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Foocharoen C, Kingkaew P, Teerawattananon Y, Mahakkanukrauh A, Suwannaroj S, Manasirisuk W, Chaiyarit J, Sangchan A. Cost-effectiveness of alginic acid in combination with proton pump inhibitor for the treatment of gastroesophageal reflux disease in systemic sclerosis patients. Int J Rheum Dis 2023; 26:2037-2046. [PMID: 37665078 DOI: 10.1111/1756-185x.14868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Systemic sclerosis (SSc) patients often become refractory to proton pump inhibitors (PPI)-a standard treatment for gastroesophageal reflux disease (GERD)-and intolerant to PPI in combination with domperidone. PPI with alginic acid is an alternative treatment option, but alginic acid is costly. OBJECTIVES We compared the costs and effectiveness of alginic acid plus PPI versus standard treatments (PPI with/without antacids as needed and lifestyle modifications) for GERD in SSc patients unsuitable for, or intolerant to, domperidone. METHODS An economic evaluation using the Markov model was conducted among SSc patients aged between 40 and 65 years with GERD, having a partial or non-response to 4 weeks of standard-dose omeprazole (40 mg/day) and being unsuitable for or intolerant to domperidone. Using a societal perspective, we computed the incremental cost-effectiveness ratios (ICERs) in terms of Thai baht (THB) per quality-adjusted life-year (QALY) between a combination of alginic acid plus PPI and standard treatment for GERD. The lifetime time horizon was used. RESULTS The ICER for alginic acid plus PPI versus standard treatments was 377 101 THB/QALY. According to the one-way sensitivity analysis, the cost of alginic acid was the most impactful parameter. If the market prices of alginic acid plus PPI were reduced by 61%, this treatment option would become cost-effective at the willingness-to-pay threshold of 160 000 THB/QALY (34.68 THB/USD data on 25 May 2023). Furthermore, if alginic acid were included in the public health insurance program, the national budget would be increased by 66 313 THB per patient, resulting in an overall budget increase of 5 106 101 to 8 885 942 THB compared with the standard treatment. CONCLUSIONS Alginic acid plus PPI does not represent good value for money compared with the standard treatment among such SSc patients in Thailand unless its price is reduced significantly.
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Affiliation(s)
- Chingching Foocharoen
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pritaporn Kingkaew
- The Health Intervention and Technology Assessment Program (HITAP), Department of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Yot Teerawattananon
- The Health Intervention and Technology Assessment Program (HITAP), Department of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Ajanee Mahakkanukrauh
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Siraphop Suwannaroj
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Witsarut Manasirisuk
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Jitjira Chaiyarit
- Department of Statistics, Faculty of Science, Khon Kaen University, Khon Kaen, Thailand
| | - Apichat Sangchan
- Special Medical Center, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Renaud A, Jirka A, Durant C, Connault J, Espitia O, Takoudju C, Agard C. [Gastrointestinal tract involvement in systemic sclerosis]. Rev Med Interne 2023; 44:410-422. [PMID: 37270380 DOI: 10.1016/j.revmed.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
Gastrointestinal tract involvement in systemic sclerosis concerns more than 90% of patients but is of heterogeneous clinical expression. It can involve the entire intestinal tract and be responsible for multifactorial malnutrition, which is frequent in this disease. It is a major source of deterioration in the quality of life and can even be life-threatening. Management is complex and multidisciplinary, ranging from simple hygienic and dietary measures, to specialized endoscopic or surgical interventional procedures, also including medical treatments, particularly proton pump inhibitors and prokinetics, with potential side effects. Ongoing research for new diagnostic and therapeutic tools promises to improve the management and prognosis of these patients.
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Affiliation(s)
- A Renaud
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France.
