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Rare gastrointestinal and liver diseases initiative EMA 8 th December 2015 Intestinal Pseudo-obstruction (Gut Motility Disorders) Nikhil Thapar Division of Neurogastroenterology & Motility Department of Paediatric Gastroenterology Great

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  1. Rare gastrointestinal and liver diseases initiative EMA 8 th December 2015 Intestinal Pseudo-obstruction (Gut Motility Disorders) Nikhil Thapar Division of Neurogastroenterology & Motility Department of Paediatric Gastroenterology Great Ormond Street Hospital & UCL Institute of Child Health

  2. Gastrointestinal Tract functions dependent on gut motility

  3. Gut Motility complex regional patterns Modified from Furness, J. B. (2012) Nat. Rev. Gastroenterol. Hepatol.

  4. Gut Motility Disorders failure of gut neuromusculature Modified from Furness, J. B. (2012) Nat. Rev. Gastroenterol. Hepatol.

  5. Paediatric Gastrointestinal Motility Disorders rare, diverse and challenging 1:500,000 ? ?1:100,000 1:5,000 ? ? Burns & Thapar (2014) Nature Reviews Gastro Hepatol

  6. Chronic Intestinal Pseudo-obstruction Failure of function of the small intestine • Symptoms/signs of small intestinal obstruction but no mechanical cause • Dilated small intestine with fluid levels

  7. Paediatric Intestinal Pseudo-obstruction natural history and prognosis In infants CIPO appears to have a particularly severe course •60%–80% requiring parenteral nutrition and •10%–25% dying before adulthood Mousa et al. Dig Dis Sci 2001 Faure et al. Dig Dis Sci 1999 Muto et al. JPS 2014 Underlying aetiology Intestinal transplantation Other Re-Tx Volvulus Tumour Aganglionosis Soh et al. JPS 2015 Motility (other) Pseudo- obstruction Gastroschisis Malabsorption (other) MVID Short gut NEC Atresias (Other)

  8. Paediatric Intestinal Pseudo-obstruction Great Ormond Street Hospital data pre-2012 Delayed referral and/or diagnosis • 11.3 years Repeated unnecessary abdominal surgeries • 3-5 surgeries before referral to tertiary centre Poor feed tolerance • ~100% on parenteral nutrition Complications (morbidity, hospitalisation days, mortality) • 90 days a year in hospital, 20-30% mortality, PN related complications Poor quality of life

  9. Paediatric Intestinal Pseudo-obstruction Epidemiology North America - NASPGHAN Survey • 100 infants are born in the United States every year with CIPO • incidence of approximately 1 per 40,000 live births • Equal sex incidence Japan - Nationwide survey • children younger than 15 years of age the prevalence of 3.7 in one million children (1 in 270,000 children) • 56.5% developed CIPO in the neonatal period • Equal sex incidence Vargas et al JPGN 1988 Muto et al. JPS 2014

  10. Paediatric Intestinal Pseudo-obstruction Pharmacotherapy • Anticholinesterase inhibitors – Neostigmine, Pyridostigmine, Donepezil • 5HT 4 Receptor Agonists – (Cisapride, Tegaserod withdrawn) – Prucalopride – TD-5108 • Motilin Agonists / Ghrelins • Octreotide • Cannabinoids • Opioid Receptor Antagonists • Chloride Channel Activators – Lubiprostone • Guanylate Cyclase Receptor Agonists – Linaclotide • Antibiotics

  11. Paediatric Intestinal Pseudo-obstruction Pharmacotherapy • Anticholinesterase inhibitors – Neostigmine, Pyridostigmine, Donepezil • 5HT 4 Receptor Agonists – (Cisapride, Tegaserod withdrawn) – Prucalopride – TD-5108 • Motilin Agonists / Ghrelins • Octreotide • Cannabinoids • Opioid Receptor Antagonists • Chloride Channel Activators – Lubiprostone • Guanylate Cyclase Receptor Agonists – Linaclotide • Antibiotics

  12. Paediatric Intestinal Pseudo-obstruction Management • Nutrition to preserve growth and development – Enteral feeds – PN • Limit symptoms & improve quality of life – Medical Rx – Surgery – Psychology • Prevent complications – Sepsis – Bacterial Overgrowth

  13. Chronic Intestinal Pseudo-obstruction Challenges • Rare – need for national/international registries – collaboration • Lack of clarity – aetiopathogenesis – diagnostic criteria – classification • Lack of uniformity – available expertise – diagnostic protocols – management strategies

  14. gut environmental factors cell signalling pathways transcription factors intracellular molecules

  15. Neuro-immune interactions role in gastrointestinal symptoms/disease Ye et al 2008 J Cell Mol Med Smyth et al 2013 Plos One Serotonin (5HT 3, 5HT 1P ) PAR 1,2 and 4 Leukotrienes MBP Histamine 1-4 Eotaxin Etc… CGRP Substance P IL-9 Substance P CAM 1 Acetylcholine Acetylcholine IL-4 Noradrenaline IL-13 IL-4 Etc… Eotaxin IL-13 IL-3 IL-5 IL-4,13 Etc… GM-CSF IL-9 IL-4, 5, 13, TNF

  16. Neuro-immune-microbiome interactions role in gastrointestinal symptoms/disease Ye et al 2008 J Cell Mol Med Smyth et al 2013 Plos One Serotonin (5HT 3, 5HT 1P ) PAR 1,2 and 4 Leukotrienes MBP Histamine 1-4 Eotaxin Etc… CGRP Substance P IL-9 Substance P CAM 1 Acetylcholine Acetylcholine IL-4 Noradrenaline IL-13 IL-4 Etc… Eotaxin IL-13 IL-3 IL-5 IL-4,13 Etc… GM-CSF IL-9 IL-4, 5, 13, TNF

  17. Neuro-immune-microbiome-brain interactions role in gastrointestinal symptoms/disease Ye et al 2008 J Cell Mol Med Smyth et al 2013 Plos One Serotonin (5HT 3, 5HT 1P ) PAR 1,2 and 4 Leukotrienes MBP Histamine 1-4 Eotaxin Etc… CGRP Substance P IL-9 Substance P CAM 1 Acetylcholine Acetylcholine IL-4 Noradrenaline IL-13 IL-4 Etc… Eotaxin IL-13 IL-3 IL-5 IL-4,13 Etc… GM-CSF IL-9 IL-4, 5, 13, TNF

  18. Human studies In vivo transplantation of post-natal neural stem cells Dissociation into single cells Rag2 - /γc - /C5 - mouse p75 NTR Natarajan et al , Neurogastroenterol Motil 2014

  19. Thank You

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