RESUMEN
Chronic intestinal pseudo-obstruction (CIPO) is a rare disorder characterized by an impairment of coordinated propulsive activity in the gastrointestinal (GI) tract, which clinically mimics mechanical intestinal obstruction. CIPO is the most severe and debilitating form of GI dysmotility. CIPO may be primary or be secondary to pathology at any level of the brain-gut axis as well as systemic disease. The clinical features of CIPO are pleomorphic and largely depend on the site and extent of the segment of the GI tract involved. The diagnostic approach includes the need for investigations to exclude mechanical GI obstruction, screening for causes of secondary CIPO and the identification of the disease phenotype as well as the prompt recognition and treatment of complications such as malnutrition and small intestinal bacterial overgrowth. In managing this disorder, a holistic, multidisciplinary approach is needed with judicious use of pharmacotherapeutic agents. While currently there are no specific therapeutic modalities for CIPO, treatment is largely directed at maintaining adequate nutrition and electrolyte balance and enhancing coordinated GI motility. Surgery should be avoided unless advisable for carefully selected patients and may include stoma formation. This narrative review provides a concise overview of the literature on this rare, severe and complex disorder, and highlights the need and areas for further research to improve both diagnostics and therapeutics.
Asunto(s)
Motilidad Gastrointestinal , Seudoobstrucción Intestinal/terapia , Intestinos/fisiopatología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Enfermedad Crónica , Técnicas de Diagnóstico del Sistema Digestivo , Femenino , Microbioma Gastrointestinal , Humanos , Seudoobstrucción Intestinal/diagnóstico , Seudoobstrucción Intestinal/etiología , Seudoobstrucción Intestinal/fisiopatología , Intestinos/microbiología , Masculino , Persona de Mediana Edad , Estado Nutricional , Valor Predictivo de las Pruebas , Recuperación de la Función , Factores de Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
Opioids are potent analgesics used for the treatment of acute and chronic pain. Side-effects are common and among the most bothersome are those associated with opioid-induced bowel dysfunction, which includes opioid-induced constipation. In this Review, we provide a summary of the pathophysiology, diagnosis, and management of opioid-induced constipation, which can be defined as a change in baseline bowel habit or defecatory patterns following initiation, alteration, or increase of opioid therapy. Opioid-induced constipation is a consequence of the action of opioids on their receptors in the gastrointestinal tract. A comprehensive clinical assessment is beneficial, including evaluation of the patient's understanding of their constipation and underlying condition for which opioids are used. Clinical assessment should also aim to differentiate opioid-induced constipation from pre-existing constipation exacerbated by the opioids. Preventive strategies need to be considered when patients start treatment with opioids, such as lifestyle changes. First-line management includes simple over-the-counter laxatives. The bowel function index can be useful to objectively identify patients who are refractory to these initial measures. In this context, alternative over-the-counter laxatives (or combinations of laxatives), secretogogues, or peripherally acting µ-opioid receptor antagonists might also be considered. Educational strategies need to be developed to improve the knowledge base of health-care providers on the identification and management of opioid-induced constipation.
Asunto(s)
Analgésicos Opioides/efectos adversos , Estreñimiento/inducido químicamente , Dolor Agudo/tratamiento farmacológico , Analgésicos Opioides/farmacología , Dolor Crónico/tratamiento farmacológico , Estreñimiento/diagnóstico , Estreñimiento/tratamiento farmacológico , Estreñimiento/fisiopatología , Tracto Gastrointestinal/efectos de los fármacos , Humanos , Laxativos/uso terapéuticoRESUMEN
OBJECTIVE: Osteoarthritis (OA) is a heterogeneous disease, and symptom progression at the foot is unclear. This study investigated the symptomatic course of 3 predefined foot OA phenotypes over an 18-month period. METHODS: The Clinical Assessment Study of the Foot is a community-based cohort of adults ages ≥50 years in North Staffordshire, UK. Participants who reported foot pain in a postal health survey and underwent radiographic assessment were mailed an 18-month followup survey. Changes in descriptive and symptomatic outcomes over 18 months were compared across the 3 phenotypes to determine within-phenotype changes and between-phenotype differences. RESULTS: Of 533 participants at baseline, 478 (89.7%) responded at 18 months. All 3 phenotypes showed small within-phenotype improvements in mean foot pain severity (scale range 0-10, where 0 = no pain and 10 = worst pain): no or minimal foot OA (18 months 4.0, mean change -1.15 [95% confidence interval (95% CI) -1.46, -0.83]), isolated first metatarsophalangeal (MTP) joint OA (18 months 4.1, mean change -0.60 [95% CI -1.11, -0.10]), and polyarticular foot OA (18 months 5.1, mean change -0.77 [95% CI -1.42, -0.12]). The isolated first MTP joint OA phenotype had an increased likelihood of hallux valgus in the left foot (adjusted odds ratio 2.96 [95% CI 1.23, 7.12]) compared to the no or minimal foot OA phenotype. CONCLUSION: Three foot OA phenotypes showed few descriptive or symptomatic changes over 18 months. Future clinical trials should consider that people recruited with mild-to-moderate symptomatic foot OA appear likely to remain relatively stable with usual care. Longer-term followup using additional time points is required to describe further the natural history of foot OA.