Received: 22 April 2022 | Revised: 20 July 2022 | Accepted: 23 August 2022 DOI: 10.1111/nmo.14462 ORIGINAL ARTICLE Clinical significance of small bowel manometry patterns suggestive of intestinal obstruction Luis G. Alcalá-­González1,2,3 | Carolina Malagelada1,2,3 | Hugo Monrroy1,2,3 | Marianela Mego1,2,3 | Anna Accarino1,2,3 | Juan-­Ramon Malagelada1,2,3 | Fernando Azpiroz1,2,3 1 Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain Abstract Introduction: Minute rhythm and prolonged simultaneous contractions are patterns 2 Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain of postprandial small bowel contractile activity that historically have been considered 3 Centro de Investigación Biomédica as suggestive of mechanical intestinal obstruction; however, these patterns have been en Red de Enfermedades Hepáticas y also encountered in patients with motility-­like symptoms in the absence of bowel ob- Digestivas (Ciberehd), Barcelona, Spain struction. The objective of this study was to determine the current diagnostic out- Correspondence come of patients with these intestinal manometry patterns. Carolina Malagelada, Digestive System Research Unit, University Hospital Vall Methods: Retrospective study of patients with chronic digestive symptoms evaluated d'Hebron, 08035 Barcelona, Spain. by intestinal manometry at our center between 2010 and 2018. Email: cmalagelada@vhebron.net Results: The minute rhythm (MRP) or prolonged simultaneous contractions (PSC) Funding information postprandial patterns were detected in 61 of 488 patients (55 MRP and 6 PSC). Instituto de Salud Carlos III; Ministerio de Economía, Industria y Competitividad, Clinical work-­up detected a previously non-­diagnosed partial mechanical obstruction Gobierno de España of the distal intestine in 10 (16%) and a systemic disorder causing intestinal neuropa- thy in 32 (53%). In the remaining 19 patients (31%, all with MRP), the origin of the con- tractile pattern was undetermined, but in 16, substantial fecal retention was detected within 7 days of the manometric procedure by abdominal imaging, and in 6 of them colonic cleansing completely normalized intestinal motility on a second manometry performed within 39 ± 30 days. Conclusion and Inference: Currently, the most frequent origin of MRP and PSC en- countered on small bowel manometry is intestinal neuropathy, while a previously un- detected mechanical obstruction is rare. Still, in a substantial proportion of patients, no underlying disease can be identified, and in them, colonic fecal retention might play a role, because in a subgroup of these patients, manometry normalized after colonic cleansing. Hence, colonic preparation may be considered prior to intestinal manometry. KEYWORDS clustered contractions, constipation, intestinal manometry, intestinal neuropathy, minute rhythm, small bowel motility This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2022 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd. Neurogastroenterology & Motility. 2023;35:e14462.  wileyonlinelibrary.com/journal/nmo | 1 of 8 https://doi.org/10.1111/nmo.14462 2 of 8 | ALCALÁ-­GONZÁLEZ et al. 1 | I NTRO D U C TI O N Key Points Intestinal manometry is the current gold standard for the evalua- • Two small bowel manometry patterns, the minute tion of small bowel motor function.1,2 Manometric criteria for ab- rhythm and the prolonged simultaneous contractions normality, indicative of intestinal dysmotility, were established patterns, have historically been considered suggestive by observational studies comparing normal recordings in healthy of mechanical intestinal obstruction. volunteers to recordings from patients with severe, unexplained, • We have found that currently, the most frequent origin and long-­standing symptoms and suspected dysmotility. Specific of these patterns is intestinal neuropathy, while a previ- manometric criteria were developed to define dysmotility patterns ously undetected mechanical obstruction is rare. associated with intestinal neuropathy, myopathy, or partial luminal • Colonic fecal retention may also generate occlusive pat- occlusion, that is, criteria for neuropathic, myopathic, and occlusive terns in the small bowel, since in some patients with dysmotility patterns (Table 1).3–­7 Occlusive manometric patterns are pooling of solid stools in the colon, manometry normal- characterized by rhythmic activity repeating every 1–­3 min in the ized after colonic cleansing. postprandial period, lasting at least 30 minutes, and include two vari- ants: the “minute rhythm pattern” (also denominated “clustered con- tractions