Motility Disorders: What are they and how to treat

Introduction

Motility disorders are a group of conditions that affect the normal movement and functioning of the gastrointestinal (GI) tract. These disorders can lead to a variety of symptoms, such as constipation, diarrhea, abdominal pain, and bloating.

In this article, we will provide a comprehensive overview of motility disorders, including the types, causes, symptoms, and diagnostic approaches. We will also discuss the various treatment options, ranging from dietary and lifestyle modifications to pharmacological interventions and surgical procedures.

What are motility disorders?

Motility disorders include a group of conditions that disrupt the normal movement and function of the gastrointestinal (GI) tract. The GI tract is a complex system that involves coordinated contractions of smooth muscles. When this is disrupted, it can lead to various motility disorders affecting different parts of the GI tract, such as the esophagus, stomach, small intestine, or colon.

These disorders can cause either hypomotility (decreased movement) or hypermotility (increased movement) of the GI tract. This can cause symptoms such as difficulty swallowing, nausea, vomiting, abdominal pain, bloating, constipation, or diarrhea. The specific symptoms and their severity can vary depending on the type of motility disorder and which part of the GI tract is affected.

The pathophysiology of motility disorders is multifaceted and can involve a combination of factors, such as abnormalities in the enteric nervous system, smooth muscle function, interstitial cells of Cajal (ICC), and gut microbiome. For example, in gastroparesis, a condition characterized by delayed gastric emptying, there may be a loss of ICC, which are responsible for generating electrical slow waves that control gastric contractions. [27] Similarly, in irritable bowel syndrome (IBS), a functional GI disorder, alterations in gut motility, visceral hypersensitivity, and gut-brain interactions have been implicated in its pathogenesis. [10, 41]

Understanding the underlying mechanisms of motility disorders is crucial for developing targeted therapies and improving patient outcomes. In the following sections, we will delve deeper into the different types of motility disorders, their causes, and the available diagnostic and treatment options.

Types of motility disorders

Motility disorders can be classified based on the affected region of the GI tract. Some of the most common types of motility disorders include:

1. Esophageal motility disorders

• Achalasia: A condition that causes impaired relaxation of the lower esophageal sphincter (LES) and decreased constriction of the esophagus, leading to difficulty swallowing and to regurgitation. [14]
• Esophageal spasm: This causes abnormal contractions of the esophageal muscles, causing chest pain and difficulty swallowing.
• Gastroesophageal reflux disease (GERD): This is when the stomach contents flow back into the esophagus, causing symptoms such as heartburn and regurgitation. While GERD is primarily a disorder of the LES, it can also be caused by abnormalities in esophageal motility. [34]

2. Gastric motility disorders

• Gastroparesis: A condition that causes delayed gastric emptying, leading to symptoms such as nausea, vomiting, early satiety, and bloating. Gastroparesis can occur alone or be caused by conditions such as diabetes, neurological disorders, or post-surgical complications. [3, 27]
• Functional dyspepsia: This causes upper abdominal pain or discomfort, often related to meals, without an identifiable cause. Functional dyspepsia can be associated with abnormalities in gastric accommodation, emptying, or hypersensitivity. [28]

3. Intestinal motility disorders

• Irritable bowel syndrome (IBS): A functional disorder that causes abdominal pain, bloating, and altered bowel habits (constipation, diarrhea, or both). IBS involves abnormalities in gut motility, hypersensitivity, the gut microbiome, and gut-brain interactions. [9, 10, 11, 33, 39, 41]
• Small intestinal bacterial overgrowth (SIBO): This causes an abnormal increase in the number of bacteria in the small intestine, leading to symptoms such as bloating, diarrhea, and malabsorption. SIBO can be associated with impaired small intestinal motility, which leads to the overgrowth of bacteria. [35]
• Chronic intestinal pseudo-obstruction: A rare disorder characterized by impaired intestinal motility, leading to symptoms that mimic mechanical obstruction, such as nausea, vomiting, and abdominal distension. This condition may be caused by systemic diseases, such as scleroderma or Parkinson's disease. [37, 38]

4. Colonic motility disorders

• Chronic constipation: A condition characterized by infrequent bowel movements, difficult or incomplete pooping. It can also cause bloating and abdominal discomfort. Chronic constipation can be related to slow colonic transit, pelvic floor dysfunction, or a combination of both. [2, 36, 43]
• Hirschsprung's disease: A congenital disorder characterized by the absence of ganglion cells in the distal colon, leading to impaired motility and constipation. This condition typically is seen in infancy or early childhood and requires surgery.
• Colonic inertia: This is when you have severely reduced colonic motility, leading to severe constipation and often requiring surgery. Colonic inertia can occur on its own or be caused by conditions such as diabetes or neurological disorders.

