculature found

among those with GERD.115


Alternatively, EMG may be used to diagnose conditions associated with the

lower GI tract, such as within the colon, rectum, and anus. A patient who

suffers from fecal incontinence or abnormalities associated with the rectum

and anus may undergo anal sphincter EMG. The test is indicated for any

patient who has had changes in bowel habits related to loss of sensation in

the anal tract, damage to the pudendal nerve in the lower pelvis, or spinal

cord lesions that can affect motor and sensory function in the lower GI

tract.116 To utilize this method of EMG recordings, the clinician may take

measurements using a combination of needle and skin electrodes for the

test. The patient is placed in a position that allows for easy access to the

anal sphincter and the clinician inserts the electrode needle directly into the

muscle of the sphincter. The patient may be asked to contract the sphincter

muscle during the test, using muscles normally involved for holding stool

within the rectum. The process takes approximately 60 minutes.

An EMG is typically performed at a hospital or through a specialty clinic. The

patient rests on a table or bed and the technician performing the test places

electrodes in the appropriate locations. During the test, the patient will most

likely need to lie still in order to get the most accurate results, although he

or she may be directed to change positions or use certain muscles during the

test to determine how these movements will affect the test outcome.

Because the electrodes typically puncture the skin or muscle tissue during

the test, the patient should be monitored for a period of time after the test

for safety.

The EMG is not necessarily the first choice of diagnostic procedures to

consider with a patient who suffers from a GI motility disorder. The process

is relatively invasive and may involve patient discomfort, particularly related

to electrode placement. However, because the EMG has the potential to


measure such miniscule muscle contractions and can record very slight

changes in muscle tone and movement, this test can be capable of detecting

abnormalities that cause GI motility problems that other types of testing

may miss.

Manometry Testing

Manometry testing measures the amount of pressure within the

gastrointestinal tract. The muscular layer within the lining of the intestine

exerts a certain amount of pressure to stimulate peristalsis and movement

of chyme and stool through the intestine. Manometry is a specialized form of

diagnostic testing that can measure and analyze the pressure exerted by the

muscles in the intestinal tract. Colonic manometry measures the strength of

muscle contractions in the large intestine, while esophageal manometry is

performed to assess motility of the esophagus.

Esophageal Manometry

Esophageal manometry gauges the patterns of peristalsis that move food

from the pharynx after swallowing to the stomach where it can be further

digested. Patients who suffer from esophageal motility disorders may

experience epigastric pain, heartburn, of difficulty swallowing; in cases of

achalasia, the patient may also experience chronic cough or regurgitation of

food, fluid, or stomach acid into the back of the throat. Esophageal

manometry can measure the motility of the esophagus by checking the

lower esophageal sphincter and the muscle tone of the esophagus, as nerve

damage in these areas can result in many of the patient’s symptoms.

According to Katz, author of an article called Esophageal Manometry, this

test is indicated for specific conditions, including evaluation of symptoms


that have not been diagnosed through endoscopy, evaluation of non-cardiac

related chest pain, assessment of dysphagia not caused by an obstruction,

analysis for diagnosis of achalasia, pre- or post-operative measurements for

patients undergoing procedures for treatment of gastroesophageal reflux

disease, and monitoring for placement prior to pH probe and electrode

positioning in the lower esophageal sphincter.39 The patient should remain in

a fasting state for at least four hours prior to the start of the esophageal

manometry study.

Many patients are apprehensive about the procedure, as it involves inserting

a tube into the nose and advancing it into the stomach. The nurse who is

working with the patient undergoing this procedure should carefully explain

the process and provide appropriate education and guidance to best alleviate

the patient’s fears. In most cases, the patient does not have to stop taking

medications that are taken on a daily basis, even if they are drugs used to

control gastrointestinal motility, as the test will measure the effects of these

drugs in the system anyway. The patient remains awake during the

procedure, but the nose and the back of the throat may be anesthetized with

lidocaine spray prior to starting the process.

To perform the test, a catheter is passed into the esophagus and all the way

through the lower esophageal sphincter into the stomach. The manometry

tube is slowly pulled back up from the stomach through the esophagus, and

it is during this time that pressure measurements are taken. Some of the

newer manometry equipment have increased catheter sensors and potential

to measure pressures within the esophagus thereby requiring less

manipulation or movement of the tube to complete testing, and producing

less discomfort to the patient undergoing the manometry procedure.


The results of the manometry vary depending on the patient’s condition. For

example, if the patient has achalasia, the manometry will measure abnormal

muscular contraction in the esophagus and pressures of the lower

esophageal sphincter characteristic of the condition. Abnormal esophageal

contractions measured through the test may indicate esophageal spasm or

some form of hypermotility disorder. When the lower esophageal sphincter

lacks tone and is prone to loosening and allowing gastric fluids to escape,

the patient may have a history of gastroesophageal reflux. Manometry is

often useful with other studies performed to diagnose and treat reflux, such

as with fundoplication or surgery to strengthen the lower esophageal

sphincter.

Antroduodenal Manometry

Another test, known as antroduodenal manometry, measures the motility of

the stomach and the small intestine. It is a valuable test that can be

performed on some patients who have motility problems that are otherwise

difficult to detect through X-ray or clinical manifestations. A patient with GI

motility problems may have generalized symptoms of nausea, vomiting, or

constipation but, in some cases, it can be difficult to determine the location

of the motility problems through clinical symptoms alone. According to a

study in the Journal of Neurogastroenterology & Motility, antroduodenal

manometry is most likely indicated for patients with certain clinical

manifestations, including patients with suspected pseudo-obstruction in the

small intestine, persons with unexplained abdominal pain and nausea and

vomiting, and for those who require GI motility tests to exclude

disseminated GI motility disorders.37

Although the antroduodenal test can measure gastrointestinal motility after

eating, the patient must remain in a fasting state for several hours before


starting the test. If the patient has prescription medications for drugs that

affect stomach activity or motility, such as metoclopramide or antispasmodic

medication, they will usually be stopped for at least 3 to 7 days before the

test as well, as these types of drugs can affect the test outcome.

The antroduodenal manometry test is performed through the insertion of a

flexible catheter into the patient’s nose and threading the catheter down into

the esophagus, stomach, and then the small intestine. Confirmation of tube

placement is done via X-ray before starting the test. The tube contains

sensors spaced at various intervals along its length that measure pressure

levels during the test; and, a transducer picks up the readings from the

sensors and displays the output as pressure tracings. There are two types of

tubes that may be used for the procedure. One tube requires that the

patient remain on bed rest during the test, while the other tube allows the

patient to be ambulatory and will record pressure readings for up to 24

hours.

The study measures small intestine motility during the fasting period, during

the time that the patient ingests a meal, and then for several hours after the

meal. Studies have shown that when patients undergo the ambulatory test,

the results are often clearer for clinicians who review them since the

ambulatory system test is performed over 24 hours and through several

meals. This permits the clinician reading the results to see the effects of

more than one meal and the fasting period on the patient’s motility, rather

than checking motility during a stationary period and one meal.

The test records the patterns of muscle contractions made within the GI

tract, and consider three phases of muscle contractions, which appear at

various times throughout the digestive process. Phases I and II involve


periods of rest and mild or intermittent contractions, respectively. Often, the

test checks the frequency and duration of Phase III contractions, which are

rhythmic movements that transfer undigested material from the stomach

into the small intestine.38 It is understood that eating a meal produces more

frequent Phase III contractions, which is why the patient will eat a meal

during the manometry test to determine how the stomach and small

intestine respond. The test can further measure whether GI motility

problems are caused by muscle weakness that do not allow for normal Phase

III contractions, or whether the motility disorder is caused by interruption in

nerve conduction, which can affect the rate and force of stomach

contractions.

Colonic Manometry

Colonic manometry determines the amount of pressure present in the large

intestine. A patient may suffer from symptoms of constipation or chronic

diarrhea associated with changes in colonic motility that might be identified

and diagnosed through colonic manometry. In fact, the

Neurogastroenterology and Motility Society has issued a recommendation

that patients who are constipated should undergo colonic manometry

testing, particularly when they have not responded to other forms of testing

and treatments. This means that the colonic manometry test can be very

beneficial for patients affected by alterations in GI motility and that have not

had any other clear answers about their conditions.45

The process of completing colonic manometry is somewhat similar to

measuring pressure results of other portions of the gastrointestinal tract.

With colonic manometry, however, the manometry tube is inserted into the

patient’s anus and advanced through the rectum to reach the large intestine.

Although colonic manometry has been shown to be beneficial in diagnosing


the cause of patient symptoms, the test can sometimes still not identify the

actual condition causing the underlying clinical manifestations.

Researchers have discovered that when recording the frequency of colonic

contractions through manometry, most patients will exhibit a certain number

of contractions as evidenced by increases in colonic pressure during a 24-

hour period. Increases in events have been shown following meal

consumption as the body is digesting food. Alternatively, some patients who

suffer from severe constipation have been shown to have very few or no

periodic increases in colonic pressure during the time period measured,

indicating a lack of movement in the large intestine, which contributes to

constipation. However, the changes in pressure within the colon can be very

subtle at times, because the manometry tube that measures these pressure

changes is quite thin and could miss some of the very small movements in

the wall of the large intestine; this means that the patient could still be

experiencing colonic contractions but the test is not necessarily accurately

measuring them.46

Nevertheless, manometry studies of the large intestine have been very

useful in helping clinicians determine colonic function for some patients who

experience GI motility problems. Because the manometry tube is placed

within the colon, the manometry test itself allows the healthcare provider to

gain better insight into what is going on inside the large intestine to better

be able to analyze the patient’s GI motility problems and to diagnose the

cause.

The colonic motility test can be done on an outpatient basis in a hospital or

clinic that has endoscopy capabilities. Prior to the test, the patient will be in

a fasting state and will need to have the colon cleansed to clear the


intestinal tract of stool and fecal matter. This is typically accomplished when

the patient consumes a laxative or has an enema designed to stimulate stool

excretion. The patient is sedated for the study, and a thin, flexible

manometry tube, which is the pressure-monitoring device, is inserted into

the anus and passed into the rectum and the large intestine. A guide wire is

threaded through the manometry tube, which acts to direct and position the

tube to obtain as accurate manometric measurements as possible until

completion of the test. After the guide wire is removed, the manometric tube

measures the pressure at various points along the colon and records the

movements as a sequence of events on a monitor so that the medical

provider can see the patterns of intestinal contractions through the test.

In some cases of colonic testing, the patient may be given a meal; after

eating, the medical provider will then check the manometer to determine

how the body is responding with colonic contractions during meal digestion.

The actual testing period may vary but it is approximately three hours long

after the tube is positioned in place and through the recording, with

additional time required both before and after the test to prepare the patient

and to recover from the procedure.

Colonic manometry testing is performed on both adults and children,

although studies have shown that the procedure has been more successful

when used in children. According to a study in the World Journal of

Gastroenterology, there are few studies that indicate much success with this

type of colonic study among adults, but when performed among children,

the results of colonic manometry are much more likely to guide the

provider’s treatment options. One study cited 88 percent of parents whose

child underwent colonic manometry testing, and who then received

treatment to manage the child’s condition, believed that the process was


helpful and improved their child’s health.45 Regardless of whether colonic

manometry is used for an adult or for a child, this specific type of testing has

been shown to be effective to detect changes in pressure levels within the

large intestine of patients affected by GI motility problems. As a result,

manometry testing remains a useful diagnostic tool to be considered

whenever the need for GI motility testing arises.

Diagnostic Laparoscopy/Laparotomy

At times, surgery may be indicated for some patients who suffer from

gastrointestinal motility problems, either to diagnose the condition that is

causing the problems or to correct a health condition to facilitate normal

motility once again. Laparoscopy and laparotomy are two types of surgical

procedures that may be implemented for various conditions.

Laparoscopy is a minimally invasive surgery. The patient will need

anesthesia and the surgeon will create a small opening in the skin but the

procedure is performed using a scope or tube that is inserted into the

opening. A camera on the end of the scope allows the surgeon to see inside

of the abdominal cavity without needing to open the skin further.

Laparoscopy can also allow the surgeon to take small amounts of tissue

samples and to take pictures of the inside of the abdomen. Alternatively,

laparotomy is an open procedure that involves a larger incision that can be

pulled apart slightly to allow the surgeon to see inside of the abdominal

cavity. Laparotomy may be exploratory, in which the surgeon is investigating

the potential cause of the patient’s symptoms. It may also be done to

correct a situation if the patient has had testing before the surgery and the

cause of the problem has been identified.


Surgical procedures may be part of diagnostic testing to take samples of

gastrointestinal tissue to determine the potential cause of the motility

problems. In many cases, diagnostic testing can be performed through

various imaging studies and minimally invasive techniques that do not

require surgery. Surgery may be necessary as part of treatment once the

condition has been diagnosed and the cause of the motility problems

identified, but laparoscopy or laparotomy may otherwise be indicated to

collect tissue for biopsy to determine how well the cells and tissues of the GI

tract are functioning.

Acquisition of tissues may be done as part of diagnostic testing;

alternatively, tissue samples may be taken as part of another type of

surgical procedure related to the patient’s symptoms and then the tissue is

examined for biopsy. Tissue samples from the GI tract are often taken from

the lining at various points along the tract, such as the lining of the

esophagus, small intestine, or colon. Biopsy specimens from the intestinal

lining may include tissue from the mucosal or submucosal surfaces, or even

full thickness of tissue from the lining of the bowel.55 Alternatively, if there is

an obstruction present, such as a polyp or lesion, a sample of this tissue

may also be surgically removed for biopsy.

Natural orifice transluminal endoscopic surgery (NOTES) is a relatively new

surgical technique that is minimally invasive and that allows the surgeon to

manage or treat a GI condition without creating an external surgical incision.

It may be performed as a type of surgical procedure to retrieve specimens

for biopsy or to collect tissue cultures as well as to remove samples and

specimens from within the body, whether as part of diagnosis or as a

method of treatment.


Normally, surgery to obtain tissue samples as part of diagnostic procedures

requires puncturing the exterior skin of the abdomen to reach the internal

cavity. When the surgeon is taking a tissue sample from an interior portion

of an organ, such as with biopsy from the internal lumen of the intestinal

tract, this could involve further perforation of the tract to reach the area

needing to be biopsied. With NOTES, however, the surgeon may puncture

the cavity of the intestinal tract to reach the interior portion, but the surgeon

has approached the internal incision through a natural orifice.117 For

example, the surgeon may take a sample of tissue from the stomach but is

able to reach the interior tissue by passing a tube through the esophagus,

rather than making an external incision.

The process of NOTES uses a combination of laparoscopic and endoscopic

techniques to obtain tissue samples and to perform diagnostic procedures.

