4. Disorders of gut mobility

📄 Definition

Conditions where peristalsis or transit of food/waste through the GI tract is abnormal, leading to symptoms without primary structural lesions. Can affect oesophagus, stomach, small bowel, or colon.

🛡️ Aetiology / Risk Factors

SharedOesophageal (Achalasia)Gastric (Gastroparesis)Colonic (Slow Transit / Ogilvie’s)
Diabetes mellitusChagas diseaseDiabetes (autonomic neuropathy)Post-operative states
Connective tissue diseaseIdiopathic degenerationPost-viral illnessElectrolyte imbalance
Drugs (opioids, anticholinergics)Oesophageal cancer (pseudoachalasia)Opioids, anticholinergicsSevere illness, immobility
Neurological disease (Parkinson’s, MS) Post-surgical vagal injuryDrugs: opioids, anticholinergics, calcium channel blockers

🤒 Clinical Features

1️⃣ Achalasia – “SOLID → LIQUID” Dysphagia

  • Progressive dysphagia (solids then liquids)

  • Regurgitation of undigested food

  • Retrosternal chest pain

  • Weight loss

  • No relief with PPIs

2️⃣ Gastroparesis – “FULL FAST”

  • Early satiety

  • Nausea, vomiting (especially after meals)

  • Bloating, abdominal discomfort

  • Weight loss in severe cases

3️⃣ Chronic Intestinal Pseudo-Obstruction (CIPO)

  • Features of bowel obstruction (distension, pain, vomiting) without a mechanical cause

  • Constipation or diarrhoea

  • Can be chronic or relapsing

4️⃣ Slow Transit Constipation (Colonic Inertia)

  • Infrequent bowel movements (<2/week)

  • Abdominal bloating

  • Often young women with long history

5️⃣ Hirschsprung’s Disease (Children)

  • Delayed passage of meconium (>48h after birth)

  • Constipation, abdominal distension

  • Bilious vomiting

6️⃣ Ogilvie’s Syndrome (Acute Colonic Pseudo-obstruction)

  • Acute massive colonic dilatation

  • Abdominal distension, pain

  • Nausea/vomiting, constipation

  • Common in elderly post-op patients or those with severe illness

🚩 Red Flag Criteria – ABCD mnemonic

  • A – Acute obstruction signs (vomiting, distension, no stool/flatus)

  • B – Bleeding (unexplained GI bleed)

  • C – Cachexia or rapid unintentional weight loss

  • D – Distension + severe pain + systemic toxicity (risk of perforation)

🔬 Investigations

TestIndicationNotes
BloodsAll suspected casesFBC, U&E, CRP, LFTs, TFTs, coeliac screen, glucose
AXR / CT abdomen-pelvisSuspected obstruction / Ogilvie’sRule out mechanical cause
Barium swallowAchalasia suspicion“Bird’s beak” narrowing at LOS
ManometryAchalasia / motility diagnosisGold standard
Gastric emptying studyGastroparesis suspicionScintigraphy most accurate
Transit studiesSuspected slow transit constipationRadiopaque marker method
Rectal biopsyHirschsprung’s diseaseDemonstrates absence of ganglion cells

📋 Management — Stepwise  (Overview)

1️⃣ Initial safety screen → 🚩obstruction/perforation, severe pain, bleeding, cachexia → urgent hospital admission
2️⃣ Stop aggravators → opioids, anticholinergics, CCBs; correct K⁺/Mg²⁺/PO₄³⁻; hydrate/nutrition
3️⃣ Targeted investigations to confirm the motility diagnosis (see condition ladders)
4️⃣ Condition-specific therapy (below)
5️⃣ Escalation & referral → specialist gastro + surgery if failing conservative therapy or if complications

1️⃣ Achalasia 

  1. While awaiting definitive therapy: small frequent meals, chew well, avoid late meals; aspiration advice.

  2. Confirm diagnosis: barium swallow → manometry (gold standard).

  3. Definitive therapy (choose one):

    • Pneumatic dilatation or Laparoscopic Heller myotomy + partial fundoplication

    • POEM (per‑oral endoscopic myotomy) in centres with expertise

  4. If unfit / bridge: endoscopic botulinum toxin; trial smooth‑muscle relaxants (nitrates/CCBs) for symptom relief.

  5. Aftercare: monitor for reflux post‑myotomy → PPI; repeat therapy if relapse.

PARA tip: Dysphagia solids → liquids, poor PPI response, “bird’s beak” = achalasia; manometry confirms.