Causes of motility disorders

Some of the main factors that can contribute to the development of these disorders include:

1. Neurological conditions: Disorders that affect the enteric nervous system, such as Parkinson's disease, multiple sclerosis, or spinal cord injuries, can disrupt the normal functioning of the GI tract. These conditions can lead to impaired motility, sensory abnormalities, and altered gut-brain interactions. [26]
2. Muscular disorders: Conditions that affect the smooth muscles of the GI tract, such as scleroderma or muscular dystrophy, can lead to impaired motility. In these disorders, the smooth muscle cells may be damaged or dysfunctional, leading to abnormal contractions and transit.
3. Endocrine and metabolic disorders: Conditions such as diabetes, hypothyroidism, or electrolyte imbalances can affect GI motility. For example, diabetes can lead to neuropathy, which can affect the function of the enteric nervous system and lead to gastroparesis or constipation. [23]
4. Medications: Certain medications, such as opioids, anticholinergics, or calcium channel blockers, can have side effects that disrupt normal GI motility. Opioids, in particular, are known to cause constipation by reducing gut motility and increasing fluid absorption in the intestines.
5. Infections: Viral, bacterial, or parasitic infections of the GI tract can lead to temporary or chronic motility disorders. For example, post-infectious IBS can develop after an acute gastroenteritis episode, leading to persistent changes in gut motility and sensitivity. [31, 32]
6. Gut microbiome imbalances: Alterations in the composition and diversity of the gut microbiome have been linked to motility disorders, particularly IBS. [9, 33, 35]
7. Psychological factors: Stress, anxiety, and depression have been linked to the development of functional GI disorders, such as IBS. These factors can affect gut motility and sensitivity through the gut-brain axis, a communication pathway between the gut and the central nervous system. [10, 41]
8. Idiopathic (unexplained) causes: In some cases, the exact cause of a motility disorder may remain unknown, despite extensive evaluation. These idiopathic disorders may involve a complex interplay of genetic, environmental, and psychosocial factors that are not yet fully understood.

Symptoms and diagnosis of motility disorders

The symptoms of motility disorders can vary depending on the specific condition and the affected region of the GI tract. Some common symptoms include:

• Difficulty swallowing (dysphagia)
• Chest pain
• Heartburn and regurgitation
• Nausea and vomiting
• Early satiety (fullness) and bloating
• Abdominal pain and discomfort
• Constipation or diarrhea
• Fecal incontinence

Diagnosing motility disorders often requires a comprehensive evaluation, including a thorough medical history, physical examination, and various diagnostic tests. Some of the commonly used diagnostic tools include:

1. Endoscopy: Procedures such as esophagogastroduodenoscopy (EGD) or colonoscopy can help visualize the GI tract and identify any structural abnormalities or inflammation. These procedures can also be used to obtain biopsies for histological analysis.
2. Manometry: This test measures the pressure and coordination of muscle contractions within the GI tract, such as the esophagus, stomach, or anorectal region. Manometry can help identify abnormalities in motility, such as impaired LES relaxation in achalasia or abnormal colonic contractions in chronic constipation. [8, 12, 15]
3. Imaging studies: Techniques like barium swallow, small bowel follow-through, or magnetic resonance imaging (MRI) can provide detailed images of the GI tract and help identify any structural or functional abnormalities. For example, a barium swallow can help assess esophageal motility and identify any strictures or diverticula.
4. Breath tests: Hydrogen breath tests can help diagnose conditions like SIBO or carbohydrate malabsorption, which can contribute to motility disorders. These tests involve ingesting a substrate (e.g., lactulose or glucose) and measuring the hydrogen content in the exhaled breath over time. [6]
5. Functional lumen imaging probe (FLIP): This novel diagnostic tool can help assess the distensibility and contractility of the GI tract, particularly in the evaluation of esophageal motility disorders. FLIP uses a balloon catheter to measure the cross-sectional area and pressure of the GI tract in response to distension. [15]
6. Scintigraphy: This nuclear medicine technique involves ingesting a radiolabeled meal and tracking its progression through the GI tract using a gamma camera. Scintigraphy can help assess gastric emptying time in gastroparesis or colonic transit time in chronic constipation. [40]
7. Wireless motility capsule: This ingestible capsule contains sensors that measure pH, pressure, and temperature as it passes through the GI tract. The data collected by the capsule can provide information on gastric emptying time, small bowel transit time, and colonic transit time. [40]