According to a report in the Annals of the Royal College of Surgeons of

England, the techniques utilized for a NOTES procedure must uphold certain

principles of safe access, including minimal tissue injury, good exposure,

avoidance of vascular and visceral injuries, and the ability to maintain a seal

to manipulate the instrument.118 This information is important, as the NOTES

procedure is designed to access those internal structures of the body,

including the GI tract, which could otherwise be exposed and laid bare

during surgical procedures. Any type of surgery places the patient at higher

risk of infection because of the invasiveness of the process. When a surgical

procedure is performed to diagnose a GI motility disorder, the surgery can

place the patient at risk of other complications. The NOTES procedure may

be performed as an alternative means of accessing the intestinal tract for

diagnostic purposes but that also keeps the patient safe and that minimizes

potential complications.


Laboratory Testing

Complete Blood Count

The complete blood count (CBC) is a

test of the health of the blood cells;

and, it is often done to test the

patient’s overall health and wellbeing.

It can be used as part of diagnosis for a

number of different medical conditions,

including anemia, infection, cancer, or

conditions that cause inflammation in

the gut. Any of these disorders could lead to gastrointestinal motility

problems. The CBC consists of various components as it tests different cells,

each of which can be related to gastrointestinal motility changes. An

alteration in the levels of certain blood cells as seen on the CBC results can

indicate if there is a specific problem present that may be affecting the

patient’s GI motility, such as the presence of an illness that affects intestinal

function.

There are three main types of cells found in the blood and the CBC

components test the amounts of each of these cells. The main cell types are

white blood cells, red blood cells, and platelets. Each category can be further

broken down into different elements that measure specific indicators within

the blood sample.

The white blood cell components of the CBC include a test of the total

number of white blood cells in the blood sample, as well as the white blood

cell differential, which measures the type and amounts of the various types

of white blood cells, including lymphocytes, monocytes, neutrophils,

basophils, and eosinophils.41 The white blood cells are responsible for


fighting infection, so when they are elevated or decreased in the CBC

sample, it can indicate that an infection is causing the GI motility problems.

For example, a patient may develop nausea, vomiting, and diarrhea after

suffering a viral gastrointestinal infection. The presence of infection can be

detected through the CBC, even though it will not detect the specific virus

causing the symptoms.

The patient who has an infection will most likely have an increased number

of white blood cells in the CBC. The normal amount of white blood cells in a

sample is 4,000 to 10,000/mm3; and, the differential portion of the CBC tells

the clinician the specific amounts of each type of white blood cell. Since each

type performs distinct functions in fighting off infection, it is important to

check the white blood cell differential to help to determine the cause of

infection. For example, if a patient complains of abdominal pain and

increased GI motility and the CBC shows an elevated white blood cell count,

the healthcare provider may consider that there is an infectious process

causing the patient’s condition. When checking the differential, it may show

that lymphocytes are elevated, which are important for fighting infection

caused by viruses. This result may better help the healthcare provider to

understand the cause of the infection.

The red blood cells are the second type of cells measured through the CBC.

The red blood cells are responsible for oxygenation of body tissues because

they contain hemoglobin and carry oxygen through the bloodstream. The red

blood cell portion of the test is further broken down to test such elements as

the total red blood cell count, hemoglobin, hematocrit, red blood cell indices,

and the reticulocyte count.


The normal red blood cell count is approximately 4.7 to 6.1 million cells/mcl

for men and 4.2 to 5.4 million cells/mcl for women, which could be increased

when a patient is dehydrated or has poor kidney function, or decreased in

cases of anemia, hemorrhage, and severe infection. The red blood cell

indices include components such as mean corpuscular volume (MCV), which

measures the average size of a red blood cell. If the red blood cells are too

large, they are considered macrocytic; this condition could occur because of

certain vitamin deficiencies or with hypothyroidism. Alternatively, microcytic

cells refer to those red blood cells that have an MCV result that is smaller

than normal. Microcytic red blood cells typically develop if the patient is

suffering from iron deficiency anemia. Other segments of the red blood cell

test include the mean corpuscular hemoglobin (MCH), which measures the

average amount of hemoglobin found within each red blood cell in the

sample; mean corpuscular hemoglobin concentration (MCHC), which is the

concentration of hemoglobin within a red blood cell; and, the red cell

distribution width (RDW), which is a measurement of the various sizes of red

blood cells found within the sample.42

The hemoglobin is the portion of the red blood cell that attaches to oxygen

molecules in the bloodstream. The normal amount of hemoglobin varies

between men and women but is typically 14 to 18 g/dL for men and 12 to 15

g/dL for women. Decreased levels of hemoglobin can indicate possible

anemia, kidney disease, toxicity, or even cancer. The hematocrit is an

indication of the volume of red blood cells within the blood sample. It is

expressed in percentage form and the normal result is between 45 and 55

percent, although this may be slightly lower in women. A patient may have a

low hematocrit if he or she has had excess fluid intake or if blood loss has

occurred.


The CBC may also include the reticulocyte count, which is a measurement of

immature red blood cells found within the blood sample. The reticulocyte

count is most often elevated in cases of anemia. If a patient has anemia and

a high reticulocyte count, there may be another condition causing blood loss

or a situation that would require the body to produce too many immature

blood cells, such as in cases of hemolysis. The reticulocyte count may be

decreased if there is a vitamin deficiency present, such as with vitamin B12

deficiency.41

Hypothyroidism, which is associated with a number of gastrointestinal

motility problems, including constipation and malabsorption, can also lead to

a drop in red blood cells and some kinds of anemia. Low thyroid levels can

impact iron absorption, which could result in iron deficiency anemia.43 This

could potentially create a negative cycle in which the intestines receive even

less oxygenated blood than what they need when red blood cells and

hemoglobin are lacking; which could then further perpetuate motility

problems if the intestinal tract is not adequately oxygenated through

circulation.

The final type of blood cells measured in the CBC is for platelet counts.

Platelets are fragments of cells that support blood clotting. This may also be

referred to as the thrombocyte count and it detects how well the patient is

able to clot blood or is prone to blood loss. A normal platelet count is

150,000 to 450,000 mm3 among men and women.

Patients with some gastrointestinal disorders may have changes in platelet

counts that range from minor variations in total counts to significantly low or

high numbers. According to Houghton, et al., in the journal

Neurogastroenterology & Motility, patients with irritable bowel syndrome


may have platelet changes. As discussed with irritable bowel syndrome,

many patients suffer from GI motility changes that are regulated with

administration of antidepressants that affect serotonin levels. This is because

a significant amount of the body’s serotonin resides in the GI tract, where it

regulates intestinal movements. Serotonin in the GI tract may also be

referred to as 5-hydroxytriptamine (5-HT). The researchers in the study

have shown that patients with irritable bowel syndrome typically have

platelet-depleted 5-HT concentrations in the bloodstream.44 The study

demonstrated that patients with constipation and diarrhea associated with

irritable bowel syndrome had elevated levels of platelet-depleted 5-HT in

serum samples, leading the researchers to believe there was a connection

between these platelet-depleted cells and sigmoid colon motility.

A CBC is a very common blood test that can be easily performed within most

healthcare facilities that have laboratory capabilities. This test should be

ordered for any patient who presents with symptoms of a gastrointestinal

motility problem that is potentially caused by infection, hemorrhage, or

anemia. In some cases, the CBC may be ordered as part of diagnostic

testing, but the results come back within normal limits. For example, a

patient who presents with symptoms associated with irritable bowel

syndrome may have completely normal laboratory studies, yet may continue

to struggle with uncomfortable symptoms of increased or decreased GI

motility.

When a patient receives treatment for a GI motility disorder, the CBC could

also be performed to check the effectiveness of such treatment. If the GI

motility problem is caused by another medical condition and the patient

receives treatment, the CBC may be repeated after the treatment process to

ensure that treatments are effective. The patient may also demonstrate a


lack of GI motility symptoms when the underlying condition is treated.

Combined with the CBC, these signs are an indication that treatment

measures are effective for the patient.

Treatment And Clinical Criteria

Treatment of gastrointestinal motility disorders is an individual course of

action that considers the symptoms, medical history, and current health

management strategies of each patient. One patient may need medication to

control pain associated, for example, with achalasia, while another patient

who takes the same drug for pain may experience drug side effects, such as

severe constipation. The healthcare provider must consider the unique needs

of the patient after diagnosing a GI motility disorder, utilizing standard

interventions such as pharmacologic therapy, changes in lifestyle factors,

and surgical approaches. Other more novel interventions may be considered

as well, including stem cell therapy.

Neural Stem Cells

Stem cells are remarkable cellular bodies that are able to divide and develop

into different types of cells. As a stem cell divides, it forms two new cells;

each new cell can perform functions or it can remain a stem cell to divide

again later. Stem cells are also important in that they may be able to repair

certain defects in the body by replacing other cells because they can

repeatedly divide and replenish them. On its own, a standard stem cell is

non-specific; however, once it divides, it can take on the functions of cells in

specialized areas of the body, including in the brain, the muscles, and the

gastrointestinal tract.

Neural stem cells are also self-renewing, in that they are able to divide and

then take on the characteristics and functions of cells of the brain and


nervous system. Neural stem cells form specific types of cells after they

divide, including neurons and astrocytes, which are primary parts of the

nervous system. Because nerves that serve various portions of the intestinal

tract control GI motility, neural stem cells have been considered as part of

treatment to replace damaged neurons that lead to GI motility disorders.

Neural cells are normally found in the submucosal or the muscular layers of

the intestinal tract. These cells stimulate peristalsis after release of

substances such as acetylcholine when nerve impulses reach the

neuromuscular junction in the intestine. Normally, the release of

neurotransmitters stimulates the muscles of the GI tract to contract and

produce peristalsis in order to move digestible materials through the system.

When a GI motility disorder develops, however, there may be damage to the

nerves that stimulate peristalsis and the person may develop dysmotility.

In 2006, researchers were able to modify some of the actions of stem cells

to essentially force certain stem cells into reproducing into specific types of

tissue. These cells are known as induced pluripotent stem cells (iPSC). In

essence, iPSC bodies can be directed to create new cells that specifically

focus on one area where new cells are needed most, such as by creating

new neurons to work in the GI tract when these cells have been damaged.

Treatment with neural stem cells involves transplanting the cells into the

gastrointestinal tract where they can then divide and reproduce some of the

neurons that affect muscular activity in the intestine. The researcher first

reprograms fibroblasts to become iPSCs that will divide to form neural stem

cells. The cells that result from this process are known as induced neural

cells. Alternatively, stem cells for transplant could be taken from a healthy

portion of the gut or from the brain.119 These cells are known as precursors,


in that they eventually form the cells needed for regeneration into healthy

neurons.

Transplantation of the cells may be performed through endoscopy, in which

the intestine is visualized and the cells may be injected directly into the

tissue. A study by Cheng, et al., in the journal Neurogastroenterology &

Motility, worked with transplanting neural stem cells into the gut as a

method of controlling Hirschsprung disease. The stem cells were injected

using endoscopic procedures to directly reach the affected areas. The study

showed that endoscopic transplantation of neural cells can be beneficial to

deliver a large number of cells to a greater area, such as with cases of

Hirschsprung disease, in which the bowel may be enlarged.120

When considering specific diseases of the gastrointestinal system, neural

stem cell transplantation shows promise as a form of treatment. The

transplant of neural stem cells into GI tissue has the potential to manage

several forms of GI motility disorders that are caused by degenerative

conditions of the nervous system, including achalasia, Hirschsprung disease,

or congenital megacolon. Researchers are continuing to expand their work to

include use of stem cells in the treatment of various other forms of GI

motility disorders, particularly those that are unresponsive to other forms of

therapy or that otherwise have no cure. The potential for technological

advances that can create cells designated to treat certain GI disorders is an

exciting thought that deserves continued study and future discussion.


Dietary History and Assessment

For many patients with gastrointestinal

motility disorders, changes in dietary

habits alone can make a significant

difference in the severity of symptoms.

Unfortunately, many Americans have

eating habits that include increased

intake of high-fructose corn syrup,

sugar alcohols, saturated fats and trans

fats, and too few vitamins, minerals,

and other important nutrients to

maintain good health. During the health

assessment, the nurse should include

dietary history as part of the evaluation of the patient’s condition, as diet

contributes significantly to the cause of many GI dysfunction symptoms.

There are many dietary changes that patients can make that will help to

alleviate some symptoms, even if they do not actually cure the motility

disorder. For symptoms of diarrhea, fluid and dietary changes can impact

stool constitution and can resolve some symptoms of loose stools, as well as

prevent excess fluid and electrolyte loss associated with diarrhea. The

patient is at high risk of developing electrolyte imbalances in sodium and

potassium with increased fluid loss through watery stool. It is important that

the patient understands the significance of food and fluid intake when

diarrhea is present, particularly when the condition has been happening for

more than several days or is the result of another underlying medical

condition that requires more extensive treatment. The patient should be

encouraged to drink plenty of fluid, including at least one cup of fluid added

for every loose stool.


The BRAT diet, while often employed as part of dietary management of

diarrhea, is not necessarily effective in managing symptoms of diarrhea in

patients with GI motility disorders. BRAT stands for bananas, rice,

applesauce, and toast, which are all relatively bland and soft foods that are

said to calm the stomach and prevent indigestion. However, there is no

evidence that states that this diet is effective in preventing diarrhea, and its

recommended use seems to be purely anecdotal.54 The diet contains very

little protein and is low in fiber, and, while it may offer some nutrients, it

does not necessarily affect diarrhea; in fact, the BRAT diet was once

recommended as part of treatment for diarrhea among children but it is now

no longer suggested by healthcare providers as part of diarrhea

management for children.60

Mild dehydration can be managed with intake of foods that provide calories

and fluid but that are easy on the gastrointestinal tract, such as soda

crackers, broth-based soup, and fruit juice. However, because of the

potential for electrolyte imbalances that can occur with chronic diarrhea, the

patient should be advised to continue to eat foods that are good sources of

vitamins and minerals. Historically, a patient with chronic diarrhea was only

given clear liquids and was not advised to eat solid foods for fear of

worsening the condition. It is now understood that the cells of the intestinal

tract are more likely to recover from damage when they are stimulated, such

as through movement and digestion of food after eating.61

When eating, the patient should eat foods that are high in nutrients but

should avoid excess sugar, caffeine, and alcohol. Some patients feel worse

after consuming dairy products, so it is often best to avoid milk or cheese

until diarrhea has resolved. Oral rehydration solutions that contain


electrolytes may prevent fluid loss and can provide balance in the intestinal

tract. The patient may choose commercial preparations that can be taken as

a drink to restore fluid and electrolytes; an example sometimes used for

children with diarrhea is Pedialyte®. Alternatively, the patient may prepare

his or her own mixture of oral rehydration solution, which should include

salt, potassium chloride, bicarbonate of soda, and a small amount of sugar

mixed with water.