| | - A Jirka
- Service d'hépato-gastro-entérologie, Nantes université, CHU de Nantes, 44000 Nantes, France
| | - C Durant
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - J Connault
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - O Espitia
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - C Takoudju
- Service d'hépato-gastro-entérologie, Nantes université, CHU de Nantes, 44000 Nantes, France
| | - C Agard
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
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Tucker AE, Perin J, Volkmann ER, Abdi T, Shah AA, Pandolfino J, Silver RM, McMahan ZH. Associations Between Patterns of Esophageal Dysmotility and Extra-Intestinal Features in Patients With Systemic Sclerosis. Arthritis Care Res (Hoboken) 2023; 75:1715-1724. [PMID: 36576023 PMCID: PMC11019887 DOI: 10.1002/acr.25080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/29/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The gastrointestinal tract is commonly involved in patients with systemic sclerosis (SSc) with varied manifestations. As our understanding of SSc gastrointestinal disease pathogenesis and risk stratification is limited, we sought to investigate whether patterns of esophageal dysfunction associate with specific clinical phenotypes in SSc. METHODS Patients enrolled in the Johns Hopkins Scleroderma Center Research Registry who completed high-resolution esophageal manometry (HREM) studies as part of their clinical care between 2011 and 2020 were identified. Associations between esophageal abnormalities on HREM (absent contractility [AC], ineffective esophageal motility [IEM], hypotensive lower esophageal sphincter [hypoLES]) and patient demographic information, clinical characteristics, and autoantibody profiles were examined. RESULTS Ninety-five patients with SSc had HREM data. Sixty-five patients (68.4%) had AC (37 patients with only AC, 28 patients with AC and a hypoLES), 9 patients (9.5%) had IEM, and 11 patients (11.6%) had normal studies. AC was significantly associated with diffuse cutaneous disease (38.5% versus 10.0%; P < 0.01), more severe Raynaud's phenomenon, including digital pits, ulcers, or gangrene (56.9% versus 30.0%; P = 0.02), and reduced median diffusing capacity of lung for carbon monoxide (50.6% versus 72.2%; P = 0.03). AC was observed in most of the patients who died (13 of 14; P = 0.06). These findings were not seen in patients with IEM. CONCLUSION Among patients with SSc, AC is associated with a significantly more severe clinical phenotype. IEM may associate with a milder phenotype. Further studies are needed to evaluate AC, IEM, and their clinical impact relative to the timing of other end-organ complications in SSc.
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Affiliation(s)
- Ana E Tucker
- Medical University of South Carolina, Charleston
| | - Jamie Perin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Tsion Abdi
- Johns Hopkins University, Baltimore, Maryland
| | - Ami A Shah
- Johns Hopkins University, Baltimore, Maryland
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Nassar M, Ghernautan V, Nso N, Nyabera A, Castillo FC, Tu W, Medina L, Ciobanu C, Alfishawy M, Rizzo V, Eskaros S, Mahdi M, Khalifa M, El-Kassas M. Gastrointestinal involvement in systemic sclerosis: An updated review. Medicine (Baltimore) 2022; 101:e31780. [PMID: 36397401 PMCID: PMC9666124 DOI: 10.1097/md.0000000000031780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The gastrointestinal tract (GI) is the second most affected organ system in individuals suffering from systemic/localized scleroderma (SSc) or localized scleroderma. SSc can affect any part of the GI, between the oral cavity and anorectum. The annual incidence of SSc in the United States is estimated to be 19.3 cases per million adults, with the highest incidence reported in people aged 44 to 55. Females are 5 times more likely than males to suffer from SSc. Morbidity and mortality rates associated with SSc are predominantly elevated among patients with GI manifestations. Esophageal and intestinal manifestations impact 90% and 40% to 70% of patients with systemic scleroderma, respectively. SSc patients are known to suffer from small bowel hypomotility and small intestinal bacterial overgrowth, which cause malabsorption and malnutrition, ultimately contributing to the 50% mortality rate. Fecal incontinence is a common symptom of SSc that can lead to depression. SSc patients may suffer from gastrointestinal complications that can negatively impact their quality of life on a daily basis. Multidisciplinary approaches are necessary for systematically managing gastrointestinal complications associated with SSc. A prospective study should focus on developing targeted therapies to improve recovery patterns and prognosis in cases of SSc. This article summarizes the epidemiology, commonly reported clinical manifestations, complications, and available treatments for treating GI pathology in SSc patients.