Treatment options for motility disorders

The treatment of motility disorders often involves a multidisciplinary approach, tailored to the specific condition and your needs. Some of the main treatment strategies include:

Dietary and lifestyle modifications

• Low-FODMAP diet: This diet, which restricts fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs), has been shown to be effective in managing symptoms of IBS. FODMAPs are poorly absorbed carbohydrates that can ferment in the gut, leading to increased gas production, bloating, and altered motility. [4, 5, 11]
• Fiber modification: Increasing or decreasing dietary fiber intake can help regulate bowel movements and alleviate symptoms of constipation or diarrhea. For example, increasing soluble fiber intake may help with constipation, while reducing insoluble fiber may help with diarrhea-predominant IBS.
• Hydration: Drinking enough fluids is important for maintaining GI motility and preventing constipation. People with motility disorders should drink adequate water throughout the day, especially if they are increasing their fiber intake.
• Regular physical activity: Exercise can help stimulate GI motility and relieve symptoms of constipation. Doing regular physical activity, such as walking, cycling, or swimming, can promote overall digestive health and improve quality of life.
• Stress management: Techniques such as relaxation training, cognitive-behavioral therapy, or mindfulness-based therapies can help reduce stress and anxiety, which can worsen motility disorders. These techniques can also help you cope with the psychological impact of your condition and improve your overall well-being. [44]

Pharmacological treatments

• Prokinetics: These medications help stimulate GI motility and relieve symptoms of gastroparesis or constipation. These drugs work by enhancing the activity of the enteric nervous system or promoting the release of neurotransmitters that stimulate muscle contractions. [1] Examples include: metoclopramide, domperidone, and prucalopride.
• Antispasmodics: These can help reduce abdominal pain and cramping associated with IBS or other functional GI disorders. They work by relaxing the smooth muscles of the GI tract and reducing abnormal contractions. Examples include dicyclomine or hyoscyamine.
• Laxatives: Osmotic laxatives (e.g., polyethylene glycol) or stimulant laxatives (e.g., bisacodyl) can be used to manage constipation. Osmotic laxatives work by drawing water into the intestines, while stimulant laxatives promote colon contractions and facilitate bowel movements. [48]
• Antidiarrheal agents: Medications like loperamide can help control diarrhea associated with IBS or other motility disorders. Loperamide works by slowing down intestinal motility and increasing fluid absorption, leading to more formed stools.
• Antibiotics: In cases of SIBO, a course of antibiotics such as rifaximin may be prescribed to reduce bacterial overgrowth and relieve symptoms. Rifaximin is a non-absorbable antibiotic that acts locally in the gut and has been shown to be effective in treating SIBO and IBS. [49, 50]
• Neuromodulators: Antidepressants, such as tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs), can help modulate gut-brain interactions and relieve symptoms of functional GI disorders. These medications can help reduce hypersensitivity, regulate motility, and improve mood and anxiety symptoms. [41]

Neurostimulation and biofeedback

• Sacral nerve stimulation: This technique involves implanting a small device that delivers electrical stimulation to the sacral nerves, which can help regulate bowel function in people with severe constipation or fecal incontinence. The electrical stimulation can modulate the activity of the enteric nervous system and promote more regular bowel movements.
• Tibial nerve stimulation: This non-invasive technique involves stimulating the tibial nerve, which can help modulate GI motility and reduce symptoms of functional constipation. The stimulation is typically delivered through a needle electrode inserted near the ankle and connected to a stimulator device. [13]
• Biofeedback therapy: This technique involves training patients to improve their pelvic floor muscle coordination and bowel habits, which can be helpful in managing conditions like dyssynergic defecation or fecal incontinence. During biofeedback sessions, people learn to recognize and control their pelvic floor muscles using visual or auditory feedback from sensors placed in the anorectal region.

Surgical interventions

• Laparoscopic Heller myotomy: This procedure involves cutting the muscle fibers of the LES to improve esophageal emptying in patients with achalasia. The myotomy is typically performed laparoscopically and can provide long-term relief of dysphagia symptoms. [14]
• Gastric electrical stimulation[a][b][c][d]:

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[a]@andrew@buoyhealth.com This article seems to be cut off. Should I just delete the surgery section?

_Assigned to andrew@buoyhealth.com_

[b]I'll get this fixed

[c]So am I done with this?

[d]No, we'll get the rest of the article written first.