Small intestinal dysmotility in cirrhotic patients: correlation with severity of liver disease and cirrhosis-associated complications

Abstract

Introduction Altered small intestinal motility has been observed in various manometry studies in patients with cirrhosis. Since small bowel manometry is available only in a few centers, interpretation of dysmotility in cirrhosis is controversial.

Patients and Methods In this study, both fasting and postprandial manometric tracings of 24-hour antroduodenojejunal manometries were analyzed using both visual analysis and computer-aided analysis.

Results In 34 patients (83 %), the mean migrating motor complex (MMC) cycle length was different compared with healthy controls. Phase II was prolonged in 27 patients (66 %), while phase I showed a reduced duration in 23 (56 %) and in phase III in 13 individuals (32 %). We also observed special motor patterns, e. g., migrating clustered contractions (MCCs) or retrograde clustered contractions (RCCs), which were present during fasting (69 %) and postprandial (92 %) motility, while none of the healthy controls showed any special motor patterns. Special motor patterns showed a significant correlation with the severity of cirrhosis (Child-Score; p > 0.05) and the existence of ascites (p < 0.05).

Discussion This study in a large cohort of patients with cirrhosis by using 24-hour, solid state portable manometry showed in most individuals disturbances of cyclic fasting motility. Special motor patterns like RCCs during fasting and postprandial motility could be observed exclusively in the cirrhosis group, showing a significant correlation with severity of cirrhosis and the occurence of associated complications.

Zusammenfassung

Einleitung Eine enterale Dysmotilität des Dünndarms wurde in verschiedenen Manometriestudien bei Patienten mit Zirrhose demonstriert. Da die Dünndarmmanometrie nur in wenigen Zentren verfügbar ist, gibt es nur wenige systematische Untersuchungen, insbesondere bezüglich einer Assoziation mit dem Schweregrad und weiteren typischen Komplikationen der Zirrhose.

Patienten und Methoden In dieser Studie wurden die Dünndarmmotilität sowohl nüchterne als auch postprandiale mittels 24-stündiger Dünndarmmanometrie mittels visueller Analyse und computergestützter Auswertung analysiert.

Ergebnisse  Bei 34 Patienten (83 %) unterschied sich die mittlere Zykluslänge des Migrating Motor Complex (MMC) von der gesunden Kontrollpopulation. Phase II war bei 27 Patienten (66 %) verlängert, Phase I zeigte bei 23 Patienten (56 %) und Phase III bei 13 Personen (32 %) eine verkürzte Dauer. Nur im Zirrhose-Kollektiv traten weiterhin spezielle motorische Ereignisse (z. B. migrierende Clusterkontraktionen, MCCs und retrograde Clusterkontraktionen, RCCs) sowohl im Nüchternzustand (in 69 %) und postprandial (in 92 %) auf. Diese pathologischen Motilitätssmuster zeigten eine signifikante Korrelation mit dem Schweregrad der Zirrhose (objektiviert durch den Child-Score; p > 0,05) und dem Vorliegen von Aszites (p < 0,05).

Diskussion  Bei den meisten Patienten mit Zirrhose zeigte sich in der 24 h-Dünndarmmanometrie eine gestörte zyklische Nüchternmotilität. Spezielle motorische Muster (z. B. RCCs) traten ausschließlich bei Patienten mit Zirrhose im Nüchtenzustand sowie postprandial auf und zeigten eine signifikante Korrelation mit dem Schweregrad der Zirrhose und dem Auftreten bestimmter assoziierter Komplikationen.

