P3.M249: Decline in gut motility in cerebral palsy patients after triggering event: a discussion on invasive versus conservative management

Introduction: Patients with cerebral palsy (CP) have bowel dysmotility at baseline, with innately compromised neuronal, hormonal and biohumoral interactions between the gut and brain. Some have a progressive decline in bowel motility or episodes of acute pseudoobstruction which can be triggered by stressful events like infection. In Pediatric Intestinal Pseudoobstruction (PIPO), decompressive therapy is considered when medical therapy has failed, but it is unclear if decompression improves quality of life or conversely actually contributes to bowel decline.

Case Description: We present four cases of patients with CP who had prolonged hospitalizations secondary to a triggering event leading to a decline in gut motility. All four patients were gastrostomy tube dependent and tolerating feeds before their sentinel events. Patient 1 struggled with feeding tolerance and bowel distention after a viral infection. She received anal sphincter Botox with a total of three hospital admissions and hospital stay (LOS) of 30 days after the inciting event. She eventually returned to tolerating jejunal feeds. Patient 2’s triggering event was aspiration pneumonia, and he eventually became dependent on parenteral nutrition (TPN). He was made comfort care and expired after complications secondary to emergent exploratory laparotomy and small bowel resection after many pseudoobstruction exacerbations. He had three procedures and a LOS of 167 days after his triggering event. Patient 3 had feeding intolerance after COVID infection, requiring TPN temporarily, chronic gastritis, and acute on chronic respiratory failure leading to tracheostomy. He had three procedures including a fundoplication, Roux-en-y gastrojejunostomy, and revision of gastrostomy tube with a LOS of 205 days. Patient 4 had congenital abnormalities that led to multiple surgical/anesthetic events starting at an early age, including Ladds procedure. His decline started after SBO and recurrent volvulus having three invasive procedures and a 138-day LOS. He was placed on comfort care and expired after being admitted with high-grade bowel obstruction.

Discussion: In these cases, more invasive bowel procedures increased hospitalizations and LOS. The alternative to surgical intervention in cases where medical management has failed is to proceed with TPN. It is often unclear if these patients have an acute pseudoobstruction and need TPN as a bridge to get back to baseline, or if they have gut failure requiring lifelong TPN. The ethical issue then arises about extending life or providing quality of life in a neurocompromised individual.

Conclusion: Patients with CP are highly susceptible to a decline in bowel function and providers should ask themselves what has the greatest chance of improving quality of life. Potentially conservative management and early initiation of TPN might help decrease hospitalizations and LOS. Invasive bowel operations should be performed if mechanical obstruction occurs, but otherwise minimized if it is not predicted to significantly increase quality of life.