How to feed patients with small intestinal dysmotility.

Purpose of review: Chronic small intestinal dysmotility is associated with a spectrum of malnutrition, varying in severity from mild nutritional compromise to intestinal failure requiring parenteral nutrition. Feeding patients with chronic small intestinal dysmotility is one of the most complex challenges in contemporary clinical gastroenterology. This review is timely due to rising diagnostic uncertainty reflected in increasing referrals for parenteral nutrition, and the growing awareness of overlapping high symptom burden but non-intestinal failure inducing disorders.

Recent findings: Whilst the pragmatic classification into chronic intestinal pseudo-obstruction (CIPO) and non-CIPO subtypes may help avoid unnecessary invasive investigations and provides insight into nutritional trajectory, this evolving approach requires careful navigation of the emerging diagnostic grey zone that encompasses highly symptomatic disorders of gut-brain interaction, disordered eating, and opioid-related bowel dysfunction that can result in pain/intolerance on small intestinal feeding. Feeding strategies must be tailored to phenotype and symptom burden, with enteral support prioritised wherever possible and parenteral nutrition reserved for clear cases of intestinal failure and/or for a temporising period of time when there is life-threatening nutritional risk. Effective management depends on early multidisciplinary input, optimisation of pharmacotherapy, and psychological assessment to guide appropriate nutritional therapies.

Summary: Individualised feeding strategies must weigh the risks of malnutrition against those associated with parenteral support, while also addressing symptom severity and maintaining oversight of the broader psychosocial context. This review reinforces the importance of early multidisciplinary team engagement, considered therapeutic approaches, and nuanced clinical reasoning in managing patients with chronic small intestinal dysmotility.