Key words

ascites - hepatic encephalopathy - liver cirrhosis - small bowel dymotility - small bowel manometry

Schlüsselwörter

Aszites - hepatische Encephalopathie - Leberzirrhose - Dünndarm-Dysmotilität - Dünndarmmanometrie

Publication History

Received: 09 November 2019

Accepted: 20 April 2020

Article published online:
08 June 2020

• References

• 1 Quigley EM. Gastric and small intestinal motility in health and disease. Gastroenterol Clin North Am 1996; 25: 113-145
• 2 Abell TL, Malagelada JR. Electrogastrography. Current assessment and future perspectives. Dig Dis Sci 1988; 33: 982-992
• 3 Chesta J, Defilippi C, Defilippi C. Abnormalities in proximal small bowel motility in patients with cirrhosis. Hepatology 1993; 17: 828-832
• 4 Madrid AM, Cumsille F, Defilippi C. Altered small bowel motility in patients with liver cirrhosis depends on severity of liver disease. Dig Dis Sci 1997; 42: 738-742
• 5 Madrid AM, Brahm J, Antezana C. et al. Small bowel motility in primary biliary cirrhosis. Am J Gastroenterol 1998; 93: 2436-2440
• 6 Morris AI, Turnberg LA. Influence of isoproterenol and propanolol on human intestinal transport in vivo. Gastroenterol 1981; 81: 1076-1079
• 7 Madrid AM, Brahm J, Buckel E. et al. Orthotopic liver transplantation improves small bowel motility disorders in cirrhotic patients. Am J Gastroenterol 1997; 92: 1044-1045
• 8 Gunnarsdottir SA, Sadik R, Shev S. et al. Small intestinal motility disturbances and bacterial overgrowth in patients with liver cirrhosis and portal hypertension. Am J Gastroenterol 2003; 98: 1362-1370
• 9 Chang CS, Chen GH, Lien HC. et al. Small intestine dysmotility and bacterial overgrowth in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology 1998; 28: 1187-1190
• 10 Benten D, Wiest R. Gut microbiome and intestinal barrier failure – the “Achilles heel” in hepatology?. J Hepatol 2012; 56: 1221-1223
• 11 Fukui H, Wiest R. Changes of intestinal functions in liver cirrhosis. Inflamm Intest Dis 2016; 1: 24-40
• 12 Nagasako CK, de Oliveira Figueiredo MJ, de Souza Almeida JR. et al. Investigation of autonomic function and orocecal transit time in patients with nonalcoholic cirrhosis and the potential influence of these factors on disease outcome. J Clin Gastroenterol 2009; 43: 884-889
• 13 Aqel BA, Scolapio JS, Dickson RC. et al. Contribution of ascites to impaired gastric function and nutritional intake in patients with cirrhosis and ascites. Clin Gastroenterol Hepatol 2005; 3: 1095-1100
• 14 Van Thiel DH, Fagiuoli S, Wright HI. et al. Gastrointestinal transit in cirrhotic patients: effect of hepatic encephalopathy and its treatment. Hepatol 1994; 19: 67-71
• 15 Chander RB, Garcia-Tsao G, Ciarleglio MM. et al. Decompensated cirrhotics have slower intestinal transit times as compared with compensated cirrhotics and healthy controls. J Clin Gastroenterol 2013; 47: 888-893
• 16 Ang D, Pannemans J, Vanuytsel T. et al. A single-center audit of the indications and clinical impact of prolonged ambulatory small intestinal manometry. Neurogastroenterol Motil 2018; 30: e13357
• 17 Lindberg G, Iwarzon M, Stal P. et al. Digital ambulatory monitoring of small-bowel motility. Scand J Gastroenterol 1990; 25: 216-24
• 18 Widmer R, Schmidt T, Pfeiffer A. et al. Computerized analysis of ambulatory long-term small-bowel manometry. Scand J Gastroenterol 1994; 29: 1076-1082
• 19 Schmidt T, Steinmann C, Pfeiffer A. et al. Computerized comparison of small bowel manometry with perfused tubes and intraluminal pressure sensors. Gastroenterol 1999; 116: A1078
• 20 Schmidt T, Widmer R, Pfeiffer A. et al. Effect of the quaternary ammonium compound trospium chloride on 24 hour jejunal motility in healthy subjects. Gut 1994; 35: 27-33