pattern”) and the “prolonged simultaneous contractions” pattern. The minute rhythm is characterized by short bursts (gener- patients´ consent for the retrospective analysis was waived by the ally <1 min) of 3–­8 contractions of >10 mmHg amplitude and 2–­5 s Ethical Committee. The study protocol was registered with the Clini​ duration each; the “prolonged simultaneous contractions” pattern calTr​ials.gov (ID: NCT05230121). All co-­authors had access to the is characterized by contractions of >20 mmHg amplitude and >8 s study data, reviewed and approved the final manuscript. duration2,8,9 (Figures 1 and 2). Clustered contractions observed dur- ing fasting or in shorter periods should not be considered abnormal, since they have been described in healthy subjects and in patients 2.2 | Patients’ management with irritable bowel syndrome.10–­13 Both prolonged simultaneous contractions and the minute 2.2.1 | Small bowel manometry rhythm pattern have been observed in patients with mechanical in- testinal obstruction, and resolve after surgical removal of the cause Small bowel manometry was performed using a standard technique, of occlusion.14–­16 However, these patterns have also been described as previously described. 21 Briefly, after an overnight fast, a mano- 3,17 in patients with intestinal neuropathy and in patients with severe metric tube (9012X1106 Special Manometric Catheter; Medtronic, 18–­20 motility-­like symptoms without bowel obstruction. Hence, it Skovlunde, Denmark) was orally introduced into the jejunum. Eight remains uncertain whether or not these types of activity reflect a water-­ perfused manometric ports (5 at 10 cm intervals and the reaction to luminal compromise, that is, whether they are obstruc- proximal 3 at 1 cm intervals) were positioned from the proximal duo- tive patterns. The objective of this study was to determine, in the denum to the mid-­jejunum with fluoroscopic assistance. Recordings current clinical setting, the diagnostic outcome of patients with the were obtained for 3 h during fasting and 2 h after ingestion of a minute rhythm (MRP) and prolonged simultaneous contractions solid–­liquid meal (450 kcal). In patients with gastroparesis diagnosed (PSC), that is, to determine to what extent they are indicative of in- by a gastric emptying scintigraphy test or unable to finish the meal, testinal obstruction. a liquid meal (Ensure HN; Abbott, Zwolle, The Netherlands; 1 kcal/ ml) was infused through the most proximal channel at 2 kcal/min to induce a postprandial activity pattern for 2 h. Manometric di- 2 | M ATE R I A L S A N D M E TH O DS agnosis of abnormal motility was established using the previously published criteria (Table 1).6,22 Specifically, patterns suggestive of 2.1 | Study design intestinal obstruction were defined as regular motor events repeat- ing every 1–­3 min and occurring over a ≥ 20-­cm intestinal segment Manometric tracings from consecutive patients referred to the Vall during a ≥ 30-­min period in postprandial conditions. Following up d'Hebron Digestive Function Unit between 2010 and 2018 for eval- previously established criteria, these patterns included two vari- uation of intestinal motility, due to severe, chronic digestive symp- ants, depending on whether the repetitive motor events consisted in toms and suspected dysmotility, were reviewed, and a retrospective short clusters of contractions (minute rhythm pattern) or prolonged analysis of cases with patterns suggestive of intestinal obstruc- simultaneous contractions (>20 mmHg amplitude and >8 s duration) tion (minute rhythm pattern and prolonged simultaneous contrac- (Figure 1). tions) was performed. The protocol was approved by the Ethics A report of the manometric study with full description of the Committee of the University Hospital Vall d'Hebron. All patients dysmotility patterns encountered was filed with the medical record provided written informed consent for the manometric evaluation; of each patient. ALCALÁ-­GONZÁLEZ et al. | 3 of 8 TA B L E 1 Diagnostic criteria for abnormal intestinal manometry motility disorder (chronic intestinal pseudo-­obstruction and/or se- Neuropathic pattern vere gastroparesis), or (d) iatrogenic neural injury. In none of the pa- • Abnormal configuration of Phase III: Tonic rises of baseline tients a surgical exploration for an intestinal full-­thickness biopsy pressure over 30 mmHg amplitude ≥3-­min duration. was indicated. • Abnormal propagation of Phase III: Simultaneous or retrograde propagation over ≥20-­cm segment of small bowel. • Inability of an adequate meal to induce a normal fed pattern: no 2.3 | Retrospective analysis changes in activity during postprandial period (no fed pattern) or phase III-­like activity during postprandial period (while disregarding the first 20 min after beginning of meal). For the present study, the manometric reports of all patients with • Bursts: At least one period of ≥5 min, or two periods of ≥2 min intestinal manometry performed between 2010 and 2018 were duration with continuous high-­amplitude (≥20 mmHg) and high-­ revised, and the manometric recordings that had been reported of frequency (10–­12/min) phasic pressure activity not followed by minute rhythm or prolonged simultaneous contraction pattern in motor quiescence. the postprandial period were retrieved and re-­analyzed by two in- • Sustained contractions: Prolonged (≥30 min duration), high-­ vestigators (HM and CM) to confirm the original report. The clinical amplitude (≥20 mmHg) and high-­frequency (10/min) phasic pressure activity that occurs in a segment of intestine with records of these patients were reviewed to obtain: (a) demographic normal or reduced activity recorded at other levels. data, (b) digestive symptoms at the time of evaluation, (c) history Myopathic pattern of abdomino-­pelvic surgeries or radiotherapy prior to manometry, • Hypomotility: Low-­amplitude contractions (i.e., contractions (d) diagnosis of systemic disorders, and (e) presence of esophageal, <10 mmHg) or contractions with amplitude <20 mmHg also gastric, or colonic dysmotility. Results from radiological and other during phase III. investigations were also revised, as well as therapeutic decisions Patterns suggestive of mechanical obstruction and clinical outcome. Particularly, it was documented whether ab- • Minute rhythm (or clustered contractions): intermittent periodic dominal imaging studies (simple abdominal X-­ray or abdominal CT activity (shorts bursts, generally lasting <1 min, and repeating scans) were performed within 7 days of the manometric study, and every 1–­3 min) occurring over a ≥ 20-­cm intestinal segment, the studies were reviewed in search of pooling of solid stools in the during a ≥ 30-­min period in postprandial conditions. right colon. • Prolonged simultaneous contractions: prolonged (>8 s duration), high-­amplitude (>20 mmHg) contractions occurring simultaneously in recording sites at least 20 cm apart, during a ≥ 30-­min period in postprandial conditions. 2.4 | Statistical analysis Statistical analysis was performed with SPSS Statistics for Windows 2.2.2 | Clinical follow-­up (V22.0, IBM, Armonk, New York). Normality of data distribution was evaluated by the Shapiro–­Wilk test. Comparisons of paramet- Based on the manometric findings and the clinical context, patients ric, normally distributed data were made by Student's t-­test, paired underwent further clinical evaluation to try to identify potential tests for intragroup comparisons, and unpaired tests for intergroup causes of intestinal dysmotility. Patients with dysmotility were comparisons; otherwise, the Wilcoxon signed rank test was used evaluated to determine whether other regions of the gut, such as for paired data within groups and the Mann–­Whitney U-­test for un- the esophagus, stomach, and colon, were affected by esophageal paired data between groups. Continuous variables were compared manometry, gastric emptying scintigraphy, colonic transit, and ab- using Pearson's R. Differences were considered significant at a p dominal imaging. If suspected, small bowel bacterial overgrowth value <0.05. (SIBO) was investigated by glucose breath tests. Diabetes, auto- immune disorders, or other systemic disorders were sought for by specific tests following clinical criteria. Since postprandial minute 3 | R E S U LT S rhythm and prolonged simultaneous contractions are considered characteristic of luminal compromise of the distal gut, patients with 3.1 | Demographic and clinical data these motor patterns routinely underwent an exhaustive radiologi- cal evaluation of the gut, to detect or exclude causes of partial me- During the 9-­year study period, between 2010 and 2018, 488 pa- chanical obstruction. 