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Affiliation(s)
- Mahmoud Nassar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Victoria Ghernautan
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Nso Nso
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Akwe Nyabera
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Francisco Cuevas Castillo
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Wan Tu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Luis Medina
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | | | - Mostafa Alfishawy
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Vincent Rizzo
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Saphwat Eskaros
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Mamdouh Mahdi
- Internal Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed Khalifa
- Hospital Management Department, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
- * Correspondence: Mohamed El-Kassas, Endemic Medicine Department, Faculty of Medicine, Helwan University, Ain Helwan 11795 Cairo, Egypt (e-mail: )
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Lepri G, Catalano M, Bellando-Randone S, Pillozzi S, Giommoni E, Giorgione R, Botteri C, Matucci-Cerinic M, Antonuzzo L, Guiducci S. Systemic Sclerosis Association with Malignancy. Clin Rev Allergy Immunol 2022; 63:398-416. [PMID: 36121543 DOI: 10.1007/s12016-022-08930-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 12/17/2022]
Abstract
The association of systemic sclerosis (SSc) and cancer is well known from several decades suggesting common genetic and environmental risk factors involved in the development of both diseases. Immunosuppressive drugs widely used in SSc may increase the risk of cancer occurrence and different SSc clinical and serological features identify patients at major risk to develop malignancy. In this context, among serological features, presence of anti-RNA polymerase III and anti-topoisomerase I autoantibodies seems to increase cancer frequency in SSc patients (particularly lung and breast cancers). Lung fibrosis and a long standing SSc pulmonary involvement have been largely proposed as lung cancer risk factors, and the exposure to cyclophosphamide and an upper gastrointestinal involvement have been traditionally linked to bladder and oesophagus cancers, respectively. Furthermore, immune checkpoint inhibitors used for cancer therapy can induce immune-related adverse events, which are more frequent and severe in patients with pre-existing autoimmune diseases such as SSc. The strong association between SSc and cancer occurrence steers clinicians to carefully survey SSc patients performing periodical malignancy screening. In the present review, the most relevant bilateral relationships between SSc and cancer will be addressed.
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Affiliation(s)
- Gemma Lepri
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology, AOUC & Scleroderma Unit, Florence, Italy.
| | - Martina Catalano
- Medical Oncology Unit, Careggi University Hospital, Florence, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology, AOUC & Scleroderma Unit, Florence, Italy
| | - Serena Pillozzi
- Medical Oncology Unit, Careggi University Hospital, Florence, Italy
| | - Elisa Giommoni
- Medical Oncology Unit, Careggi University Hospital, Florence, Italy
| | | | - Cristina Botteri
- Medical Oncology Unit, Careggi University Hospital, Florence, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology, AOUC & Scleroderma Unit, Florence, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Antonuzzo
- Medical Oncology, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology, AOUC & Scleroderma Unit, Florence, Italy
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Vitton V, Bazin C, Luciano L, Granel B, Alessandrini M, Harle JR. Oesophageal motor disorders and oesophageal endoscopic involvement in patients with systemic sclerosis: a systematic association? Scand J Gastroenterol 2021; 56:508-513. [PMID: 33689560 DOI: 10.1080/00365521.2021.1881813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Although oesophageal motor disorders (OMDs) are frequent in systemic sclerosis (SSc), the frequency of associated endoscopic lesions is unknown. We aimed at assessing the presence of endoscopic lesions in SSc patients with OMD. The secondary objective was to identify the clinical and serological profile of such patients. METHODS This retrospective study included SSc patients suffering from OMD diagnosed by oesophageal high-resolution manometry (OHRM) and with recent upper gastro-intestinal endoscopy (UGIE). Clinical data collected were age, gender, body mass index, SSc disease duration, tobacco, SSc cutaneous type, non-digestive SSc visceral disorders, oesophageal symptoms, serological profile (autoantibodies), proton pump inhibitor use, time between SSc diagnosis and UGIE. RESULTS 53 selected patients from 210 SSc patients investigated by OHRM in our department were included. Among these patients, 25 (47.2%) had endoscopic lesions: 18 (34.6%) had oesophagitis and 7 (13.5%) had Barrett's oesophagus. The only two parameters significantly associated with endoscopic lesions were a shorter disease duration (6 vs. 11 years; p = .002) and a shorter delay between SSc diagnosis and UGIE (3 vs. 8.5 years; p = .002). No other clinical or biological parameters could help identify the patients at risk of endoscopic lesion. CONCLUSION In our study, only a shorter disease duration and a shorter delay between SSc diagnosis and UGIE were significantly associated with the presence of endoscopic lesions in patients with OMD, but no other parameters were identified. This study highlights the need to perform UGIE in SSc patients with OMD whatever their clinical symptoms.