• 21 Pugh RN, Murray-Lyon IM, Dawson JL. et al. Transection of the esophagus for bleeding oesophageal varices. Br J Surg 1973; 60: 646-649
• 22 Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut 2006; 55: 1-12
• 23 Schmidt T, Pfeiffer A, Hackelsberger N. et al. Dysmotility of the small intestine in achalasia. Neurogastroenterol Motil 1999; 11: 11-17
• 24 Hackelsberger N, Schmidt T, Renner R. et al. Ambulatory long-term jejunal manometry in diabetic patients with cardiac autonomic neuropathy. Neurogastroenterol Motil 1997; 9: 77-83
• 25 Wackerbauer R, Schmidt T, Widmer R. et al. Discrimination of irritable bowel syndrome by non-linear analysis of 24-h jejunal motility. Neurogastroenterol Motil 1998; 10: 331-337
• 26 Schmidt T, Eberle R, Pfeiffer A. et al. Effect of ethanol on postprandial duodenojejunal motility in humans. Dig Dis Sci 1997; 42: 1628-1633
• 27 Schmidt T, Pfeiffer A, Kaess H. Abnormal intestinal motility in irritable bowel syndrome. Gastroenterol 1996; 111: 1400-1401
• 28 Schmidt T, Pfeiffer A, Hackelsberger N. et al. Effect of intestinal resection on human small bowel motility. Gut 1996; 38: 859-863
• 29 Schmidt T, Hackelsberger N, Widmer R. et al. Ambulatory 24-hour jejunal motility in diarrhea-predominant irritable bowel syndrome. Scand J Gastroenterol 1996; 31: 581-559
• 30 Schmid HR, Ehrlein HJ. Effects of enteral infusion of hypertonic saline and nutrients on canine jejunal motor patterns. Dig Dis Sci 1993; 38: 1062-1072
• 31 Husebye E. The patterns of small bowel motility: physiology and implications in organic disease and functional disorders. Neurogastroenterol Motil 1999; 11: 141-161
• 32 Medhus AW, Sandstad O, Bredesen J. et al. Stimulation of the small intestine by nutrients in relation to phase of the migrating motor complex. Scand J Gastroenterol 2000; 35: 494-500
• 33 Sarna SK, Soergel KH, Harig JM. et al. Spatial and temporal patterns of human jejunal contractions. Am J Physiol 1989; 257: G423-G432
• 34 Ledeboer M, Masclee AA, Biemond I. et al. Effect of intragastric or intra- duodenal administration of a polymeric diet on gallbladder motility, small-bowel transit time, and hormone release. Am J Gastroenterol 1998; 93: 2089-2096
• 35 Karlsen S, Fynne L, Grønbæk H. et al. Small intestinal transit in patients with liver cirrhosis and portal hypertension: a descriptive study. BMC Gastroenterol 2012; 12: 176
• 36 Galati JS, Holdeman KP, Dalrymple GV. et al. Delayed gastric emptying of both the liquid and solid components of a meal in chronic liver disease. Am J Gastroenterol 1994; 89: 708-711
• 37 Van V, Schoonjans RS, Struijk DG. et al. Influence of dialysate on gastric emptying time in peritoneal dialysis patients. Perit Dial Int 2002; 22: 32-38
• 38 Schoonjans R, Van Vlem B, Vandamme W. et al. Gastric emptying of solids in cirrhotic and peritoneal dialysis patients: influence of peritoneal volume load. Eur J Gastroenterol Hepatol 2002; 14: 395-398
• 39 Scolapio JS, Ukleja A, McGreevy K. et al. Nutritional problems in end-stage liver disease: contribution of impaired gastric emptying and ascites. J Clin Gastroenterol 2002; 34: 89-93
• 40 Camilleri M, Bharucha AE, di Lorenzo C. et al. American Neurogastroenterology and Motility Society consensus statement on intraluminal measurement of gastrointestinal and colonic motility in clinical practice. Neurogastroenterol Motil 2008; 20: 1269-1282
• 41 Kellow JE, Gill RC, Wingate DL. Prolonged ambulant recordings of small bowel motility demonstrate abnormalities in the irritable bowel syndrome. Gastroenterol 1990; 98: 1208-1218
• 42 Yiannakou Y, Piessevaux H, Bouchoucha M. et al. A randomized, double-blind, placebo-controlled, phase 3 trial to evaluate the efficacy, safety, and tolerability of prucalopride in men with chronic constipation. Am J Gastroenterol 2015; 110: 741-748