Probiotics have been shown to be an effective preventive measure against

some types of diarrhea and they may be incorporated into the patient’s diet

through food intake that contain the bacteria or through specially designed

supplements. Probiotics are microorganisms that support growth of healthy

bacteria in the GI tract. They are effective in that, after ingestion, probiotics

can destroy some toxins that contribute to illness-causing diarrhea, prevent

harmful bacteria from infecting the gastrointestinal tract, stimulate increased

mucus production in the intestinal tract, may help to decrease GI

inflammation, and diminish the effects of gas and bloating.62

The two most common types of bacteria used as part of probiotics are

Lactobacillus and Bifidobacterium. These bacteria can be purchased through

supplements that the patient may buy over-the-counter to take. However, if

the patient is suffering from diarrhea, he or she should consult with a

healthcare provider about the best type of probiotic supplement to use.

Alternatively, probiotics are also found in many foods; a patient with

diarrhea may choose to include many foods that contain probiotics into the

diet to help with GI motility and to potentially relieve some of the patient’s

symptoms. Probiotics are found in foods such as yogurt and kefir, and in

many fermented products, such as sauerkraut, sourdough bread, sour

pickles, and tempeh.


Based on information available, probiotics can potentially shorten the time

period that a patient suffers from acute diarrhea, although the individual will

need to take enough of a dose of probiotics to impact the digestive system.

A minimum suggested amount to achieve positive effects is at least 5 billion

per day.54 Although the efficacy of probiotics has been demonstrated in

controlling symptoms of diarrhea among affected patients, they do not

necessarily counteract diarrhea from all causes. A study in the Scandinavian

Journal of Gastroenterology presented a summary of conditions that can be

effectively managed by probiotic use, including diarrhea caused by antibiotic

use, acute infectious diarrhea, diarrhea that developed as a healthcare

associated infection, and persistent diarrhea.65 The evidence for probiotics

continues to demonstrate that inclusion of foods with these beneficial

microorganisms is helpful to patients with GI motility problems, particularly

those with diarrhea.

While dietary changes are not always a complete cure for certain GI motility

disorders and many patients suffer from symptoms due to damage of an

underlying disease, a proper diet can make a significant difference in the

patient’s symptoms. For the patient struggling with nausea, food may not

sound appealing and it may be difficult to eat or prevent vomiting. However,

food and fluid intake is important for patients who suffer from nausea and

vomiting because of GI dysmotility, in order to best prevent anorexia and

dehydration.

For the patient suffering from gastroparesis that causes nausea, there are

several dietary suggestions that may help. The patient should be advised to

monitor food consumption, not only in the kinds of foods eaten, but also how

food is eaten. The patient should be advised to chew foods carefully and


thoroughly and to avoid taking large bites or swallowing pieces of food

whole. Instead of eating three large meals a day, the patient would more

likely benefit from six small meals each day, which can prevent stomach

distention.

Many patients benefit from sitting at the table to eat and then sitting up or

walking around for at least one hour after the meal is finished. Lying down

after eating may slow the rate of stomach emptying and the patient may be

more likely to experience nausea after the meal. The individual should also

avoid greasy foods or those items that contain a lot of fat, as fat is slow to

leave the stomach and enter the duodenum. If the patient is still unable to

keep down solid food without vomiting, he or she may still try to take sips of

liquids and consume foods that are less likely to lead to nausea, including

broth, popsicles, or citrus juice. The patient may also be encouraged to

blend foods with extra liquid to break them down so that they are in a liquid

or semi-solid state, which could make them easier to tolerate.

Certain foods have been organized into a descriptive classification known as

FODMAP: fermentable, oligo-, di-, and monosaccharides and polyols. These

foods, when eaten in excess, could increase the risk of bacterial infection,

may not be absorbed well, and may increase the amount of water pulled into

the digestive tract. Examples of these types of foods include those with high

fructose corn syrup, dairy products, foods containing wheat or rye, beans

and legumes, honey; and those containing certain sweeteners, such as

xylitol, sorbitol, and isomalt. Studies have shown that FODMAP foods tend to

worsen symptoms of certain GI motility disorders, including irritable bowel

syndrome.20

One element of dietary management is removing FODMAP foods or

significantly limiting their intake to reduce symptoms of IBS. An article by


Halmos, et al., in the journal Gastroenterology explained that decreasing

FODMAPs in the diet has been shown to help patients with IBS. The study

examined the effects of a diet low in FODMAPs when compared to a standard

diet; the subjects with IBS who followed a low FODMAP food diet suffered

from fewer symptoms of bloating, gas, and abdominal pain when compared

to those who followed standard fare diets.21 The study suggests that limited

intake of FODMAP foods should be considered as first-line therapy for

functional GI conditions such as IBS.

Not all symptoms associated with gastrointestinal motility disorders can be

successfully managed with changes to the diet; however, managing dietary

habits and choosing healthy foods in the right amount can make a difference

for many people. Because the GI tract is responsible for digestion,

absorption, and excretion of food and nutrients, it is essential to consider the

effects of dietary intake when assessing patients who suffer from disorders

of GI motility.

Activity and Exercise

Activity and exercise have been shown to be beneficial for many patients

who suffer from gastrointestinal conditions, particularly those who are

struggling with GI dysmotility. The healthcare provider may recommend

increasing activity levels for some patients, as exercise can improve

symptoms of some types of motility problems. Even when exercise does not

directly impact GI dysmotility symptoms, the patient should be encouraged

to continue with normal activities and to avoid immobility if possible, since

exercise and activity are beneficial for organ systems beyond just the GI

tract.


Among patients who suffer from

diarrhea, increasing activity levels may

be undesirable, particularly if diarrhea

is so severe that it impacts the person’s

ability to participate in exercise or

many other activities outside of the

home. For instance, if a person is

struggling with fecal incontinence in the

form of diarrhea, he or she may have

difficulties with leaving the house for

fear of being incontinent of stool when

away from home. It may be difficult to

help a patient understand the

importance of maintaining activity levels in this type of situation.

Normally, decreased activity levels and immobility are associated with

slowed colonic motility and constipation, not necessarily diarrhea. In fact,

strenuous exercise may actually increase GI motility and could contribute

further to diarrhea when the body shunts blood away from the intestinal

tract to meet the high needs of the muscles with activity. Some people

struggle with activity-induced diarrhea when they exercise and then

experience abdominal pain and an increased urge to have a bowel

movement.

When a patient is suffering from diarrhea, rest and rehydration are typically

recommended to cope with the situation, rather than encouraging an

increase in activity levels. The healthcare provider can recommend the

appropriate amount of exercise for a patient who is already accustomed to

regular activity but who has developed diarrhea. Likewise, a patient who


suffers from fecal incontinence may be less likely to engage in regular

exercise and may have difficulties with participating in any outside activities,

so increasing activity levels is not always an option; however, the patient

who suffers from overflow incontinence as a result of fecal impaction from

constipation should avoid long periods of immobility, if possible, and strive

to increase activity levels to prevent further constipation. While it is not

necessary to take on a vigorous exercise regimen, an increase in activity

levels in a previously sedentary person can help by improving circulation,

stimulating peristalsis, and enhancing overall feelings of well being, which is

important for the patient who feels embarrassed and humiliated because of

fecal incontinence.

Similar to diarrhea or fecal incontinence, a patient with nausea and vomiting

associated with pseudo-obstruction or gastroparesis may have reduced

activity levels and may be less likely to participate in exercise or other

activities. Movement sometimes worsens symptoms of nausea and the

patient may experience dizziness, which can further increase the risk of

vomiting. Some antiemetic drugs can cause drowsiness and may make the

patient feel lethargic, such that he or she does not have enough energy to

participate in extra activities.

However, exercise can be helpful in some situations in which the underlying

cause of the nausea could be managed. In the case of gastroparesis, a

patient may benefit from mild exercise to help improve GI motility;

recommendations associated with eating and activity levels in this situation

often advise taking a walk after eating to avoid lying down and to promote

gastric emptying of stomach contents. Often, gastroparesis is associated

with diabetes, a condition that can also benefit from regular exercise to

control weight and to promote healthy blood circulation. It is therefore


important that the patient, who suffers from nausea as a result of intestinal

dysmotility, whether it is due to gastroparesis or some other medical

condition, consult with a healthcare provider for guidance about the

appropriate amount of exercise and activity.

Surgery — A Palliative Approach

Surgical treatment of gastrointestinal

motility disorders is palliative in nature

in that the procedures are performed to

keep the patient comfortable and to

manage symptoms. Among patients

who suffer from primary intestinal

motility disorders, surgery is not

necessarily an effective form of

treatment to cure the situation.57 The

exception is in cases of refractory

constipation that has the potential to

cause severe complications for the affected patient.

Surgical interventions for the management of GI dysmotility is done to

relieve symptoms of distress and to help the patient to manage the condition

despite its presence. Many GI motility disorders, particularly those caused by

degenerative or congenital conditions, have no cure. However, complications

that develop as a result of these disorders can cause painful and debilitating

symptoms and may even shorten the life of the affected patient. For

example, a patient who suffers from scleroderma may develop swallowing

difficulties and slow peristalsis between the esophagus and the stomach.

Surgery may be performed to eliminate some of the scar tissue present,


which will help the situation; however, the surgery is not able to cure the

scleroderma.

Surgical treatment of esophageal conditions, such as in cases of achalasia, is

primarily aimed at improving swallowing, peristaltic action of the esophagus,

and muscular tone of the lower esophageal sphincter. Because achalasia is

caused by nerve damage or lack of neurons that serve the esophagus,

surgical treatment will not actually treat the condition. Instead, the goal of

surgery is to relieve any obstructions that have developed in the esophagus

and to alter the muscle tone of the LES so that it can allow food and fluids to

pass into the stomach.121 Surgery does help to manage symptoms of

achalasia, though, and will help to control the patient’s pain as well as

prevent certain conditions that could develop as complications, such as

malnutrition or dehydration.

Within the large intestine, disorders of motility can cause chronic diarrhea or

constipation. When constipation is severe, or the patient suffers from a GI

motility disorder because of a degenerative condition, surgical intervention

may be required to remove part of the colon and to make the patient more

comfortable. As with other types of surgical intervention for dysmotility,

surgery may initially cause discomfort because of the procedure, but the

ultimate goal is to improve the patient’s quality of life by reducing symptoms

of disease and extending the patient’s life that may otherwise be shortened

because of his or her condition.

Surgery may be indicated if a patient suffers from a GI condition that could

cause such complications as to be life threatening, such as toxic megacolon.

The condition occurs as a complication of inflammatory bowel disease or with

colon infection. When infection develops in the gut, the large intestine swells


and expands, potentially leading to severe dehydration and even shock.

Treatment of the inflammation is paramount to avoid critical consequences.

An article by Autenrieth and Baumgart in Inflammatory Bowel Diseases

explained that surgical intervention in cases of toxic megacolon is sometimes

necessary to treat the underlying disorder causing the inflammation and

swelling.122 In this case, surgery takes a palliative approach in that the

patient will be more comfortable following the procedure, and it prevents

widespread inflammation and possible septic shock.

Colectomy is one of the more common types of surgical procedures

performed on the large intestine in order to treat some disorders of motility.

Also called a colon resection, a colectomy involves removal of some or all of

the large intestine when it is diseased and then rerouting the remaining

portions so that stool exits outside of the body through a stoma. The surgery

may be performed laparoscopically or it may be an open procedure. After

removal of the diseased part of the bowel, the healthy ends of the bowel are

then reattached. Depending on the amount of tissue removed, the colostomy

may be temporary, requiring another surgery to restore normal bowel

function, or it may be a permanent fixture.

Colectomy may be performed as a surgical procedure in a number of colonic

conditions that affect gastrointestinal motility. A study in the Journal of

Laparoendoscopic Surgeons demonstrated that a combination of subtotal

colectomy, which is a procedure that removes most of the colon but leaves

the rectum behind, combined with a modified Duhamel procedure, which

involves anastomosis of lower and upper segments of the GI tract, could be

used for the management of mixed constipation. Mixed constipation in this

case is described as a combination of slow-transit constipation and outlet

obstructive constipation. The study showed that when implemented into


adults who suffered from mixed constipation, combination subtotal

colectomy with modified Duhamel, patients had favorable long-term effects,

including improved constipation and bowel function, as well as improved

quality of life.123

Because gastrointestinal motility disorders can arise from various pathologic

processes and their symptoms can vary widely, there is not one surgical

procedure designed to manage all types. In some cases of GI motility

disorders, such as irritable bowel syndrome, surgery is not necessarily

indicated at all. However, for those who have suffered from symptoms of GI

dysmotility as the result of an underlying disease process, surgery could be

an option that would reduce or even eliminate some uncomfortable

symptoms. The goal of palliative care is to provide comfort for the patient

and to improve quality of life. When surgery for GI dysmotility takes a

palliative approach, the patient will not necessarily receive a cure for his or

her condition but may benefit from control of symptoms, prevention of

complications, and improved feelings of wellbeing.

Pharmacologic Therapy

Prescription and over-the-counter

medication use has increased rapidly in

recent decades, with almost one-half of

Americans using some form of

prescription drug on a daily basis.

Medications are well known for their

positive benefits in controlling

symptoms associated with illness and

disease, and yet medications are also


responsible for a number of unpleasant side effects that may prohibit some

patients from taking them. Furthermore, some medications place certain

patients at risk of complications that make their use too hazardous.

There are several classes of medications that cause gastrointestinal motility

problems. While side effects of nausea or upset stomach are extremely

common to many types of drugs and are listed on pharmaceutical

packaging, there are a few medications that can cause significant motility

problems in the GI tract. When these issues arise, patients often need to

examine whether the drug is worth the GI motility problems it causes or if

their conditions can be controlled through other means.

Opioids

One of the most well-known medication culprits that cause gastrointestinal

motility problems is the opioid analgesic. Taken for pain and used widely in

all manner of settings, including outpatient treatment centers, in-hospital

intravenous administration, or home prescription use, opioids are often

responsible for keeping patients comfortable and managing moderate-to-

severe pain from procedures and from the complications of illness. Patients

suffer from the effects of pain, whether it is chronic pain from a wound or

due to illness, or acute pain as that from an injury.

Hospitals and healthcare centers have also increased their focus on

improving pain relief for patients and ensuring that patients within their

facilities gain control over their pain, and do not suffer when they are

receiving treatment. As a result, use and administration of analgesics is

more prominent than ever in the United States as healthcare providers

continue to seek methods of best controlling patient pain and maintaining

appropriate comfort levels.


Analgesics are medications taken to control pain; they typically are

differentiated between opioid and non-opioid analgesics, with the type and

amount of the drug administered varying depending on the kind of pain the

patient is experiencing. Mild-to-moderate pain is often controlled through

non-opioid analgesics, while moderate-to-severe pain is more often

managed with opioid analgesics. Drugs described as opioids are those that

come from opium of the poppy plant; and, they may be natural or synthetic

versions of the drug. After administration, opioid medications attach to

certain receptors in the brain, producing a chemical response that induces

feelings of pleasure by stimulating the brain to release dopamine. This

attachment to receptors also produces feelings of calm and it blocks the

sensation of pain.