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Affiliation(s)
- Véronique Vitton
- Department of Gastroenterology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - Camille Bazin
- Department of Gastroenterology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - Laure Luciano
- Department of Gastroenterology, Instruction Hospital of French Army Laveran, Marseille, France
| | - Brigitte Granel
- Internal Medicine Department, CHU Nord, Assistance Publique Hôpitaux de Marseille (AP-HM), Aix-Marseille University, Vascular Research Center of Marseille, INSERM UMRS-1076, Aix-Marseille University, Marseille, France
| | - Marine Alessandrini
- EA 3279 - Public Health, Chronic Diseases and Quality of Life - Research Unit, Aix-Marseille University, Marseille, France
| | - Jean-Robert Harle
- Internal Medicine Department, CHU La Timone, Assistance Publique Hôpitaux de Marseille (AP-HM), Aix-Marseille University, Marseille, France
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Prevalence of Barrett's Esophagus in Female Patients With Scleroderma. Am J Gastroenterol 2021; 116:517-521. [PMID: 33657040 DOI: 10.14309/ajg.0000000000001109] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Systemic sclerosis or scleroderma (SSc) is a chronic autoimmune disease that renders the esophagus prone to significant gastroesophageal reflux due to impaired esophageal clearance and reduced lower esophageal sphincter pressure. The reported prevalence of Barrett's esophagus (BE) in women with SSc varies from 2% to 37% and is derived from older studies with small sample sizes. We aimed to assess the prevalence of BE in a large cohort of women with SSc. METHODS Women with SSc referred from the Mayo Clinic Arizona Rheumatology Clinic who completed esophagogastroduodenoscopy between 2002 and 2020 were included. Demographic and high-resolution manometry data were evaluated. The diagnosis of scleroderma was confirmed by an expert rheumatologist. The BE diagnosis was confirmed by an expert gastrointestinal pathologist. RESULTS There were 235 women with SSc who underwent EGD. High-resolution manometry (HRM) was completed in 172 patients. Women with SSc with BE were significantly more likely to have scleroderma esophagus (absent contractility with hypotensive lower esophageal sphincter) on HRM than women with SSc without BE (P = 0.018). There were 30 patients with SSc (12.8%) with histologically proven BE. Dysplasia was found in 13 (43.3%): 4 with indefinite, 7 with low grade, and 2 with adenocarcinoma. The incidence of any dysplasia was 5.3% per year (0.9% per year for adenocarcinoma). DISCUSSION This the largest study on prevalence of BE in women with SSc, yielding a prevalence of 12.8%. Women with SSc with BE were significantly more likely to have absent contractility with hypotensive lower esophageal sphincter findings on HRM. The high prevalence and incidence of dysplasia found suggest that women with SSc should be included in the screening recommendations for BE.
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Shukla R, Warner R, Whorwell P, Herrick AL. Upper gastrointestinal vascular ectasia: an under-recognized complication of systemic sclerosis. Scand J Rheumatol 2020; 50:325-326. [PMID: 32783483 DOI: 10.1080/03009742.2020.1794029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- R Shukla
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R Warner
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - P Whorwell
- Neurogastroenterology Unit, Wythenshawe Hospital, Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK
| | - A L Herrick
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, University of Manchester, Manchester, UK
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10
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Maria ATJ, Partouche L, Goulabchand R, Rivière S, Rozier P, Bourgier C, Le Quellec A, Morel J, Noël D, Guilpain P. Intriguing Relationships Between Cancer and Systemic Sclerosis: Role of the Immune System and Other Contributors. Front Immunol 2019; 9:3112. [PMID: 30687318 PMCID: PMC6335319 DOI: 10.3389/fimmu.2018.03112] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/17/2018] [Indexed: 01/09/2023] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune connective tissue disorder, characterized by multisystem involvement, vasculopathy, and fibrosis. An increased risk of malignancy is observed in SSc (including breast and lung cancers), and in a subgroup of patients with specific autoantibodies (i.e., anti-RNA polymerase III and related autoantibodies), SSc could be a paraneoplastic syndrome and might be directly related to an immune response against cancer. Herein, we reviewed the literature, focusing on the most recent articles, and shed light onto the potential relationship between cancer and scleroderma regarding temporal and immunological dimensions.