2 In the absence of mechanical obstruction, in tients (16–­84 age range, 363 women) who had been referred for patients with MRP or PSC the diagnosis of intestinal neuropathy evaluation of intestinal motility underwent small bowel manom- was established in the presence of (a) other manometric criteria etry. Patterns considered suggestive of intestinal obstruction were of neuropathy, (b) previous history of a systemic disorder causing detected in 13% of the patients (61 patients, 23–­80 age range, 40 intestinal neuropathy (either long-­ s tanding diabetes with other women). In the great majority of these patients (n = 55), the pattern neuropathic complications or predisposing neurological or auto- consisted of minute rhythm, while prolonged simultaneous contrac- immune disorders), (c) evidence of an advanced gastrointestinal tions were only present in 6 patients. Re-­analysis of their manometric 4 of 8 | ALCALÁ-­GONZÁLEZ et al. F I G U R E 1 Examples of the prolonged simultaneous contractions and minute rhythm patterns in the postprandial state F I G U R E 2 Example of minute rhythm pattern: expanded view. Note characteristic short bursts of 3–­8 contractions repeating every 1–­3 min tracings confirmed the original report in all cases. Review of their pattern after the meal, duration of the pattern, or length of intestine clinical records showed that all patients had severe chronic digestive affected by the pattern) were detected among the three categories symptoms (abdominal pain, abdominal bloating, chronic constipa- of patients or between the two manometric variants (minute rhythm tion, chronic diarrhea, chronic vomiting) of 3.5 years median duration and prolonged simultaneous contractions). (range 0.5–­25 years). Based on the manometric and clinical data, 10 patients were ascribed to mechanical obstruction and 32 patients to intestinal neuropathy, and in the remaining 19 patients, the min- 3.2 | Mechanical obstruction ute rhythm pattern was of undetermined origin (Figure 3). All 6 pa- tients exhibiting the prolonged simultaneous contraction pattern In 10 patients (16%) (8 patients featuring minute rhythm and 2 had either mechanical obstruction (n = 2) or intestinal neuropathy prolonged simultaneous contractions), mechanical intestinal ob- (n = 4) and none undetermined origin (see below). No differences in struction was documented during follow-­ up by either radiology the characteristics of the minute rhythm pattern (time to initiate the or surgery. The cause of the obstruction was inflammatory bowel ALCALÁ-­GONZÁLEZ et al. | 5 of 8 disease with intestinal stenosis in 2 patients, radiation enteritis con- intestinal neuropathy was established, as follows. Twenty-­t wo pa- secutive to previous radiotherapy in 3 patients, anastomotic stric- tients presented disorders known to cause intestinal neuropathy ture in 1 patient, colonic volvulation in 1 patient, and adhesions in (long-­s tanding diabetes mellitus with other neuropathic complica- the remaining 3 patients (all with previous abdominal surgeries). In tions in 10 patients, autoimmune/systemic disorder in 9 patients, this group of patients with documented mechanical obstruction, no and iatrogenic vagal nerve damage post-­fundoplication in 3 pa- other manometric abnormalities were detected. tients); 4 patients in this group (2 patients with diabetes and 2 with a systemic disorder) presented also other manometric criteria of neuropathy. In 6 patients, the diagnosis of intestinal neuropathy 3.3 | Intestinal neuropathy was established by presence of concomitant manometric criteria of intestinal neuropathy (uncoordinated bursts in 4 patients, and In 32 patients (53%) (28 patients featuring minute rhythm postprandial phase III in 2 patients). A third group of 4 patients had and 4 prolonged simultaneous contractions), the diagnosis of evidence of an advanced gastrointestinal motility disorder with radiological criteria of intestinal pseudo-­obstruction (n = 2) and/ or severe gastroparesis (n = 3). Patients with intestinal neuropathy exhibited higher incidence of SIBO than the other categories (73% vs 33% in the rest; p = 0.005). 3.4 | Minute rhythm of undetermined origin In the remaining 19 patients (31%), no mechanical cause of intestinal obstruction was detected nor was a diagnosis of intestinal neuropa- thy supported by other manometric or clinical criteria, and hence, the origin of the manometric pattern could not be determined; to note, all these patients exhibited a “minute rhythm pattern.” As compared to the other categories, patients with minute rhythm of F I G U R E 3 Study flow chart showing the classification of undetermined origin had a higher prevalence of chronic constipa- patients with manometric patterns suggestive of intestinal tion (63% vs 19% in patients with neuropathy and 10% in mechanical obstruction during the 9-­year study period obstruction; p = 0.001). F I G U R E 4 Example of the effect of bowel cleansing on the postprandial minute rhythm pattern in a patent with fecal retention. Manometric tracings and the corresponding abdominal X-­ray images, before (upper panel) and after