Because of the increase in use of opioids within healthcare facilities and

within the community, patients are also experiencing an increase in their

side effects. Opioid medications have been known to cause neurological

changes such as confusion or mental “fog,” may slow the breathing rate,

sometimes to a dangerously low level; and, they produce gastrointestinal

side effects, typically including nausea, vomiting, and constipation. Opioids

can attach to various receptors, including the mu, kappa, and delta

receptors, which affect different sites throughout the body, so they are able

to control pain but also cause side effects in numerous locations in the body.

There are many opioid receptors in the gastrointestinal tract. When opioids

are administered, they can affect these receptors and cause changes,

including a decrease in mucus secretions, an increase in fluid reabsorption,

and delayed gastric emptying. As a result, the patient who takes these drugs

is more likely to suffer from GI complaints such as nausea and constipation.

Approximately 25 percent of patients who are treated with opioids


experience nausea as a side effect.35 This effect can be worsened if the

patient with nausea also experiences central nervous system changes that

cause dizziness or that affect balance.

Even more common as a side effect, constipation may impact up to 95

percent of patients who use opioid analgesics.35 The development of hard,

dry stools and slowed transit times in the large intestine results from

decreased intestinal mucus production and increased reabsorption of fluid

from the colon, thereby slowing GI motility and making stools difficult to

pass. In some cases, constipation may also be worsened if the patient has

gone for periods without eating, such as with anorexia that has developed

because of nausea or because of requirements for certain medical

procedures. In such cases, the patient does not have the food intake needed

to stimulate the GI tract to promote motility.

Fortunately, the awareness and knowledge of the gastrointestinal side

effects of opioid analgesics is so well known that healthcare providers can

take measures to prevent these complications before they begin. For

patients at risk of nausea because of slowed gastric motility, the provider

may order antiemetic drugs to be administered prophylactically. Other

measures to prevent or control nausea include distraction and relaxation

techniques, as well as administration of other types of drugs to control

dizziness or vertigo that may accompany the nausea, such as antihistamines

and anticholinergic preparations.

For prevention and control of constipation, the provider may need to ensure

that the patient maintains adequate fluid intake while taking opioid

analgesics and that dietary fiber intake is adequate to prevent fluid

reabsorption in the GI tract. For many patients, stool softeners are ordered


concomitantly with the opioid analgesics to help maintain normal bowel

habits. Bulk forming and stimulant laxatives may also be needed to improve

bowel function and to reduce constipation. Many patients reduce intake or

even eliminate taking opioids because of the GI side effects; however, with

the availability of these measures to treat nausea and constipation, the

patient may not need to cut back on opioid medications to avoid their

adverse effects.

Antidepressants

One of the most commonly prescribed medications in the United States,

antidepressants are recommended for treatment of depression and some

other forms of mental illness, as well as certain other chronic conditions that

can cause pain or anxiety, including fibromyalgia and chronic fatigue

syndrome. Antidepressants, while helpful to many, can also cause symptoms

of gastrointestinal distress and can affect GI motility.

Antidepressants regulate levels of serotonin, which are found in the brain

and in the GI tract. Serotonin is a neurotransmitter that affects human

behavior and emotion; consequently, a person may take antidepressants to

control depression or regulate anxiety. Since serotonin receptors are present

in the GI tract and associated with pain from rectal distention, i.e., as occurs

with irritable bowel syndrome (IBS), antidepressants are used as part of

treatment for IBS, as well as depression.36 In fact, antidepressant

prescription is part of routine management of irritable bowel syndrome. This

may be because of the effects of these medications on serotonin in the GI

tract; however, it could also be due to the psychological symptoms

associated with IBS. Persons who suffer from chronic constipation or

diarrhea associated with IBS may experience a worsening of symptoms

during times of stress or emotional suffering.


Antidepressants can cause a number of gastrointestinal side effects. Patients

with IBS who take antidepressants, as part of treatment for IBS, should also

be aware of the potential side effects associated with these drugs. Likewise,

other individuals who take antidepressants but who have not necessarily

been diagnosed with a gastrointestinal condition may also suffer the

abnormal GI effects that these drugs can cause.

The most common offenders in these cases are tricyclic antidepressants and

selective serotonin reuptake inhibitors. Tricyclics have the potential to slow

intestinal transit because they have anticholinergic activity, in which they

block the action of acetylcholine in the parasympathetic nervous system. As

a result, the affected person is more likely to suffer constipation and slowed

colonic transit due to decreased GI motility.70 These drugs also may diminish

secretions in the stomach and intestines and salivation in the mouth,

resulting in xerostomia, abdominal pain, bloating, and nausea.

Alternatively, selective serotonin reuptake inhibitors (SSRIs) can have the

opposite effect on the gastrointestinal system and may cause increased

intestinal transit.70

As stated previously, serotonin is found in the GI tract and exerts some

control over sensorimotor function. When food is digested and chyme passes

through the intestinal tract, certain cells known as enterochromaffin cells

release serotonin, which triggers peristalsis through nerve pathways. When

a person takes a SSRI antidepressant, the availability of serotonin in the GI

tract is prolonged, thereby potentially increasing the rate of peristalsis and

intestinal motility.71 Selective serotonin reuptake inhibitors are often

prescribed for patients who suffer from IBS with predominant constipation,

as the increased GI motility associated with their use can reduce these

symptoms. However, SSRI use may also cause the opposite effects and may


set off too rapid of peristaltic action, resulting in diarrhea. The affected

individual may also suffer from abdominal pain and excess flatulence.

A study by Choung, et al., in the journal Neurogastroenterology & Motility,

used questionnaires to examine patient responses to discern the effects of

antidepressant use on the gastrointestinal system. The most common

symptom reported by participants in the study was abdominal bloating and

distention. The researchers in the study believed that this was possibly due

to slowed GI motility, delayed gastric emptying, or that antidepressants

promote bacterial overgrowth within the small bowel, leading to excess gas

production and bloating.70 When a patient needs an antidepressant for

support for mental health issues, or if these drugs are prescribed as adjunct

medications for other conditions, affected patients should be counseled

about the GI effects they can cause. Some effects may be transient and may

cause minor symptoms; while other effects can be significant enough that

affected patients may want to change prescriptions entirely.

Anticholinergics

Anticholinergic drugs are prescribed to work against the effects of the

neurotransmitter acetylcholine within either the central or the peripheral

nervous systems. There are a number of anticholinergic drugs available and

their uses vary, depending on the body system involved. Anticholinergics are

prescribed for respiratory disorders, as they act as bronchodilators in cases

of asthma or chronic bronchitis; and, they may be prescribed for dizziness or

insomnia, and they may also be used for some genitourinary conditions,

such as when patients suffer from bladder dysfunction. Additionally, some

anticholinergics are prescribed to control GI conditions and may be

prescribed in cases of ulcerative colitis, gastritis, diarrhea, nausea, and

vomiting.


There are two main types of cholinergic receptors in the body: nicotinic and

muscarinic receptors. Nicotinic receptors are found in the neuromuscular

junction between the nerve and the muscle, whereas muscarinic receptors

are found in cell membranes of certain neurons. As a neurotransmitter,

acetylcholine binds to both types of receptors. There are different sub-types

of muscarinic receptors, which are found in specific locations throughout the

body. For example, muscarinic-1 receptors are found in the brain, the

salivary glands, and the stomach, while muscarinic-3 receptors are located

in certain smooth muscles. Stimulation of muscarinic-3 receptors in the

smooth muscle can lead to increased production of gastric acid.40 Within the

gastrointestinal system, stimulation of muscarinic receptors has been shown

to increase GI motility and to potentially cause nausea and vomiting.

Alternatively, antagonism of muscarinic receptors has been shown to

decrease both GI motility and gastric acid production.

When an anticholinergic medication is administered and the drug blocks the

effects of acetylcholine, there is less of the neurotransmitter to bind to the

nicotinic and muscarinic receptors in the body. A study in the journal BMC

Geriatrics investigated defecation frequency among older adults with chronic

obstructive pulmonary disease (COPD) who used muscle relaxant

medications to control some of their respiratory symptoms. The study

showed that those adults who used the drugs to control respiratory

symptoms also had lower levels of defecation frequency and were more

likely to suffer from constipation and slowed colonic transit.86 Because

anticholinergic drugs are prescribed for so many different conditions, there is

potential for patients to develop a number of gastrointestinal motility

disorders with regular use of these drugs. As with other medications,

patients should be counseled to understand the GI side effects associated

with anticholinergic drugs when they begin taking them.


Loperamide

There may be times when an individual takes medications specifically for

symptomatic management of gastrointestinal motility problems but then

ends up suffering adverse effects, sometimes because the medication seems

to have too much of an effect on intestinal transit. An example of this is the

use of antidiarrheal medications such as loperamide, which are often

prescribed for the management of acute or chronic diarrhea, as well as

traveler’s diarrhea among patients who are suffering from loose stools.

Antidiarrheal medications such as loperamide are typically indicated for use

on a controlled or short-term basis, rather than being taken daily on a long-

term basis. In general, many antidiarrheal drugs are not necessarily meant

to be taken for an indefinite period of time; if a patient needs to take these

types of drugs because of chronic diarrhea that is not responding to other

medication, then the situation should be discussed with a healthcare

provider first.

Loperamide works by decreasing gut motility to slow down the rate of

intestinal transit so that the affected person is less likely to suffer from

diarrhea. When colonic transit slows, more fluid is absorbed and the stools

are less watery and become more formed. For some people, though, the

effects of the drug can go in the opposite direction and can slow colonic

transit so much that constipation develops. If excess fluid is reabsorbed in

the colon to avoid watery stools, the body could ultimately absorb too much

fluid from the intestinal tract, creating hard and dry stools associated with

constipation.

The potential for constipation with loperamide use is enough that

researchers sometimes induce constipation using the drug in lab animals in


order to study treatment options for constipation symptoms.87 For many,

however, use of antidiarrheals such as loperamide is effective in treating

diarrhea and controlling its unpleasant symptoms without causing

constipation. Patients who want to use this type of drug for treatment of

diarrhea should take it carefully and according to directions. Side effects can

often occur when a person takes the drug incorrectly.

Anti-Parkinson Drugs

Although Parkinson’s disease (PD) was originally classified as a nervous

system disorder, it is now considered a multi-organ syndrome, affecting

various systems throughout the body.32 Gastrointestinal symptoms have

been shown to worsen as Parkinson’s disease progresses; alternatively, a

patient with PD who takes medication to control symptoms of the illness may

be more likely to end up suffering from gastrointestinal effects as well.

Certain drugs used for management of disorders such as Parkinson’s disease

have been shown to affect gastrointestinal motility, typically within the

stomach, causing delayed gastric emptying. Parkinson’s disease is more

common among older adults; this population of patients often suffers from

symptoms of nausea, vomiting, constipation, and feelings of gastric fullness

after taking medication. Levodopa is the most common agent prescribed for

management of Parkinson’s disease. Levodopa is a precursor of dopamine.

This drug may be more likely to slow GI motility because of its effects on

dopamine receptors in the intestinal tract. Levodopa has also been shown to

act on the stomach wall, decreasing movement of the pyloric sphincter and

slowing the rate of gastric emptying.34

A person with Parkinson’s disease often develops neurological deficits

including tremor, slow motor movements, and rigidity; and, these symptoms


are caused by lack of dopamine in the brain. After administration of

levodopa, the brain converts it into dopamine, where it is stored until the

body needs it to regulate its movement. Levodopa has been used

successfully for management of PD for years. Its formulation has changed

somewhat since the time of its initial release. Levodopa is now available in

extended release forms that may have less of an effect on the GI system if

the drug is released over a longer period of time.

The introduction of carbidopa, another medication used to enhance the

effects of levodopa, results in a much lower dose requirement of levodopa

when the two drugs are taken together.33 Carbidopa on its own has little to

no therapeutic benefit, so it must be taken with levodopa for the patient to

gain positive effects. Sinemet® is an example of a drug that is a

combination of levodopa and carbidopa.

Dopamine cannot be administered to patients with PD because dopamine

cannot cross the blood-brain barrier. Levodopa is the next best option

because it is converted to dopamine in the body. However, because of its

gastrointestinal side effects, there is a catch to taking this drug on its own;

the patient often must either suffer from neuromuscular side effects

associated with PD or must endure GI problems related to levodopa.

Fortunately, the administration of carbidopa along with levodopa inhibits

certain enzymes that affect levodopa’s conversion to dopamine, thereby

reducing the amount of levodopa needed. The patient can still achieve the

desired effects of the drug but with fewer instances of GI disturbances.

Medications used for the management of GI dysmotility may be administered

to treat the underlying cause of the motility problems. Alternatively, they

may also be given to counteract many of the negative symptoms the patient


with a motility disorder is experiencing. In many cases, drugs for symptom

control and for treatment of the medical condition may be administered

concomitantly.

Pharmacologic intervention for management of the symptoms of GI motility

problems may make the patient more comfortable in terms of coping with

his or her condition, but administering medication to counteract symptoms

will not treat the underlying disease. Drugs are often given to work against

some of the more common symptoms of dysmotility, including diarrhea,

constipation, nausea and vomiting, and stool incontinence. Pharmacologic

management of diarrhea is often administered in the form of antidiarrheal

medications. These drugs slow peristalsis in the intestinal tract, thereby

prolonging the time that food and waste is digested and absorbed. Some

medications also allow more time for fluid to be absorbed in the intestinal

tract so that stools are not liquid and watery.

Antidiarrheal medications are best indicated for conditions that cause

increased GI motility and diarrhea, including irritable bowel syndrome with

predominant diarrhea, for occasional use among patients who struggle with

fecal incontinence, and with other situations that cause transient bouts of

diarrhea. Antidiarrheals are available in prescription strength but they can be

purchased over the counter as well. The patient who wants to consider using

this type of drug should consult with a healthcare provider first to determine

the most appropriate medication for use and to find out if the drugs would

otherwise mask an illness that requires further treatment. Some common

types of antidiarrheal medications that are available without a prescription

include loperamide (Imodium®) and bismuth subsalicylate (Kaopectate®).

In addition to controlling diarrhea, these drugs can also help to manage

other unpleasant symptoms the patient may be experiencing as a result of


the illness. For example, the makers of Pepto Bismol, which is a brand name

for bismuth subsalicylate, state that their product is also able to treat

indigestion, nausea, and heartburn.53 Other drugs used for management of

diarrhea and that may be available by prescription include diphenoxylate

with atropine (Lomotil®), which can be also be accessed without a

prescription but the dosage available as an over-the-counter product is lower

than prescription strength. Note that this drug is considered to be a

Schedule V controlled substance. Difenoxin with atropine (Motofen®) is

another prescription antidiarrheal that has been discontinued in the United

States and there is no generic equivalent.

Patients who take antidiarrheal medications should be aware that these

drugs can sometimes work too well, and they may end up struggling with

constipation and slowed GI motility instead of diarrhea. A patient who has

had chronic diarrhea may or may not be an appropriate candidate for

antidiarrheal therapy, at least not on a long-term basis. Antidiarrheals

change the motility of the gastrointestinal tract but they are often not meant

to be permanent additives to a therapeutic regimen. A patient who takes

antidiarrheal medications on a long-term basis without the advice of a

healthcare professional may only conceal underlying symptoms of illness

without treating the actual disease. Long-term use may also lead to chronic

constipation and the process should only be undertaken with the help of a

healthcare provider.

