Pseudo-pseudo-obstruction: lessons in diagnosis and management

Abstract

Chronic intestinal pseudo-obstruction (CIP) is a rare and severe motility disorder for which strict diagnostic criteria have been described.

It is suggested that the radiographic features of dilated bowel with air–fluid levels in the absence of a fixed, lumen-occluding lesion are too restrictive, and that patients with typical clinical and manometric criteria and/or histopathological features of CIP should be included within the diagnosis of CIP.

In this issue of the Journal, a case of pseudo-pseudo-obstruction is reported. Initially managed as a case of CIP, the patient eventually underwent laparoscopic adhesiolysis with successful alleviation of symptoms during a 6-year follow-up.

The worsening of symptoms during treatment with a prokinetic agent, and small-intestinal manometric features suggesting a more distal mechanical obstruction, prompted the authors to recommend surgery.

Both measures are recommended to be applied to patients with suspected or proven CIP who present with difficult and persistent obstructive symptoms.

Chronic intestinal pseudo-obstruction (CIP) has been defined as a rare and severe, disabling disorder, which is characterised by recurring episodes or continuous symptoms and signs of bowel obstruction, including radiological features of obstruction. It is suggested that the diagnosis should be broadened to include patients with severe gastrointestinal symptoms who do not have radiological features of obstruction but who have manometric features of CIP and/or have demonstrable end organ list of pathological features described in CIP. A case of pseudo-pseudo-obstruction is described in this issue of the Journal. Originally the patient was thought to have CIP, and a mechanical cause of obstruction was suspected based on small intestine manometric features, suggesting a distal mechanical obstruction and a worsening of symptoms when treated with a prokinetic agent. As patients with CIP can develop mechanical obstruction and episodes of mechanical obstruction can mimic CIP, small intestine manometry and trials of prokinetic therapy should be undertaken in all difficult cases of obstruction and particulary in patients with documented CIP.