colonic cleansing (lower panel) in the same patient. Note that in the same postprandial interval, colonic cleansing is associated with a complete resolution of the minute rhythm pattern 6 of 8 | ALCALÁ-­GONZÁLEZ et al. In 16 patients with minute rhythm of undetermined origin, ab- a proper flow of contents. In analogy to organic occlusion, the MRP dominal imaging (abdominal X-­ray or CT scan) was performed within and PSC patterns in patients with intestinal neuropathy may be a 7 days of the manometric procedure, and 11 of them presented sub- reaction to a downstream functional obstruction. In a recent study stantial fecal retention in the proximal colon. In 6 of these patients using an ex-­vivo animal model, minute rhythm was induced by intes- with fecal retention, a second intestinal manometry was performed tinal distension and found to be dependent on cholinergic nerves of with prior colonic cleansing within 39 ± 30 days after the first test. the enteric nervous system and nitric oxide. 23 Colonic cleansing was performed by a combination of oral laxatives In one third of cases, the origin of the minute rhythm pattern and enemas, and was confirmed by a subsequent abdominal X-­ray. In could not be determined and finally fell into the undetermined cat- all 6 patients, the second manometry was normal without criteria of egory. Interestingly in this group of patients, constipation was more minute rhythm or other dysmotility patterns (Figure 4). prevalent than in the rest of the patients with the MRP or PSC pat- terns. This finding fits with previous manometric studies in patients with slow-­transit constipation, which also reported increased clus- 4 | DISCUSSION tered contractions compared to healthy controls, although in these studies it is not specified if the pattern was observed during the post- This study shows that currently the most frequent cause of the prandial period or if it lasted more than 30 min. 24–­27 In a subgroup of minute rhythm and prolonged simultaneous contractions patterns patients with minute rhythm of undetermined origin, abdominal im- in small bowel manometry is a neuropathic disorder affecting the aging was performed closely before or after the manometric study, gut, whereas a previously undetected mechanical obstruction is and in the majority (16 out of 19) prominent fecal retention in the rare. Still, in approximately one third of our patients, no underlying proximal colon was observed. Anecdotally, in six patients a second disease could be identified, and the pattern might be related to co- manometric study was performed after colonic cleansing, and in all lonic fecal retention, because in a subgroup of patients with severe of them, the minute rhythm disappeared and the motor activity nor- constipation manometry normalized after the colon was cleansed. malized. We acknowledge that the value of these non-­systematic Previous studies dating over 20 years ago reported that 60–­ and retrospective observations is orientative at most, but it may in- 70% of patients exhibiting minute rhythm or prolonged simulta- dicate that the minute rhythm pattern may be related to a reaction neous contractions in the postprandial period had an underlying to downstream pooling of contents and dumped flow; hence, it could 16,17 mechanical intestinal obstruction; furthermore, surgical re- be speculated that under these circumstances, the manometric pat- moval of the cause of obstruction was shown to normalize the tern reflects a reactive pattern triggered by fecal retention. Vis-­a-­vis manometric pattern. By contrast, our data reflect that mechanical this information, we recently performed an experimental study in obstruction is only found in a minority of cases, less than one fifth healthy subjects, to determine the effect of colonic filling on small of our patients. The most plausible explanation for this observa- bowel motility. 28 The study showed that mild colonic filling with gas tion is the marked improvement of imaging studies, which now triggered a long-­distance retrograde reflex: high-­resolution jejunal allow accurate and prompt diagnosis of mechanical obstruction manometry detected repeat fronts of propagated contractions, in the early stages of the diagnostic work-­up, before second line with inhibition of background of segmental contractions, a motor studies, such as intestinal manometry, come into play. MRP and pattern reminiscent of the minute rhythm pattern described in this PSC patterns are a form of repetitive rhythmic activity that may study. Conceivably, advances in the recording techniques will help represent a motor