When diarrhea is suspected of having an infectious cause, antibiotics may be

administered to not only manage the symptoms of the diarrhea, but also to

treat the underlying bacterial infection that is causing the GI motility

problems. Antibiotics are not recommended in all cases, and they should not

be used if the patient’s cause of diarrhea is because of viral infection. It


should also be noted that antibiotic use for treatment of diarrhea is less

common than using other non-pharmacological forms of treatment, such as

with fluid and electrolyte rehydration. However, there are some cases in

which a patient who suffers from prolonged diarrhea because of a specific

type of infection would benefit from the administration of antibiotics,

including infection with Clostridium difficile, prolonged infection with

Escherichia coli bacteria, and Salmonella infection in very young children.54

Antimicrobials are given to break down the infectious organism and prevent

its further spread within the gastrointestinal tract. The type and brand of

medication to use depends on the organism and the extent of the patient’s

symptoms. Isolation of the specific kind of organism causing the infection

may be necessary through serum or stool samples. Antibiotics manage

bacterial infections; and, they may be broad spectrum, in which they harm

many different strains of bacteria, or narrow spectrum, in which they target

specific types of bacteria. The healthcare provider may prescribe a broad-

spectrum antibiotic as coverage against the bacterial infection but may

change to a specific drug when the exact organism has been isolated.

Examples of antibiotics that may be prescribed for the management of

infectious diarrhea include cefotaxime (Claforan®), vancomycin, and

erythromycin.54

Parasitic infection may also lead to diarrhea, which should be treated with

antiparasitic medications to control spread and to prevent worsening of

symptoms. Antiparasitic drugs may target certain species or they may be

broad-spectrum types that provide coverage against any number of parasitic

organisms. An example of this type of drug is furazolidone (Furoxone®). It

is important to remember that whenever a patient is suffering from

infectious diarrhea, antimicrobial medications can help to manage symptoms


and to control the spread of the infection in the body, but the patient must

still take precautions to prevent spreading the infection to others.

Unfortunately, the nature of diarrhea excretion increases the risk of

exposure to infectious microorganisms to caregivers and healthcare

personnel, so the patient should be taught safety measures to practice good

hygiene and prevent further spread of microorganisms.

There are several pharmacological treatment options available when the

patient is suffering from prolonged constipation as a symptom of dysmotility.

The slowed colonic transit may be best managed through certain types of

drugs that are designed to speed up passage of stool through the intestinal

tract; as with antidiarrheal medications, these drugs are often available

without a prescription. Laxatives are commonly used for the intermittent

management of constipation. Many laxatives can be purchased without a

prescription, making them easy and inexpensive to use.

Bulk-forming laxatives prevent and

treat constipation, and are typically

made up of products such as

psyllium or methylcellulose; and,

include Metamucil® and Citrucel®.

Magnesium laxatives treat

constipation by causing the colon to

retain more fluid, thereby preventing

the hardening of stool. An example

of this type of laxative is Phillips Milk

of Magnesia®. Stimulant laxatives

(Senokot®, Ex-Lax®, Dulcolax®)

manage constipation by stimulating the nerves that feed the large intestine,

promoting colonic motility.


Stool softeners are usually taken as oral medications or as liquid

preparations to help some patients who are unable to strain while

defecating. They are optimally for those who have pain with defecation

because of obstruction or a medical condition, such as anal fissures.

Examples include docusate (Colace®, Correctol®).25 When using

medications to control constipation, the patient should be informed about

the potential side effects that some of these drugs can cause. Most laxatives

and stool softeners are able to adequately treat constipation, which can be

further prevented with changes in lifestyle habits. However, if the patient

takes too much of the medication, takes it unnecessarily out of fear of

developing constipation, or otherwise uses the drug inappropriately, he or

she could develop diarrhea and could be at risk of complications associated

with that symptom. As with drugs to control any symptoms of GI motility

disorders, the patient must always be educated about the correct use of the

drug in order to best control his or her condition but also to stay safe while

using medication.

Nausea and vomiting can develop as significant symptoms from GI motility

disorders. These two common symptoms are most frequently seen with GI

dysmotility conditions such as gastroparesis, intestinal pseudo-obstruction,

and dumping syndrome. As a symptom, nausea may be treated with certain

medications to control the unpleasant feeling and to prevent vomiting. Anti-

nausea medications are designed to control nausea and motion sickness

without necessarily treating the underlying disorder. If the patient has

developed nausea as a result of a GI condition, antiemetic drugs will only be

a temporary solution until the underlying cause is also controlled.

There are various drugs available for treatment of nausea. These drugs may

be accessible to the patient with or without a prescription. Some non-

prescription medications that are used to symptomatically control diarrhea


may also be used to manage nausea, such as bismuth subsalicylate. Over-

the-counter antihistamines can also control nausea by preventing the inner

ear from sensing motion and sending the message about the sense of

nausea to the brain. Prescription antiemetic medications can be used for

more severe cases of nausea and they may be administered in other

methods beyond the oral route, which can be particularly effective if the

patient has been vomiting.

Prescription antiemetics may work in a manner similar to non-prescription

drugs in that they can block messages to the brain that stimulate the sense

of nausea. An example of this type of drug is promethazine (Phenergan™).

Additionally, some prescription antiemetics work by increasing gut motility to

speed up the rate that food moves through the intestine. Metoclopramide

(Reglan®) is an example of this type of drug. In addition to oral

preparations, antiemetics may be administered as rectal suppositories,

transdermal patches, intramuscular injections, or as intravenous injections.

Symptomatic management of fecal incontinence involves control of the rate

at which the bowel moves stool through the intestinal tract. If a person

suffers from diarrhea associated with fecal incontinence, he or she may

benefit from antidiarrheal medication to reduce fluid loss and to retain stool

bulk to avoid accidental loss of stool from the rectum. When overflow fecal

incontinence occurs, the patient may need to try medications to control

constipation without further inducing diarrhea. Medications such as

loperamide will reduce stool frequency among patients with fecal

incontinence, which can help them to achieve greater control. As with other

symptomatic treatments, though, unless the underlying condition is

managed, these medications may only temporarily control the situation.


Certain drugs may be administered to manage not only the symptoms

associated with a gastrointestinal motility disorder, but also to control the

underlying cause of the condition. Cholinergic agonists are drugs that act in

a manner similar to the neurotransmitter acetylcholine. The cholinergic

system is also referred to as the parasympathetic nervous system; when this

system is stimulated, the body responds through vasodilation, increased

secretion of sweat and saliva, and increased mucus secretion. Studies have

shown that patients who suffer from intestinal pseudo-obstruction may have

excessive suppression of the parasympathetic system.57 Administration of

cholinergic agonist medications may then change this response and help to

alleviate some symptoms. Some cholinergic agonists that may be used

specifically for the management of intestinal motility disorders include

neostigmine (Prostigmin®) and bethanechol (Uricholine®).

Delayed gastric motility, such as that seen with gastroparesis, can lead to

nausea that may well respond with antiemetic medications. However, these

drugs only manage some of the symptoms of the condition but do not treat

the underlying GI motility problems. Prokinetic medications can be

administered to increase the speed of GI motility to move food through the

intestinal tract at a faster rate. These drugs have been mentioned as

treating nausea associated with gastroparesis, in that they facilitate faster

gastric emptying, thereby reducing symptoms of nausea as well as other

complications, such as abdominal distention, pain, and bloating.

Drugs known as dopamine antagonists are also useful when administered to

some patients with GI motility disorders, namely those who suffer from

delayed motility problems. Normally, dopamine inhibits certain activities

within the gastrointestinal tract, such as the ability of the LES to close

properly as well as the overall rate of motility.65 Dopamine antagonist


medications block dopamine receptors in the GI tract, although they may

also be used for the management of some other conditions to prevent

dopamine’s effects in other parts of the body. The main dopamine antagonist

medications used for management of delayed GI motility are domperidone

and metoclopramide, which has been mentioned as an antiemetic medication

and is also called Reglan. Macrolides, which are drugs that are traditionally

used as antibiotics, may also be administered for GI motility disorders, as

they have been shown to increase the rate of transit in the GI tract. The

most commonly used drug in this class is erythromycin, which may be

administered intravenously or orally, depending on the patient’s condition.

Erythromycin has been shown to accelerate the rate of gastric emptying in

patients who suffer from gastroparesis in which they otherwise experience

delayed gastric motility.64

Future Trends in Treatment

In earlier sections, Rome III Criteria

to diagnose and treat varied

functional gut disorders was

discussed. The growing field of

neurogastroenterology involves a

unique body of research, and

medical specialists have come

together to form working

committees to develop improved

algorithms aimed at supporting

clinicians to identify GI dysmotility symptoms, and to diagnose and to treat

GI motility disorders. Presently, Rome IV guidelines are being developed

related to novel treatments for gut microflora and the nature and severity of

functional gut disorders. Additionally, the role of dietary nutrients is a major


area of clinical research focused on the development of new diagnostic

criteria to treat gastrointestinal conditions. Clinicians are encouraged in

newer treatment guidelines to utilize screening questionnaires and quality of

life assessment tools when developing a plan of care for patients affected by

a GI motility disorder. In addition to existing pharmacotherapy approaches

to care, a systematic multidisciplinary approach to evaluate GI symptoms,

chronicity and complexity of treatments to control symptoms, has evolved to

assist primary care clinicians by clarifying important treatment questions and

implementing up to date solutions for patients.

The burden of health care for patients affected by a GI motility disorder has

been a major impetus in the development of multidisciplinary approaches to

treatment to assist primary care providers to translate newer criteria into

ways that better meet patient care needs. While this growing body of

research is beyond the scope of this study, clinicians should know of newer

helpful screening tools and algorithms to guide patient care. More diverse,

cross-cultural influences in the treatment of a GI motility disorder that

involves a growing body of research and practice guidelines have emerged.

The field of neurogastroenterology has increasingly developed into multi-

dimensional working committees of clinical researchers organized to develop

improved therapeutic options for the wide spectrum of individuals suffering

from functional gut disorders.

Summary

Gastrointestinal motility disorders comprise a complex grouping of conditions

that affect the rate at which the intestinal system is able to process food and

excrete waste. Motility disorders may produce mild symptoms or even no

symptoms at all for some people. Alternatively, symptoms from pathologic

processes that cause GI dysmotility may lead to pain and other debilitating


symptoms that can significantly decrease quality of life. Healthcare providers

have many options for technological procedures that can successfully

diagnose specific types of GI motility disorders. Furthermore, scientific

advancements, new research developments, and proven methods of surgical

intervention can all effectively assist patients who suffer with these

conditions to be able to live normal and healthy lives despite having a GI

motility disorder.

Clinicians are increasingly able to rely upon improved diagnostic

classification systems and treatment approaches that capture a patient’s

clinical profile more completely than in previous years. The burden on

healthcare due to the chronicity and complexity of the nature of many GI

motility disorders has been an impetus of many working groups to develop a

diagnostic classification system that supports clinicians to diagnosis and

treat conditions at various stages of progress. Patients with a diagnosis of

IBS seen in primary care settings today may be treated quite differently

according to newer practice guidelines, including greater consideration of

psychological and physiological co-morbidities. The direction of future

research and new clinical guidelines considers the multi-dimensional profile

of patients, enabling clinicians to better identify and classify GI motility

disorders than in prior years.

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1. Ninety percent of absorption of nutrients occurs in the

a. stomach. b. duodenum. c. small intestine. d. large intestine.



a. True b. False


a. ileocecal valve. b. cecum. c. pyloric sphincter. d. duodenum.



a. malnutrition. b. fluid and electrolyte imbalances. c. overgrowth of intestinal bacteria. d. All of the above



a. True b. False

6. Within the gastrointestinal system, stimulation of muscarinic

receptors has been shown

a. to decrease gastric acid production. b. to decrease gastrointestinal motility. c. to increase GI motility. d. slow colonic transit.


7. Adults who use anticholinergic medication to control respiratory symptoms

a. may have lower levels of defecation frequency. b. may have increased colonic transit. c. may have improved gastrointestinal motility. d. will suffer from diarrhea as a side effect.

8. Intestinal neuropathy may occur as a result of

a. poorly controlled diabetes. b. Parkinson’s disease. c. spinal injury. d. All of the above

9. True or False: Carbidopa is a dopamine precursor.

a. True b. False

10. Loperamide is given to patients

a. to accelerate the rate of intestinal transit. b. as a treatment for diarrhea. c. as a treatment for constipation. d. None of the above

11. True or False: Carbidopa on its own has little to no therapeutic

benefit, so it must be taken with levodopa for the patient to treat diarrhea.

a. True b. False

12. Scintigraphy is a diagnostic test that uses the following item(s):

a. radiographic isotopes. b. scrambled eggs. c. technetium or iodine. d. All of the above


13. True or False: The term enteric dysmotility is used to describe motility disorders of the colon.

a. True b. False

14. Enteric dysmotility is demonstrated as abnormal contractions in

the intestinal tract that typically lead to delays in the transport of food through

a. the small intestine. b. the large intestine. c. duodenum. d. anal canal.

15. In hypertensive lower esophageal sphincter,

a. there is decreased function of the excitatory nerves feeding the

esophagus. b. the neurons in the esophagus work at a faster pace. c. a patient will have increased muscle contractions within the lower

esophageal sphincter. d. All of the above

16. Anismus describes a condition in which the patient

a. swallows large amounts of air. b. is unable to control his pelvic floor muscles normally. c. passes stool through the anus with little to no control. d. swallowing food and then regurgitating it.

17. Hypothyroidism is associated with

a. weight loss. b. an decrease in thyroid hormone production. c. constipation. d. decreased sensitivity to cold.


18. To reduce symptoms of IBS, a patient should remove or limiting FODMAP foods; FODMAP foods include

a. high fructose corn syrup. b. dairy products. c. foods containing wheat or rye. d. All of the above

19. True or False: Patients diagnosed with IBS cannot take tricyclic

antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs).

a. True b. False

20. If a patient increases dietary fiber intake to combat

constipation, the patient should

a. increase daily fiber to 60 g per day all at once for immediate results.

b. avoid insoluble fiber completely. c. increase fluid intake. d. avoid nuts and seeds.

21. Achalasia is a condition that affects how food is transitioned

between the mouth and the stomach, and it typically

a. develops as an acute condition. b. develops over time. c. causes initial symptoms of mild reflux. d. Answers b., and c., above

22. Chronic intestinal pseudo-obstruction (CIP) develops as a

disorder that

a. results in poor intestinal motility. b. causes the bowel to become hyperactive. c. always involves a tumor. d. Answers b., and c., above


23. Management of chronic intestinal pseudo-obstruction (CIP) is

a. palliative. b. curative. c. supportive (treat symptoms and prevent complications). d. None of the above

24. Examples of degenerative diseases that affect swallowing

include

a. Huntington’s disease. b. Dementia. c. Creutzfeldt-Jakob disease. d. All of the above

25. One condition that may be more likely to develop with

polymyositis is

a. chronic constipation. b. genetic predisoposition to polyp formation. c. gastroparesis. d. reflux disease.