2️⃣ Gastroparesis 

  1. Fix the fixables: optimise glycaemic control; stop/limit opioids, anticholinergics; correct electrolytes.

  2. Dietetic first‑line: small, low‑fat, low‑fibre meals; liquid nutrient supplements; dietitian review.

  3. Prokinetic ± antiemetic (short courses):

    • Metoclopramide or domperidone; consider erythromycin short‑term (tachyphylaxis).

    • Safety: watch QT/extrapyramidal risks; review drug interactions.

  4. Nutrition escalation (refractory): trial liquid diet → jejunal feeding; consider venting gastrostomy.

  5. Specialist options: tertiary referral; selected cases gastric electrical stimulation.

PARA tip: Diagnosis = gastric emptying scintigraphy. Always mention dietitian + drug review first.

3️⃣ Chronic Intestinal Pseudo‑Obstruction (CIPO) 

  1. Exclude mechanical obstruction (CT ± endoscopy). Treat precipitants (sepsis, hypothyroid, electrolytes).

  2. Decompression & support: NG/nasojejunal decompression, IV fluids, analgesia that avoids opioids.

  3. Prokinetic trial (specialist‑guided): e.g., metoclopramide/domperidone; manage pain with non‑opioid regimens.

  4. Nutrition: step up oral → enteral → parenteral if needed; MDT (gastro, nutrition, surgery).

  5. Definitive: treat underlying neuromuscular/systemic cause; avoid extensive resections unless complications.

🚩 Admit if uncontrolled pain, systemic toxicity, or persistent dilatation despite conservative care.

4️⃣ Slow Transit Constipation (Colonic Inertia)  

  1. Foundations: fluids, fibre titration, activity, bowel routine, correct toileting position.

  2. First‑line meds: osmotic laxative (macrogol) → titrate; add stimulant (senna/bisacodyl) if needed.

  3. If impaction: high‑dose macrogols → suppositories/enema if required.

  4. Second‑line (laxative‑refractory): prucalopride (5‑HT4 agonist) after exclusion of secondary causes.

  5. Specialist: transit/pelvic floor studies; biofeedback if dyssynergia; surgery (subtotal colectomy) only after MDT.

PARA tip: Document response to each step; don’t jump to prucalopride before adequate laxative trial.

5️⃣ Hirschsprung’s Disease (Paediatrics)  

  1. Stabilise: NBM, NG/rectal decompression, IV fluids/electrolytes; screen/treat enterocolitis.

  2. Diagnosis: rectal suction biopsy (absent ganglion cells).

  3. Definitive: pull‑through surgery by paediatric surgeons.

  4. Aftercare: bowel regime, manage constipation/soiling; educate parents on HAEC signs (fever, distension, diarrhoea).

🚩 Immediate paediatric surgery referral for suspected cases, or enterocolitis features.

6️⃣ Ogilvie’s Syndrome (Acute Colonic Pseudo‑obstruction)  

  1. Conservative (24–48 h): stop precipitating drugs, NBM, NG + rectal tube, IV fluids, correct K⁺/Mg²⁺/Ca²⁺, mobilise, treat pain without opioids.

  2. Pharmacologic decompression: IV neostigmine with cardiac monitoring if persistent dilatation or caecum large.

  3. Endoscopic decompression: if neostigmine fails/contraindicated; consider decompression tube.

  4. Surgery: for ischaemia/perforation or refractory dilation (e.g., caecostomy/hemicolectomy).

🚩 Escalate urgently if caecal diameter ≥ ~12 cm, worsening pain, fever, acidosis, or peritonism.

🧠 Exam Quick‑View (PARA)

  • Start with safety, stop aggravators, correct electrolytes, dietitian.

  • Achalasia needs manometry and definitive mechanical therapy (dilatation/myotomy/POEM).

  • Gastroparesis = dietetic + prokinetic; escalate nutrition early; optimise diabetes.

  • Ogilvie’s = conservative → neostigmine → scope → surgery (watch caecal size).

⚠️ Complications

  • Bowel perforation

  • Severe electrolyte disturbance (K+, phosphate, Mg)

  • Malnutrition and weight loss

  • Aspiration (achalasia regurgitation)

📅 Last updated in line with:

  • NICE CG99 (Constipation in adults) – Published May 2010 • Last updated Nov 2017

  • NICE NG130 (Constipation in children and young people) – Published July 2019

  • NICE NG6 (Diabetes in adults – gastroparesis) – Published Dec 2015 • Last updated Aug 2023
    Last reviewed: August 2025
    PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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