reaction, attempting to overcome the obstruc- to understand the significance of reactive small bowel propagated tion to flow. The significance of the two variants, minute rhythm activity. versus prolonged simultaneous contractions, is uncertain. Both We acknowledge that we used stringent criteria to define dys- types of motor events display the same temporal organization, motility patterns, and particularly MRP and PSC, which restricts with the prolonged contractions seemingly representing a fusion the validity of our observation to very clear, severe cases. More of repeated contractions into a sustained event. Alternatively, it compliant criteria (shorter segment of intestine involved, less has been proposed that the prolonged contractions reflect a com- duration or appearance in fasting conditions) would reduce the mon cavity phenomenon in a dilated loop of intestine upstream specificity of the observations, and as discussed above, minor or the obstruction, which is plausible considering the simultaneous incomplete minute rhythm patterns can be observed in a num- pressure rise over a long intestinal segment.17 Previous data in- ber of functional digestive disorders and even in healthy sub- dicate that MRPs may be propagated; however, we acknowledge jects.10,12,13 Appearance of the MRP and PSC during postprandial that conventional manometric catheters, such as the ones used in conditions was a key criterion. Passage of chyme into the small this study, have limitations to determine the propagation of con- bowel during the postprandial period may activate small bowel tractile events. motility in case of downstream resistance to flow; indeed, in the In our cohort, the most frequent cause of minute rhythm or experimental study in healthy subjects, colonic gas filling during prolonged simultaneous contractions was intestinal neuropathy, fasting conditions did not modify small bowel activity, and the generally caused by an underlying systemic disorder. The intestine reactive pattern was only triggered with concomitant infusion of affected by a neuropathic disorder may be inefficient in achieving nutrients in the small bowel. 28 ALCALÁ-­GONZÁLEZ et al. | 7 of 8 6. Malagelada C, Karunaratne TB, Accarino A, et al. Comparison be- We also acknowledge that in this retrospective study the adscrip- tween small bowel manometric patterns and full-­thickness biopsy tion of individual patients to each category may be questionable, but histopathology in severe intestinal dysmotility. Neurogastroenterol this does not invalidate the broad observations on the etiology of Motil. 2018;30:e13219. 7. Ang D, Pannemans J, Vanuytsel T, Tack J. A single-­center audit MRP and PSC, particularly of luminal obstruction and intestinal neu- of the indications and clinical impact of prolonged ambula- ropathy, and the potential role of colonic fecal retention in case of tory small intestinal manometry. Neurogastroenterol Motil. undetermined origin. As a practical implication, colonic preparation 2018;30:e13357. may be recommended prior to intestinal manometry. 8. Rosen R, Garza JM, Tipnis N, Nurko S. An ANMS-­NASPGHAN con- sensus document on esophageal and antroduodenal manometry in children. Neurogastroenterol Motil. 2018;30:e13239. AU T H O R C O N T R I B U T I O N S 9. Verhagen MA, Samsom M, Jebbink RJ, et al. Clinical relevance LA was involved in data analysis and manuscript preparation; CM of antroduodenal manometry. Eur J Gastroenterol Hepatol. was involved in study design, study management, data analysis 1999;11:523-­528. and manuscript preparation; HM was involved in collecting and 10. Gorard DA, Libby GW, Farthing MJG. Ambulatory small intestinal motility in “diarrhoea” predominant irritable bowel syndrome. Gut. interpreting data; MM was involved in collecting and interpreting 1994;35:203-­210. data; AA was involved in conduction of studies and data interpre- 11. Chaussade S, Merite F, Hautefeuille M, Valleur P, Hautefeuille P, tation; JRM was involved in study design and data interpretation; Couturier D. Motility of the jejunum after proctocolectomy and FA was involved in study design, data interpretation and manu- ileal pouch anastomosis. Gut. 1989;30:371-­375. 12. Wilmer A, Andrioli A, Coremans G, Tack J, Janssens J. Ambulatory script preparation. small intestinal manometry. Detailed comparison of duodenal and jejunal motor activity in healthy man. Dig Dis Sci. 1997;42:1618-­1627. AC K N OW L E D G M E N T S 13. Kellow JE, Gill RC, Wingate DL. Prolonged ambulant recordings This work was supported by the Instituto de Salud Carlos III and co-­ of small bowel motility demonstrate abnormalities in the irritable bowel syndrome. Gastroenterology. 