26. Dumping syndrome is best managed with

a. changes in dietary practices. b. long-acting insulin. c. routine use of a prokinetic agent. d. Answers b., and c., above

27. Much of the peristalsis and transit of food occurs by

a. voluntary chewing action that stimulates chyme. b. involuntary control of smooth muscles in the GI tract. c. voluntary and involuntary actions. d. None of the above

28. True or False: A person with Hirschsprung’s disease has GI

hypermotility.

a. True b. False


29. _________________ most often occurs because of motion sickness or as nausea during the first trimester of pregnancy.

a. Peristalsis b. Tachygastria c. Achalasia d. Gastroparesis

30. True or False: Too much glucose in the bloodstream damages

parts of the GI system.

a. True b. False

31. Drugs that promote gastric emptying are

a. Metoclopramide (Reglan®). b. Erythromycin. c. Amitiza. d. Answers a., and b., above

32. Thyroid abnormalities may

a. later develop GI motility problems. b. have no correlation to GI motility conditions. c. cause constipation or diarrhea. d. Answers a., and c., above

33. Addison’s disease is also called

a. Cushing syndrome. b. hypocortisolism. c. hypercortisolism. d. hypothyroidism.

34. True or False: Brain-gut dysfunction describes a condition in

which a patient may experience GI symptoms in response to emotions and psychological distress.

a. True b. False


35. A patient with IBS-C type may need medications that include

a. osmotic laxatives, stool softeners, and non-bulking agents. b. stool softeners and non-bulking agents. c. osmotic laxatives, stool softeners, and bulking agents. d. None of the above

36. Biofeedback helps patients with fecal incontinence and can be

done with

a. manometric measures of the LES. b. an anorectral manometry procedure. c. both LES and duodenal manometry. d. Answers b., and c., above

37. Pelvic floor dysfunction affects the person’s ability to

a. pass stool regardless of transit time or stool consistency. b. pass stool due to transit time. c. pass stool due to stool dryness. d. Answers b., and c., above

38. Sarnelli, et al., in the World Journal of Gastrointestinal

Pathophysiology, investigated

a. IBS. b. biliary stenosis. c. specific genes contributing to development of achalasia. d. gastroparesis.

39. A known risk factor for fecal incontinence include

a. ages 1 – 2. b. male gender. c. having a physical disability. d. nerve injuries affecting the LES.

40. True or False: Genes and familial tendencies are a large part of

whether certain patients are at high risk of GI motility problems.

a. True b. False


41. Chronic megacolon may be

a. a congenital condition. b. an acquired condition because of illness. c. an acquired condition due to toxicity. d. All of the above

42. Tachygastria is a condition that causes

a. high-frequency electrical activity in the stomach with digestion. b. low frequency electrical activity in the stomach between meals. c. fainting spells. d. extreme hunger pains.

43. Rumination is a behavior disorder where a person

a. swallows food and then regurgitates it. b. thinks about food all the time. c. swallows large amounts of air and does not expel it. d. belches but does not vomit.

44. True or False: Anismus is a condition in which the patient is

unable to control pelvic floor muscles normally in order to defecate.

a. True b. False

45. A person with aerophagia

a. has GERD. b. will experience increased flatulence, not belching. c. swallows large amounts of air. d. All of the above

46. True or False: Functional fecal retention is the most common

behavioral disorder that causes motility problems in the large intestine, rectum, and anus.

a. True b. False


47. At an initial meeting with a patient, the nurse should question the patient about

a. symptoms, including history of pain. b. changes in stool output or toileting practices. c. feelings of pressure or bloating in the abdomen and lower pelvis. d. All of the above

48. A patient with diabetes who has uncontrolled blood glucose

levels could develop neuropathy and gastroparesis to the point that the patient

a. develops high-frequency electrical activity in the stomach. b. develops low-frequency electrical activity in the stomach. c. is unable to detect the need to have a bowel movement. d. has regular, extreme hunger pains.

49. Scintigraphy is an X-ray that is performed

a. before meal consumption. b. after meal consumption. c. to help diagnose a GI motility disorder. d. Answers b., and c., above

50. True or False: Enterography is seldom done because it is more

invasive than endoscopic procedures.

a. True b. False

51. A colonoscopy involves the following preparation

a. a clear liquid diet for 6 hours before the procedure. b. a clear liquid diet 1 day before the procedure. c. a clear liquid diet 3 days before the procedure. d. None of the above

52. Proctoscopy involves examination of

a. the rectum. b. the distal portion of the small bowel. c. the second portion of the small bowel to rule out inflammation. d. Answers a., and b., above


53. True or False: Another name for an esophagography is the barium swallow test.

a. True b. False

54. True or False: The single-contrast technique describes

application of contrast using a barium enema alone, while the double-contrast technique involves administering a barium enema and air into the large intestine.

a. True b. False

55. A drawback to capsule endoscopy is that it

a. only takes pictures of GI conditions in the bowel. b. is mostly designed to take pictures of only the large bowel. c. must be retrieved endoscopically. d. Answers b., and c., above

56. Electrodes used with EMG are often special types of __________

that are placed within the muscle tissue.

a. electrodes b. needles c. calibrators d. sensors

57. Dyssynergic defecation may be defined and characterized as

a. a functional defecation disorder. b. paradoxical contractions of anal sphincter muscle. c. inability to relax the anal sphincter muscle. d. All of the above

58. Three main types of cells in the blood and CBC test are

a. white blood cells, absolute neutrophils and eosinophils. b. white blood cells, red blood cells and platelets. c. red blood cells, platelets and neutrophils. d. red blood cells, basophils and absolute neutrophils.


59. Microcytic red blood cells typically develop if the patient

a. has an iron deficiency anemia. b. is suffering from a GI motility disorder. c. has hyponatremia. d. has a vitamin deficiency.

60. Hypothyroidism is a condition associated with

a. a number of GI motility problems. b. a possible drop in red blood cells. c. hyponatremia (low sodium). d. Answers a., and b., above

61. Normal platelet count in men and women is

a. 90,000 to 100,000 mm3. b. 150,000 to 450,000 mm3. c. 120,000 to 135,000 mm3. d. 60,000 to 100,000 mm3.

62. A standard stem cell is non-specific, but once it divides it can

a. take on the functions of cells in specialized areas of the body. b. no longer be of use and atrophies. c. only take on functions in the muscles. d. only take on functions in the liver and pancreas.

63. True or False: Induced pluripotent stem cells (iPSC) can create

new cells that specifically focus on one area where new cells are needed most.

a. True b. False

64. Cheng, et al., published a study that worked with transplanting

neural stem cells into the gut as a method of controlling

a. Crohn’s disease. b. Ulcerative colitis. c. Hirschsprung disease. d. Answers a., and b., above


65. True or False: During the health assessment, the nurse should include dietary history as part of the evaluation of the patient’s GI condition.

a. True b. False

66. The BRAT diet is often employed as part of a dietary

management of diarrhea

a. and it is recommended especially for children today. b. because evidence supports its efficacy. c. but its recommended use seems to be purely anecdotal. d. because it is high in protein.

67. ___________ have been shown to be an effective preventive

measure against some types of diarrhea.

a. Antidiarrheal medications b. Probiotics c. Electrolytes d. Answer a., and c., above

68. ____________ can destroy some toxins that contribute to

illness-causing diarrhea, among other benefits to GI motility.

a. Antibiotics b. Antidiarrheals c. Electrolytes d. Probiotics

69. True or False: The two most common types of bacteria used as

part of probiotics are Lactobacillus and Bifidobacterium.

a. True b. False

70. Patients with gastroparesis that causes nausea should

a. monitor food consumption. b. chew foods carefully and thoroughly. c. eat six small meals each day. d. All of the above


71. FODMAP foods, when eaten in excess, could

a. increase risk of bacterial infection. b. decrease risk of bacterial infection. c. decrease water in the digestive tract. d. None of the above

72. Activity-induced diarrhea can lead to

a. abdominal pain. b. increased urge to have a bowel movement. c. the need for rest and rehydration. d. All of the above

73. True or False: With gastroparesis, a patient is recommended to

avoid even mild exercise due to GI dysmotility.

a. True b. False

74. True or False: Surgery for dysmotility is done with the goal to

improve the patient’s quality of life by reducing symptoms of disease.

a. True b. False

75. Opioid receptors in the gastrointestinal tract affected by opioid

medication can cause

a. increase in mucus secretions. b. decrease in fluid reabsorption. c. increased gastric emptying. d. None of the above

76. Approximately _____ percent of patients who are treated with

opioids experience nausea as a side effect

a. 15 b. 25 c. 50 d. 70


77. ___________________ are ordered concomitantly with the opioid analgesics to help maintain normal bowel habits.

a. Bowel preparations b. Purgatives c. Stool softeners d. Prokinetics

78. Antidepressant medication may be used as part of treatment for

________________________ as well as depression.

a. irritable bowel syndrome b. inflammatory bowel disease c. diabetic gastroparesis d. None of the above

79. An upper endoscopy or EGD may be used

a. to insert biopsy forceps. b. to narrow down the cause of the motility issues. c. to look for inflammation in the gastrointestinal tract. d. All of the above

80. True or False: Endoscopy is a valuable process that helps to

visualize the internal segments of the GI tract to better pinpoint a diagnosis when GI motility problems are present.

a. True b. False

81. Predominant forms of IBS are known as

a. IBS-C (IBS with constipation) or IBS-D (IBS with diarrhea). b. Irritable bowel syndrome or inflammatory bowel disease. c. IBS-S (IBS with fatty stools) or IBS-U (IBS untyped). d. IBS or IBS with brain-gut dysfunction.

82. A patient with dysphagia may be recommended the following to

facilitate easier swallowing

a. thin liquids. b. thickening liquids. c. solid foods only. d. None of the above


83. Dysphagia can develop as a consequence of conditions, such as

a. stroke. b. carcinoma. c. degenerative disorders. d. All of the above

84. Choung, et al., reported the most common symptom experienced

by participants using antidepressants was

a. diarrhea. b. constipation. c. abdominal bloating/distention. d. both diarrhea and constipation.

85. True or False: Two main types of cholinergic receptors in the

body are nicotinic and muscarinic receptors.

a. True b. False

86. A study of older adults with chronic obstructive pulmonary

disease (COPD) who used muscle relaxant medications also showed

a. higher levels of defecation frequency. b. lower levels of defecation frequency. c. constipation. d. Both b., and c., above

87. Loperamide works by _____________ gut motility to slow down

the rate of intestinal transit and reduce diarrhea.

a. increasing b. both increasing and decreasing c. decreasing d. eliminating


88. Certain drugs used to manage Parkinson’s disease have been shown to affect GI motility, typically within the stomach, causing

a. tachygastria. b. delayed gastric emptying. c. globus. d. Both a., and c., above

89. ______________ cannot be administered to patients with

Parkinson’s disease (PD) because it cannot cross the blood-brain barrier.

a. Dopamine b. Levodopa c. Reglan d. Both b., and c., above

90. True or False: Antidiarrheals are available only in prescription

strength.

a. True b. False

91. Antibiotics are administered for infection

a. with Clostridium difficile. b. that is prolonged due to Escherichia coli bacteria. c. with Salmonella infection in very young children. d. All of the above

92. Examples of antibiotics that may be prescribed for the

management of infectious diarrhea include

a. cefotaxime. b. vancomycin. c. augmentin. d. Both a., and b., above


93. ______________ is a broad-spectrum antiparasitic medication.

a. Furazolidone (Furoxone®) b. Augmentin c. Erythromycin d. Ampicillin

94. True or False: Psyllium or methylcellulose is given to treat

diarrhea by causing the colon to retain more fluid, thereby preventing diarrhea.

a. True b. False

95. Nausea and vomiting are common symptoms most frequently

seen with GI dysmotility conditions such as

a. gastroparesis. b. intestinal pseudo-obstruction. c. dumping syndrome. d. All of the above

96. Antiemetics can ____________ messages to the brain that

stimulate the sense of nausea.

a. block b. send c. facilitate d. mimic

97. Antiemetics may be administered as

a. rectal suppositories. b. transdermal patches. c. intramuscular/intravenous injections. d. All of the above

98. True or False: Cholinergic agonists are drugs that act in a

manner opposite to the neurotransmitter acetylcholine.

a. True b. False


99. Prokinetic medications can be administered to __________ the speed of GI motility.

a. decrease b. moderate c. increase d. impair

100. _______________ is a growing medical field with working

committees to develop improved algorithms to diagnose and treat GI motility disorders.

a. Gastroenterology b. Neuropsychiatry c. Neurogastroenterology d. Neurology

CORRECT ANSWERS: 1. Ninety percent of absorption of nutrients occurs in the

c. small intestine. “Absorption occurs because of the microscopic projections on the surface of the small intestine; these projections, known as villi, are located on the mucosal surface and are where absorption takes place. Ninety percent of absorption occurs in the small intestine along its full length.”



b. False “Although it is referred to as ‘small,’ the small intestine is actually the longest segment of the GI tract. Its description as being small refers to its diameter, which is less than that of the nearby colon.”



a. ileocecal valve. “The ascending colon is connected to the small intestine at the ileocecal valve and is located on the right side of the body; undigested material travels through this portion of the colon first.”



a. malnutrition. b. fluid and electrolyte imbalances. c. overgrowth of intestinal bacteria. d. All of the above [correct answer]

“Because the small intestine is responsible for much of the absorption that takes place in the GI tract, when motility disorders occur, the affected patient may then suffer consequences associated with malabsorption, including malnutrition, fluid and electrolyte imbalances, and overgrowth of intestinal bacteria.”



a. True “Taken for pain and used widely in all manner of settings, including outpatient treatment centers, in-hospital intravenous administration, or home prescription use, opioids are often responsible for keeping patients comfortable and managing moderate-to-severe pain from procedures and from the complications of illness ... Because of the increase in use of opioids within healthcare facilities and within the community, patients are also experiencing an increase in their side effects. Opioid medications have been known to ... produce gastrointestinal side effects, typically including nausea, vomiting, and constipation.”


6. Within the gastrointestinal system, stimulation of muscarinic receptors has been shown

c. to increase GI motility. “Within the gastrointestinal system, stimulation of muscarinic receptors has been shown to increase GI motility and to potentially cause nausea and vomiting.”

7. Adults who use anticholinergic medication to control respiratory

symptoms

a. may have lower levels of defecation frequency. “The study showed that those adults who used the drugs to control respiratory symptoms also had lower levels of defecation frequency and were more likely to suffer from constipation and slowed colonic transit.”

