Soffer EE
Cleveland Clinic Foundation, Gastroenterology Department S40, 9500 Euclid Avenue, Cleveland, OH 44195.
Curr Treat Options Gastroenterol. 1998 Dec;1(1):8-14. doi: 10.1007/s11938-998-0002-1.
The most important initial step in treating patients with intestinal dysmotility is to exclude reversible causes, in particular mechanical obstruction. The presence or absence of bacterial overgrowth should be determined by small bowel aspirate or breath test, although an empiric trial with antibiotics is an appropriate alternative. Physicians should use agents effective against gram-negative organisms, such as broad-spectrum penicillins or tetracycline, particularly those that provide coverage of anaerobes, such as metronidazole. Nutritional support, by enteral or parenteral means, is currently the most important aspect of management of patients with severe intestinal dysmotility. A low-fat diet, supplemented by liquid formulas, can be tried first. The presence of gastroparesis should be determined; if severe, jejunal feeding should be attempted. Because of the costs and risks associated with total parenteral nutrition (TPN), every attempt should be made to use the native intestine for feeding. A trial of several days of naso-jejunal feeding can help select those patients who can obtain sufficient nutrition by enteral routes and is recommended prior to committing a patient to TPN therapy. Even while on TPN, some oral intake should be encouraged. Prokinetic agents currently in use are less effective in the small bowel than they are in the stomach. They should always be tried initially, though, particularly because improvement of concomitant gastric dysmotility can alleviate symptoms. Although certain manometric patterns can select those patients who respond better to therapy, manometry should not be used to direct therapy in individual patients. For the moment, cisapride is the drug of choice. Erythromycin, particularly when given intravenously and in small, sub-antibiotic doses, can also be tried. The role of octreotide is not clear, but when given at small doses, and when combined with erythromycin, it may be useful in selected patients. Ablative surgery may be useful in a few, highly selected patients. One of the most beneficial surgical procedures is a venting jejunostomy. The use of this simple intervention can substantially reduce the number of hospital admissions and emergency room visits in selected patients with intermittent obstructive symptoms.
治疗肠道动力障碍患者最重要的初始步骤是排除可逆性病因，尤其是机械性梗阻。应通过小肠抽吸物或呼气试验来确定是否存在细菌过度生长，不过经验性使用抗生素进行试验也是一种合适的选择。医生应使用对革兰氏阴性菌有效的药物，如广谱青霉素或四环素，特别是那些能覆盖厌氧菌的药物，如甲硝唑。通过肠内或肠外途径进行营养支持，是目前严重肠道动力障碍患者管理的最重要方面。可先尝试低脂饮食，并辅以流食配方。应确定是否存在胃轻瘫；如果严重，应尝试空肠喂养。由于全胃肠外营养（TPN）相关的费用和风险，应尽一切努力利用自身肠道进行喂养。进行几天的鼻空肠喂养试验有助于筛选出那些可通过肠内途径获得足够营养的患者，并且在让患者接受TPN治疗之前推荐进行此项试验。即使在接受TPN治疗期间，也应鼓励患者进行一些口服摄入。目前使用的促动力药物在小肠中的效果不如在胃中显著。不过，一开始总是应该尝试使用促动力药物，特别是因为改善伴随的胃动力障碍可以缓解症状。虽然某些测压模式可以筛选出对治疗反应较好的患者，但测压不应被用于指导个体患者的治疗。目前，西沙必利是首选药物。也可以尝试使用红霉素，特别是静脉注射小剂量、低于抗生素剂量的红霉素。奥曲肽的作用尚不清楚，但小剂量给药并与红霉素联合使用时，可能对部分患者有用。切除手术可能对少数经过严格筛选的患者有用。最有益的外科手术之一是空肠造口排气术。这种简单的干预措施的应用，可以大幅减少部分有间歇性梗阻症状患者的住院次数和急诊就诊次数。