1990;98:1208-­1218. financed by the European Union (FEDER/FSE) [PI17/01794]; Spanish 14. Summers RW, Anuras S, Green J. Jejunal manometry patterns in Ministry of Economy and Competitiveness (Dirección General de health, partial intestinal obstruction, and pseudoobstruction. Investigación Científica y Técnica) [SAF 2016-­76648-­R]; Ciberehd is Gastroenterology. 1983;85:1290-­1300. funded by the Instituto de Salud Carlos III. LA was supported by the 15. Loftus E v, Farrugia G, Donohue JH, et al. Duodenal obstruc- tion: diagnosis by gastroduodenal manometry. Mayo Clin Proc Instituto de Salud Carlos III (CM20/00182). 1997;72:130–­2. 16. Frank JW, Sarr MG, Camilleri M. Use of gastroduodenal ma- C O N FL I C T O F I N T E R E S T nometry to differentiate mechanical and functional intestinal No conflicts of interest. obstruction: an analysis of clinical outcome. Am J Gastroenterol. 1994;89:339-­3 44. 17. Camilleri M. Jejunal manometry in distal subacute mechanical ob- ORCID struction: significance of prolonged simultaneous contractions. Luis G. Alcalá-­González https://orcid.org/0000-0003-3247-1539 Gut. 1989;30:468-­475. Carolina Malagelada https://orcid.org/0000-0001-7097-1492 18. Wilmer A, van Cutsem E, Andrioli A, Tack J, Coremans G, Janssens Hugo Monrroy https://orcid.org/0000-0002-4740-3945 J. Ambulatory gastrojejunal manometry in severe motility-­like dys- pepsia: lack of correlation between dysmotility, symptoms, and gas- Fernando Azpiroz https://orcid.org/0000-0002-7327-960X tric emptying. Gut. 1998;42:235-­242. 19. Stanghellini V, Ghidini C, Maccarini MR, Paparo GF, Corinaldesi REFERENCES R, Barbara L. Fasting and postprandial gastrointestinal motility in 1. Husebye E. The patterns of small bowel motility: physiology ulcer and non-­ulcer dyspepsia. Gut. 1992;33:184-­190. and implications in organic disease and functional disorders. 20. Cogliandro RF, Antonucci A, Giorgio R de, et al. Patient-­reported Neurogastroenterol Motil. 1999;11:141-­161. outcomes and gut dysmotility in functional gastrointestinal disor- 2. Camilleri M, Bharucha AE, Lorenzo C, et al. American ders. Neurogastroenterol Motil 2011;23:1084–­1091. Neurogastroenterology and motility society consensus state- 21. Malagelada C. Antroduodenojenunal Manometry. Encyclopedia of ment on intraluminal measurement of gastrointestinal and gastroenterology. Vol 1. 2nd ed. Elsevier; 2020:149-­163. colonic motility in clinical practice. Neurogastroenterol Motil 22. Stanghellini V, Camilleri M, Malagelada JR. Chronic idiopathic intes- 2008;20:1269–­1 282. https://www.ncbi.nlm.nih.gov/pubme​ tinal pseudo-­obstruction: clinical and intestinal manometric find- d/19019032. ings. Gut. 1987;28:5-­12. 3. Stanghellini V, Cogliandro RF, de Giorgio R, et al. Natural history of 23. Parsons SP, Huizinga JD. Nitric oxide is essential for generating the chronic idiopathic intestinal pseudo-­obstruction in adults: a single minute rhythm contraction pattern in the small intestine, likely via center study. Clin Gastroenterol Hepatol. 2005;3:449-­458. ICC-­DMP. Front Neurosci. 2020;14:592664. 4. Connor FL, Hyman PE, Faure C, et al. Interobserver variabil- 24. Bassotti G, Stanghellini V, Chiarioni G, et al. Upper gastrointestinal ity in antroduodenal manometry. Neurogastroenterol Motil. motor activity in patients with slow-­transit constipation. Further 2009;21:500-­507. evidence for an enteric neuropathy. Dig Dis Sci. 1996;41:1999-­2005. 5. Lindberg G, Iwarzon M, Tornblom H. Clinical features and long-­ 25. Glia A, Lindberg G. Antroduodenal manometry findings in pa- term survival in chronic intestinal pseudo-­obstruction and enteric tients with slow-­ transit constipation. Scand J Gastroenterol. dysmotility. Scand J Gastroenterol. 2009;44:692-­699. 1998;33:55-­62. 8 of 8 | ALCALÁ-­GONZÁLEZ et al. 26. Mollen RM, Hopman WP, Kuijpers HH, et al. Abnormalities of upper gut motility in patients with slow-­transit constipation. Eur J How to cite this article: Alcalá-­González LG, Malagelada C, Gastroenterol Hepatol. 1999;11:701-­708. Monrroy H, et al. Clinical significance of small bowel 27. Seidl H, Gundling F, Pehl C, et al. Small bowel motility in functional chronic constipation. Neurogastroenterol Motil. 2009;21:1278. manometry patterns suggestive of intestinal obstruction. 28. Alcalá-­ Gonzalez LG, Malagelada C, Livovsky DM, Azpiroz F. Neurogastroenterology & Motility. 2023;35:e14462. doi: Effect of colonic distension on small bowel motility measured 10.1111/nmo.14462 by jejunal high-­resolution manometry. Neurogastroenterol Motil 2022;34:e14351.