8. Intestinal neuropathy may occur as a result of

a. poorly controlled diabetes. b. Parkinson’s disease. c. spinal injury. d. All of the above [correct answer]

“There are a number of systemic conditions that can cause enteric dysmotility within this section of the GI tract. Some examples include intestinal neuropathy, as with what occurs through poorly controlled diabetes, as well as Parkinson’s disease, scleroderma, and spinal injury.”

9. True or False: Carbidopa is a dopamine precursor.

b. False “The introduction of carbidopa, another medication used to enhance the effects of levodopa, results in a much lower dose requirement of levodopa when the two drugs are taken together.”


10. Loperamide is given to patients

b. as a treatment for diarrhea. “Some common types of antidiarrheal medications that are available without a prescription include loperamide ... In addition to controlling diarrhea, these drugs can also help to manage other unpleasant symptoms the patient may be experiencing as a result of the illness.”

11. True or False: Carbidopa on its own has little to no therapeutic

benefit, so it must be taken with levodopa for the patient to treat diarrhea.

a. True “Carbidopa on its own has little to no therapeutic benefit, so it must be taken with levodopa for the patient to gain positive effects. Sinemet® is an example of a drug that is a combination of levodopa and carbidopa.”

12. Scintigraphy is a diagnostic test that uses the following item(s):

a. radiographic isotopes. b. scrambled eggs. c. technetium or iodine. d. All of the above [correct answer]

“Scintigraphy utilizes radiographic isotopes that are transferred into the gastrointestinal tract to assess a patient’s motility and gastric emptying time. The patient eats a meal, typically scrambled eggs, which contain the isotopes needed for the study; the most common isotopes used are technetium and iodine.”

13. True or False: The term enteric dysmotility is used to describe

motility disorders of the colon.

b. False “The term enteric dysmotility is used to describe motility disorders of the small intestine.”


14. Enteric dysmotility is demonstrated as abnormal contractions in the intestinal tract that typically lead to delays in the transport of food through

a. the small intestine. “The term enteric dysmotility is used to describe motility disorders of the small intestine.”

15. In hypertensive lower esophageal sphincter,

c. a patient will have increased muscle contractions within the lower esophageal sphincter. “An example of a questionable entity associated with the esophagus is increased pressure found within the lower esophageal sphincter. The condition may be referred to as hypertensive LES, ... hypertensive LES occurs when there are changes to the nerves affecting the esophagus. In this case, there is increased function of the excitatory nerves feeding the esophagus, such that the neurons are working at a faster pace and are causing increased muscle contractions within the LES.”

16. Anismus describes a condition in which the patient

b. is unable to control his pelvic floor muscles normally. “Anismus is a condition in which the patient is unable to control pelvic floor muscles normally in order to defecate.”

17. Hypothyroidism is associated with

c. constipation. “Hypothyroidism is associated with slowing of many metabolic processes, and affected patients often struggle with symptoms of weight gain, fatigue, muscle and joint pain, depression, and increased sensitivity to cold. One of the most common GI complaints among patients with hypothyroidism is constipation ...”


18. To reduce symptoms of IBS, a patient should remove or limiting FODMAP foods; FODMAP foods include

a. high fructose corn syrup. b. dairy products. c. foods containing wheat or rye. d. All of the above [correct answer]

“Certain foods have been organized into a descriptive classification known as FODMAP: ... Examples of these types of foods include those with high fructose corn syrup, dairy products, foods containing wheat or rye, beans and legumes, honey; and those containing certain sweeteners, such as xylitol, sorbitol, and isomalt.”

19. True or False: Patients diagnosed with IBS cannot take tricyclic

antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs).

b. False “Antidepressants can cause a number of gastrointestinal side effects. Patients with IBS who take antidepressants, as part of treatment for IBS, should also be aware of the potential side effects associated with these drugs.”

20. If a patient increases dietary fiber intake to combat

constipation, the patient should

c. increase fluid intake. “As a patient increases dietary fiber intake, he or she should be counseled to increase fluid intake accordingly.”


21. Achalasia is a condition that affects how food is transitioned between the mouth and the stomach, and it typically

a. develops as an acute condition. b. develops over time. c. causes initial symptoms of mild reflux. d. Answers b., and c., above [correct answer]

“Achalasia typically does not develop all at once; instead, symptoms progressively worsen over time as the patient loses more ability to drink liquids and to eat solid food. The condition may initially cause symptoms of mild reflux that can eventually develop into severe pain any time that the individual tries to eat.”

22. Chronic intestinal pseudo-obstruction (CIP) develops as a

disorder that

a. results in poor intestinal motility. “Chronic intestinal pseudo-obstruction (CIP) develops as a disorder that results in poor intestinal motility.”

23. Management of chronic intestinal pseudo-obstruction (CIP) is

c. supportive (treat symptoms and prevent complications). “Management of CIP is usually not curative and the best approach is to treat the patient’s symptoms and to prevent complications, such as malnutrition or dehydration that may develop from the condition.”

24. Examples of degenerative diseases that affect swallowing

include

a. Huntington’s disease. b. Dementia. c. Creutzfeldt-Jakob disease. d. All of the above [correct answer]

“Examples of degenerative diseases that affect neurological function and swallowing include such conditions as Huntington’s disease, dementia, or Creutzfeldt-Jakob disease.”


25. One condition that may be more likely to develop with polymyositis is

c. gastroparesis. “One condition that may be more likely to develop with polymyositis is delayed gastric emptying, also called gastroparesis, which occurs when food moves too slowly from the stomach and into the small intestine.”

26. Dumping syndrome is best managed with

a. changes in dietary practices. “Dumping syndrome is best managed with changes in dietary practices, including avoiding anything that would overstimulate the muscles of the stomach and cause it to contract too quickly.”

27. Much of the peristalsis and transit of food occurs by

b. involuntary control of smooth muscles in the GI tract. “While some of the gastrointestinal tract utilizes the work of voluntary muscles, much of the peristalsis and transit of food and chyme is done through involuntary control of the smooth muscles lining the GI tract.”

28. True or False: A person with Hirschsprung’s disease has GI

hypermotility.

b. False “... patients with Hirschsprung’s disease are at risk of intestinal infection because of poor motility.”

29. _________________ most often occurs because of motion

sickness or as nausea during the first trimester of pregnancy.

b. Tachygastria “Tachygastria is a condition that causes high-frequency electrical activity within the stomach during digestion. The condition most often occurs because of motion sickness or as nausea during the first trimester of pregnancy.”


30. True or False: Too much glucose in the bloodstream damages parts of the GI system.

a. True “... too much glucose in the bloodstream that circulates without being used for energy damages parts of the GI system, including the nerves that serve the intestinal tract, which may lead to severe GI motility disturbances.”

31. Drugs that promote gastric emptying are

a. Metoclopramide (Reglan®). b. Erythromycin. c. Amitiza. d. Answers a., and b., above [correct answer]

“Additionally, some prescription antiemetics work by increasing gut motility to speed up the rate that food moves through the intestine. Metoclopramide (Reglan®) is an example of this type of drug.... Erythromycin has been shown to accelerate the rate of gastric emptying in patients who suffer from gastroparesis in which they otherwise experience delayed gastric motility.”

32. Thyroid abnormalities may

a. later develop GI motility problems. b. have no correlation to GI motility conditions. c. cause constipation or diarrhea. d. Answers a., and c., above [correct answer]

“A commonly seen gastrointestinal motility disorder associated with hyperthyroidism is diarrhea, as the transit times in the intestine are increased due to the effects of the hormones.... One of the most common GI complaints among patients with hypothyroidism is constipation, as colonic motility slows with a decrease in thyroid hormone production.... Patients who suffer from thyroid abnormalities may not initially develop gastrointestinal motility problems. These difficulties may occur later in the course of thyroid disease, particularly when there is poor control over thyroid hormone secretion and poor management of thyroid disease.”


33. Addison’s disease is also called

b. hypocortisolism. “Addison’s disease is most often caused by an autoimmune disorder in which the body attacks its own tissues and causes the adrenal glands to work inappropriately. Eventually, the damage from the autoimmune system destroys the adrenal cortex, which is the outer protective covering to the adrenal glands. The patient is no longer able to secrete sufficient amounts of cortisol and aldosterone needed to regulate various body functions, including weight control, the ability to fight infection, and control of heart rate and blood pressure. For this reason, Addison’s disease is also known as hypocortisolism.”

34. True or False: Brain-gut dysfunction describes a condition in

which a patient may experience GI symptoms in response to emotions and psychological distress.

a. True “Brain-gut dysfunction describes a condition in which a patient may experience gastrointestinal symptoms in response to emotions and psychological distress.”

35. A patient with IBS-C type may need medications that include

c. osmotic laxatives, stool softeners, and bulking agents. “... a patient who struggles with IBS-C type may need medications and diet therapy that manages and prevents hard stools from forming, such as osmotic laxatives, stool softeners, and bulking agents.”

36. Biofeedback helps patients with fecal incontinence and can be

done with

b. an anorectral manometry procedure. “Biofeedback is a second method of controlling fecal incontinence. With biofeedback, the patient learns to consciously contract the muscles of the rectum that control defecation. The healthcare provider may perform biofeedback during a procedure known as anorectal manometry,...”


37. Pelvic floor dysfunction affects the person’s ability to

a. pass stool regardless of transit time or stool consistency. “Pelvic floor dysfunction ... affects the person’s ability to pass stool at all, regardless of transit time or stool consistency.”

38. Sarnelli, et al., in the World Journal of Gastrointestinal

Pathophysiology, investigated

c. specific genes contributing to development of achalasia. “Sarnelli, et al., in their work published in the World Journal of Gastrointestinal Pathophysiology, investigated specific genes that may contribute to the development of achalasia among certain patients.”

39. A known risk factor for fecal incontinence include

c. having a physical disability. “Known risk factors for fecal incontinence include advancing age, female gender, physical disabilities, and injury to the nerves affecting the anal sphincter, such as through childbirth.”

40. True or False: Genes and familial tendencies are a large part of

whether certain patients are at high risk of GI motility problems.

a. True “In some cases, genetic factors do not play a role in whether a patient will develop symptoms of a disorder; alternatively, genes and familial tendencies are a large part of whether certain patients are at high risk of GI motility problems.”


41. Chronic megacolon may be

a. a congenital condition. b. an acquired condition because of illness. c. an acquired condition due to toxicity. d. All of the above [correct answer] “Chronic megacolon may be used as a term to describe the condition when it is congenital, although it can be later acquired because of illness or toxicity.”

42. Tachygastria is a condition that causes

a. high-frequency electrical activity in the stomach with digestion. “Tachygastria is a condition that causes high-frequency electrical activity within the stomach during digestion.”

43. Rumination is a behavior disorder where a person

a. swallows food and then regurgitates it. “Rumination refers to swallowing food and then regurgitating it; the patient may then repeatedly swallow the food or may vomit it.”

44. True or False: Anismus is a condition in which the patient is

unable to control pelvic floor muscles normally in order to defecate.

a. True “Anismus is a condition in which the patient is unable to control pelvic floor muscles normally in order to defecate.”

45. A person with aerophagia

c. swallows large amounts of air. “Aerophagia is a rare type of disorder in which a person swallows large amounts of air. The air passes through the esophagus and enters the stomach but is then regurgitated, causing frequent belching.”


46. True or False: Functional fecal retention is the most common behavioral disorder that causes motility problems in the large intestine, rectum, and anus.

a. True “... the purposeful holding of stool within the body leads to constipation when excess fluid is absorbed from feces held in the rectum ... The clinical entity in these situations is known as functional fecal retention; it is the most common behavioral disorder that causes motility problems in the large intestine, rectum, and anus.”

47. At an initial meeting with a patient, the nurse should question

the patient about

a. symptoms, including history of pain. b. changes in stool output or toileting practices. c. feelings of pressure or bloating in the abdomen and lower pelvis. d. All of the above [correct answer]

“Upon the initial meeting, the patient may present with symptoms that vary according to the disorder present. Because the patient most likely will not know the cause of his or her symptoms upon arrival, it is up to the healthcare provider to make a diagnosis based on the information presented. The nurse should ask questions that focus not only on symptoms affecting the GI system, but also other symptoms that may be impacting different areas of the body. Starting with the GI system, the nurse should question the patient about symptoms, including history of pain, changes in stool output, feelings of pressure or bloating in the abdomen and lower pelvis, and any changes in toileting practices.”

48. A patient with diabetes who has uncontrolled blood glucose levels could develop neuropathy and gastroparesis to the point that the patient

c. is unable to detect the need to have a bowel movement. “... a patient with diabetes who has uncontrolled blood glucose levels could develop neuropathy and gastroparesis to the point that he or she is unable to detect the need to have a bowel movement.”


49. Scintigraphy is an X-ray that is performed

a. before meal consumption. b. after meal consumption. c. to help diagnose a GI motility disorder. d. Answers b., and c., above [correct answer]

“Scintigraphy utilizes radiographic isotopes that are transferred into the gastrointestinal tract to assess a patient’s motility and gastric emptying time. The patient eats a meal, typically scrambled eggs, which contain the isotopes needed for the study; the most common isotopes used are technetium and iodine. After consuming the meal, the images are taken to detect the food as it passes through the patient’s GI tract.”

50. True or False: Enterography is seldom done because it is more

invasive than endoscopic procedures.

b. False “Enterography is beneficial because it is less invasive than endoscopic procedures ... Because of the non-invasive process involved with this type of study, and that it is sensitive enough to pick up changes in GI motility, enterography is a viable option for diagnostic treatment among patients who are suffering GI motility disturbances.”

51. A colonoscopy involves the following preparation

b. a clear liquid diet 1 day before the procedure. “The colonoscopy is often used as a cancer screening tool [and] it may also be utilized to assess for potential obstructions in the large intestine, the presence of inflammation or polyps, bleeding, diverticulosis, or whenever the patient is suffering symptoms and is experiencing a change in bowel habits ... Prior to the procedure, the patient must undergo a bowel cleanse as preparation in order to remove any fecal matter in the intestine. This often requires a clear liquid diet for one day before the procedure and administration of a laxative that will empty the colon.”


52. Proctoscopy involves examination of

a. the rectum. “Proctoscopy involves examination of the rectum. The process is similar to that of a colonoscopy or anoscopy in that the physician inserts a scope into the patient’s anus and advances it to the rectum to visualize the internal structures of this portion of the colon.”

53. True or False: Another name for an esophagography is the

barium swallow test.

a. True “The barium swallow is actually called an esophagography. It is referred to in simpler terms as a barium swallow because the patient actually drinks barium contrast that has been prepared as a mixture.”

54. True or False: The single-contrast technique describes

application of contrast using a barium enema alone, while the double-contrast technique involves administering a barium enema and air into the large intestine.

a. True “The single-contrast technique describes application of contrast through administration of barium enema alone, while the double-contrast technique involves administration of a barium enema and air into the large intestine.”

55. A drawback to capsule endoscopy is that it

a. only takes pictures of GI conditions in the bowel. “A drawback to capsule endoscopy is that if it detects a problem within the gastrointestinal tract, it only takes pictures of it with the camera; the healthcare provider must still follow up with further testing to diagnose a condition or to obtain tissue samples.”


