Management of Chronic Intestinal Pseudo-Obstruction (CIPO)

Introduction to CIPO Management

The American Gastroenterological Association recommends a multidisciplinary team approach for CIPO management, prioritizing nutritional support, symptom control with prokinetics and antibiotics for bacterial overgrowth, and avoidance of unnecessary surgery, with parenteral nutrition reserved for patients who cannot maintain nutrition enterally 1, 2

A multidisciplinary team for CIPO management should include gastroenterologists, gastrointestinal physiologists, surgeons, pain specialists, psychiatrists/psychologists, dietitians, specialist nurses, clinical biochemists, histopathologists, and pharmacists, with regional networking encouraged for support and data collection 1

The primary aims of CIPO treatment are to reduce symptoms, reduce morbidity and mortality, achieve a normal BMI, and improve quality of life 1

The European Society for Clinical Nutrition and Metabolism recommends oral nutrition optimization as the first step, beginning with oral supplements and dietary adjustments if the patient is malnourished or at risk 2
The American Gastroenterological Association suggests frequent small meals (4-6 per day) with low-fat, low-fiber content and liquid nutritional supplements, as many CIPO patients tolerate liquids better than solids 3, 4
Separating liquids from solids by avoiding drinking 15 minutes before or 30 minutes after eating can help minimize bacterial overgrowth 4

The American Gastroenterological Association recommends attempting a trial with prokinetics, even though they help only a minority of patients with generalized motility disorders 3
Main drugs used include metoclopramide, domperidone, erythromycin, octreotide, and neostigmine 3
Octreotide (50-100 mcg/day subcutaneously) has shown benefit in adults with scleroderma-associated CIPO 3
Sequential antibiotic therapy is very effective in treating intestinal bacterial overgrowth and reducing malabsorption, improving nutritional status and sometimes bloating 3
Rifaximin (550mg twice daily for 1-2 weeks) is recommended as first-line treatment due to its non-systemic action and favorable side effect profile 5

The American Gastroenterological Association advises avoiding high doses of opioids, as they worsen intestinal dysmotility and can lead to narcotic bowel syndrome 1, 2
If the patient has taken long-term opioids, consider gradual supervised opioid withdrawal with involvement of a pain specialist 1

The European Society for Clinical Nutrition and Metabolism recommends monitoring for deficiencies in fat-soluble vitamins (A, D, E, K) and supplementing with water-miscible forms: Vitamin A (10,000 IU daily), Vitamin D (3000 IU daily), Vitamin E (100 IU daily), and Vitamin K (300 mcg daily) 4, 5
Check vitamin B12 and iron status, as these are commonly depleted 4

The American Gastroenterological Association recommends avoiding surgery in CIPO patients whenever possible due to the risk of postoperative worsening of intestinal function and need for subsequent reoperation 3
A venting ostomy (either endoscopically or surgically) can diminish symptoms in selected patients 3
Optimize nutritional status before any surgical procedure whenever possible 2

Assess nutritional status regularly, aiming for BMI within normal range 1
Monitor for complications of bacterial overgrowth including malabsorption, vitamin deficiencies, and sepsis 3
If numbness or tingling in feet develops while on antibiotics, stop immediately and contact physician, as this indicates peripheral neuropathy 4
Monitor for persistent steatorrhea (fatty, foul-smelling stools) 4