56. Electrodes used with EMG are often special types of __________ that are placed within the muscle tissue.

b. needles “Contrary to the surface electrodes used as part of cardiac testing, electrodes used with EMG are often special types of needles that are placed within the muscle tissue.”

57. Dyssynergic defecation may be defined and characterized as

a. a functional defecation disorder. b. paradoxical contractions of anal sphincter muscle. c. inability to relax the anal sphincter muscle. d. All of the above [correct answer]

“... dyssynergic defecation ... is defined as a functional defecation disorder characterized by impaired pushing forces, paradoxical contractions, or an inability to relax the anal sphincter muscle.”

58. Three main types of cells in the blood and CBC test are

b. white blood cells, red blood cells and platelets. “There are three main types of cells found in the blood and the CBC components test the amounts of each of these cells. The main cell types are white blood cells, red blood cells, and platelets.”

59. Microcytic red blood cells typically develop if the patient

a. has an iron deficiency anemia. “If the red blood cells are too large, they are considered macrocytic; this condition could occur because of certain vitamin deficiencies or with hypothyroidism. Alternatively, microcytic cells refer to those red blood cells that have an MCV result that is smaller than normal. Microcytic red blood cells typically develop if the patient is suffering from iron deficiency anemia.”


60. Hypothyroidism is a condition associated with

a. a number of GI motility problems. b. a possible drop in red blood cells. c. hyponatremia (low sodium). d. Answers a., and b., above [correct answer]

“Hypothyroidism, which is associated with a number of gastrointestinal motility problems, including constipation and malabsorption, can also lead to a drop in red blood cells and some kinds of anemia. Low thyroid levels can impact iron absorption, which could result in iron deficiency anemia. This could potentially create a negative cycle in which the intestines receive even less oxygenated blood than what they need when red blood cells and hemoglobin are lacking; which could then further perpetuate motility problems if the intestinal tract is not adequately oxygenated through circulation.”

61. Normal platelet count in men and women is

b. 150,000 to 450,000 mm3. “A normal platelet count is 150,000 to 450,000 mm3 among men and women.”

62. A standard stem cell is non-specific, but once it divides it can

a. take on the functions of cells in specialized areas of the body. “On its own, a standard stem cell is non-specific; however, once it divides, it can take on the functions of cells in specialized areas of the body, including in the brain, the muscles, and the gastrointestinal tract.”

63. True or False: Induced pluripotent stem cells (iPSC) can create

new cells that specifically focus on one area where new cells are needed most.

a. True “... iPSC bodies can be directed to create new cells that specifically focus on one area where new cells are needed most, such as by creating new neurons to work in the GI tract when these cells have been damaged.”


64. Cheng, et al., published a study that worked with transplanting neural stem cells into the gut as a method of controlling

c. Hirschsprung disease. “A study by Cheng, et al., in the journal Neurogastroenterology & Motility, worked with transplanting neural stem cells into the gut as a method of controlling Hirschsprung disease.”

65. True or False: During the health assessment, the nurse should

include dietary history as part of the evaluation of the patient’s GI condition.

a. True “During the health assessment, the nurse should include dietary history as part of the evaluation of the patient’s condition, as diet contributes significantly to the cause of many GI dysfunction symptoms.”

66. The BRAT diet is often employed as part of a dietary

management of diarrhea

c. but its recommended use seems to be purely anecdotal. “The BRAT diet, while often employed as part of dietary management of diarrhea, is not necessarily effective in managing symptoms of diarrhea in patients with GI motility disorders.... there is no evidence that states that this diet is effective in preventing diarrhea, and its recommended use seems to be purely anecdotal.”

67. ___________ have been shown to be an effective preventive

measure against some types of diarrhea.

b. Probiotics “Probiotics have been shown to be an effective preventive measure against some types of diarrhea and they may be incorporated into the patient’s diet through food intake that contain the bacteria or through specially designed supplements.”


68. ____________ can destroy some toxins that contribute to illness-causing diarrhea, among other benefits to GI motility.

d. Probiotics “Probiotics are microorganisms that support growth of healthy bacteria in the GI tract. They are effective in that, after ingestion, probiotics can destroy some toxins that contribute to illness-causing diarrhea, prevent harmful bacteria from infecting the gastrointestinal tract, stimulate increased mucus production in the intestinal tract, may help to decrease GI inflammation, and diminish the effects of gas and bloating.”

69. True or False: The two most common types of bacteria used as

part of probiotics are Lactobacillus and Bifidobacterium.

a. True “The two most common types of bacteria used as part of probiotics are Lactobacillus and Bifidobacterium.”

70. Patients with gastroparesis that causes nausea should

a. monitor food consumption. b. chew foods carefully and thoroughly. c. eat six small meals each day. d. All of the above [correct answer]

“For the patient suffering from gastroparesis that causes nausea, there are several dietary suggestions that may help. The patient should be advised to monitor food consumption, not only in the kinds of foods eaten, but also how food is eaten. The patient should be advised to chew foods carefully and thoroughly and to avoid taking large bites or swallowing pieces of food whole. Instead of eating three large meals a day, the patient would more likely benefit from six small meals each day, which can prevent stomach distention.”


71. FODMAP foods, when eaten in excess, could

a. increase risk of bacterial infection. “Certain foods have been organized into a descriptive classification known as FODMAP: ... These foods, when eaten in excess, could increase the risk of bacterial infection ...”

72. Activity-induced diarrhea can lead to

a. abdominal pain. b. increased urge to have a bowel movement. c. the need for rest and rehydration. d. All of the above [correct answer] “Some people struggle with activity-induced diarrhea when they exercise and then experience abdominal pain and an increased urge to have a bowel movement. When a patient is suffering from diarrhea, rest and rehydration are typically recommended to cope with the situation, rather than encouraging an increase in activity levels.”

73. True or False: With gastroparesis, a patient is recommended to

avoid even mild exercise due to GI dysmotility.

b. False “In the case of gastroparesis, a patient may benefit from mild exercise to help improve GI motility; recommendations associated with eating and activity levels in this situation often advise taking a walk after eating to avoid lying down and to promote gastric emptying of stomach contents.”

74. True or False: Surgery for dysmotility is done with the goal to improve the patient’s quality of life by reducing symptoms of disease.

a. True “As with other types of surgical intervention for dysmotility, surgery may initially cause discomfort because of the procedure, but the ultimate goal is to improve the patient’s quality of life by reducing symptoms of disease and extending the patient’s life that may otherwise be shortened because of his or her condition.”


75. Opioid receptors in the gastrointestinal tract affected by opioid medication can cause

a. increase in mucus secretions. b. decrease in fluid reabsorption. c. increased gastric emptying. d. None of the above [correct answer]

“There are many opioid receptors in the gastrointestinal tract. When opioids are administered, they can affect these receptors and cause changes, including a decrease in mucus secretions, an increase in fluid reabsorption, and delayed gastric emptying.”

76. Approximately _____ percent of patients who are treated with

opioids experience nausea as a side effect

b. 25 “Approximately 25 percent of patients who are treated with opioids experience nausea as a side effect.”

77. ___________________ are ordered concomitantly with the

opioid analgesics to help maintain normal bowel habits.

c. Stool softeners “For many patients, stool softeners are ordered concomitantly with the opioid analgesics to help maintain normal bowel habits.”

78. Antidepressant medication may be used as part of treatment for

________________________ as well as depression.

a. irritable bowel syndrome “Since serotonin receptors are present in the GI tract and associated with pain from rectal distention, i.e., as occurs with irritable bowel syndrome (IBS), antidepressants are used as part of treatment for IBS, as well as depression. In fact, antidepressant prescription is part of routine management of irritable bowel syndrome. This may be because of the effects of these medications on serotonin in the GI tract; however, it could also be due to the psychological symptoms associated with IBS.”


79. An upper endoscopy or EGD may be used

a. to insert biopsy forceps. b. to narrow down the cause of the motility issues. c. to look for inflammation in the gastrointestinal tract. d. All of the above [correct answer]

“Upper endoscopy, also called esophagogastroduodenoscopy or EGD, involves insertion of a tube into the patient’s mouth and then advancing it down the esophagus.... The test is beneficial to look for conditions that may be causing the patient’s symptoms of pain, nausea, or vomiting, which may or may not be related to GI motility problems. It may also be done to rule out another condition and narrow down the cause of the motility issues. The upper endoscopy is more accurate than traditional X-rays when looking for certain issues within the gastrointestinal tract, such as inflammation. The endoscope can also be used to insert biopsy forceps through the channel to remove small tissue samples from the GI tract if the endoscopist determines it is necessary to perform a tissue pathology test.”

80. True or False: Endoscopy is a valuable process that helps to

visualize the internal segments of the GI tract to better pinpoint a diagnosis when GI motility problems are present.

a. True “... endoscopy is a valuable process that helps the endoscopist to visualize the internal segments of the GI tract, which can better pinpoint a diagnosis when GI motility problems are present.”

81. Predominant forms of IBS are known as

a. IBS-C (IBS with constipation) or IBS-D (IBS with diarrhea).

“Irritable bowel syndrome can cause symptoms that predominantly involve diarrhea or constipation, although some patients suffer from both. It is classified according to the predominant forms of stool that occur with symptoms, and may be considered IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), IBS mixed (IBS-M), or IBS unsubtyped (IBS-U) in which the stool consistency does not meet the criteria for the other forms of the condition.”


82. A patient with dysphagia may be recommended the following to facilitate easier swallowing

b. thickening liquids. “The healthcare provider who works with a patient with dysphagia may provide some interventions that would facilitate easier swallowing. As mentioned, this may involve thickening liquids and otherwise modifying food textures and consistencies.”

83. Dysphagia can develop as a consequence of conditions, such as

a. stroke. b. carcinoma. c. degenerative disorders. d. All of the above [correct answer]

“Dysphagia can develop as a consequence of a number of conditions, including physical disabilities, stroke, and carcinoma, and, it may also develop because of difficulties related to certain types of degenerative disorders.”

84. Choung, et al., reported the most common symptom experienced

by participants using antidepressants was

c. abdominal bloating/distention. “A study by Choung, et al., in the journal Neurogastroenterology & Motility, used questionnaires to examine patient responses to discern the effects of antidepressant use on the gastrointestinal system. The most common symptom reported by participants in the study was abdominal bloating and distention.”

85. True or False: Two main types of cholinergic receptors in the

body are nicotinic and muscarinic receptors.

a. True “There are two main types of cholinergic receptors in the body: nicotinic and muscarinic receptors.”


86. A study of older adults with chronic obstructive pulmonary disease (COPD) who used muscle relaxant medications also showed

a. higher levels of defecation frequency. b. lower levels of defecation frequency. c. constipation. d. Both b., and c., above [correct answer]

“A study in the journal BMC Geriatrics investigated defecation frequency among older adults with chronic obstructive pulmonary disease who used muscle relaxant medications to control some of their respiratory symptoms. The study showed that those adults who used the drugs to control respiratory symptoms also had lower levels of defecation frequency and were more likely to suffer from constipation and slowed colonic transit.”

87. Loperamide works by _____________ gut motility to slow down

the rate of intestinal transit and reduce diarrhea.

c. decreasing “Loperamide works by decreasing gut motility to slow down the rate of intestinal transit so that the affected person is less likely to suffer from diarrhea.”

88. Certain drugs used to manage Parkinson’s disease have been

shown to affect GI motility, typically within the stomach, causing

b. delayed gastric emptying. “Certain drugs used for management of disorders such as Parkinson’s disease have been shown to affect gastrointestinal motility, typically within the stomach, causing delayed gastric emptying.


89. ______________ cannot be administered to patients with Parkinson’s disease (PD) because it cannot cross the blood-brain barrier.

a. Dopamine “Dopamine cannot be administered to patients with PD because dopamine cannot cross the blood-brain barrier.”

90. True or False: Antidiarrheals are available only in prescription

strength.

b. False “Antidiarrheals are available in prescription strength but they can be purchased over the counter as well.”

91. Antibiotics are administered for infection

a. with Clostridium difficile. b. that is prolonged due to Escherichia coli bacteria. c. with Salmonella infection in very young children. d. All of the above [correct answer]

“However, there are some cases in which a patient who suffers from prolonged diarrhea because of a specific type of infection would benefit from the administration of antibiotics, including infection with Clostridium difficile, prolonged infection with Escherichia coli bacteria, and Salmonella infection in very young children.”

92. Examples of antibiotics that may be prescribed for the

management of infectious diarrhea include

a. cefotaxime. b. vancomycin. c. augmentin. d. Both a., and b., above [correct answer]

“Examples of antibiotics that may be prescribed for the management of infectious diarrhea include cefotaxime (Claforan®), vancomycin, and erythromycin.”


93. ______________ is a broad-spectrum antiparasitic medication.

a. Furazolidone (Furoxone®) “Antiparasitic drugs may target certain species or they may be broad-spectrum types that provide coverage against any number of parasitic organisms. An example of this type of drug is furazolidone (Furoxone®).”

94. True or False: Psyllium or methylcellulose is given to treat

diarrhea by causing the colon to retain more fluid, thereby preventing diarrhea.

b. False “Bulk-forming laxatives prevent and treat constipation, and are typically made up of products such as psyllium or methylcellulose...”

95. Nausea and vomiting are common symptoms most frequently seen with GI dysmotility conditions such as

a. gastroparesis. b. intestinal pseudo-obstruction. c. dumping syndrome. d. All of the above [correct answer]

“Nausea and vomiting can develop as significant symptoms from GI motility disorders. These two common symptoms are most frequently seen with GI dysmotility conditions such as gastroparesis, intestinal pseudo-obstruction, and dumping syndrome.”

96. Antiemetics can ____________ messages to the brain that

stimulate the sense of nausea.

a. block “Prescription antiemetics may work in a manner similar to non-prescription drugs in that they can block messages to the brain that stimulate the sense of nausea.”


97. Antiemetics may be administered as

a. rectal suppositories. b. transdermal patches. c. intramuscular/intravenous injections. d. All of the above [correct answer]

“In addition to oral preparations, antiemetics may be administered as rectal suppositories, transdermal patches, intramuscular injections, or as intravenous injections.”

98. True or False: Cholinergic agonists are drugs that act in a

manner opposite to the neurotransmitter acetylcholine.

b. False “Cholinergic agonists are drugs that act in a manner similar to the neurotransmitter acetylcholine.”

99. Prokinetic medications can be administered to __________ the

speed of GI motility.

c. increase “Prokinetic medications can be administered to increase the speed of GI motility to move food through the intestinal tract at a faster rate.”

100. _______________ is a growing medical field with working

committees to develop improved algorithms to diagnose and treat GI motility disorders.

c. Neurogastroenterology “The field of neurogastroenterology has increasingly developed into multi-dimensional working committees of clinical researchers organized to develop improved therapeutic options for the wide spectrum of individuals suffering from functional gut disorders.”


References

The reference section of in-text citations include published works intended as helpful material for further reading.

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