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Affiliation(s)
- Alexandre Thibault Jacques Maria
- Medical School, Montpellier University, Montpellier, France.,Department of Internal Medicine-Multiorganic Diseases, Local Referral Center for Auto-immune Diseases, Saint-Eloi Hospital, Montpellier University, Montpellier, France.,IRMB, INSERM, CHU Montpellier, Montpellier University, Montpellier, France
| | - Léo Partouche
- Medical School, Montpellier University, Montpellier, France.,Department of Internal Medicine-Multiorganic Diseases, Local Referral Center for Auto-immune Diseases, Saint-Eloi Hospital, Montpellier University, Montpellier, France
| | - Radjiv Goulabchand
- Medical School, Montpellier University, Montpellier, France.,Department of Internal Medicine-Multiorganic Diseases, Local Referral Center for Auto-immune Diseases, Saint-Eloi Hospital, Montpellier University, Montpellier, France
| | - Sophie Rivière
- Department of Internal Medicine-Multiorganic Diseases, Local Referral Center for Auto-immune Diseases, Saint-Eloi Hospital, Montpellier University, Montpellier, France
| | - Pauline Rozier
- Medical School, Montpellier University, Montpellier, France.,Department of Internal Medicine-Multiorganic Diseases, Local Referral Center for Auto-immune Diseases, Saint-Eloi Hospital, Montpellier University, Montpellier, France.,IRMB, INSERM, CHU Montpellier, Montpellier University, Montpellier, France
| | - Céline Bourgier
- Medical School, Montpellier University, Montpellier, France.,Department of Radiation Oncology, INSERM U1194/IRCM, ICM-Val d'Aurelle, Montpellier, France
| | - Alain Le Quellec
- Medical School, Montpellier University, Montpellier, France.,Department of Internal Medicine-Multiorganic Diseases, Local Referral Center for Auto-immune Diseases, Saint-Eloi Hospital, Montpellier University, Montpellier, France
| | - Jacques Morel
- Medical School, Montpellier University, Montpellier, France.,Department of Rheumatology, Lapeyronie Hospital, Montpellier, France
| | - Danièle Noël
- IRMB, INSERM, CHU Montpellier, Montpellier University, Montpellier, France
| | - Philippe Guilpain
- Medical School, Montpellier University, Montpellier, France.,Department of Internal Medicine-Multiorganic Diseases, Local Referral Center for Auto-immune Diseases, Saint-Eloi Hospital, Montpellier University, Montpellier, France.,IRMB, INSERM, CHU Montpellier, Montpellier University, Montpellier, France
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McMahan ZH, Frech T, Berrocal V, Lim D, Bruni C, Matucci-Cerinic M, Smith V, Melsens K, Proudman S, Zhang J, Mendoza F, Woods M, Khanna D. Longitudinal Assessment of Patient-reported Outcome Measures in Systemic Sclerosis Patients with Gastroesophageal Reflux Disease — Scleroderma Clinical Trials Consortium. J Rheumatol 2018; 46:78-84. [DOI: 10.3899/jrheum.180004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2018] [Indexed: 12/11/2022]
Abstract
Objective.Validated gastrointestinal (GI) symptoms scales are used in clinical practice to assess patient-reported GI involvement. We sought to determine whether University of California, Los Angeles (UCLA) GI Tract Questionnaire (GIT) 2.0 Reflux scale, Patient-Reported Outcomes Measurement Information System (PROMIS) Reflux scale, and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD) are sensitive to identifying changes in GI symptoms following therapeutic intervention in participants with systemic sclerosis (SSc) and gastroesophageal reflux disease (GERD).Methods.Participants with active GERD were recruited during clinical visits at 6 international SSc centers. Patient-reported outcome surveys and the GI self-reported questionnaire were completed at baseline and again at 4 weeks following a single intervention, and patients were classified as “improved” or “not improved.” Effect size (ES) was calculated to assess the sensitivity to change. ES was interpreted as 0.50–0.79 as moderate effect and ≥ 0.80 as large effect.Results.There were 116 participants with SSc and active GERD who enrolled. The average age was 53.8 years and mean disease duration was 12.0 years. The UCLA GIT 2.0 Reflux scale and PROMIS Reflux scale had a significant correlation at baseline (0.61, p < 0.0001), and both instruments correlated with the QOLRAD domains (−0.56 to −0.71). In participants who had the UCLA GIT 2.0, PROMIS Reflux scale, and QOLRAD administered over 2 timepoints (n = 57) and were classified as improved, the ES was large for the UCLA GIT 2.0 and PROMIS Reflux scale, and moderate to large across all QOLRAD domains.Conclusion.The UCLA GIT 2.0 Reflux scale, PROMIS Reflux scale, and QOLRAD are sensitive to change and can be included in future clinical trials.
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12
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Esophageal abnormalities in juvenile localized scleroderma: is it associated with other extracutaneous manifestations? REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:521-525. [PMID: 29173689 DOI: 10.1016/j.rbre.2016.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/30/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess esophageal involvement (EI) in juvenile localized scleroderma (JLS) population and the possible association between this gastrointestinal manifestation and demographic data, clinical features, laboratory exams, treatments and outcomes. METHODS For a period of 30 years, 5881 patients with rheumatic diseases were followed in our Pediatric Rheumatology Division. EI was defined by the presence of symptoms (solid/liquid dysphagia, heartburn, esophageal regurgitation, nausea/vomiting and epigastralgia) and confirmed by at least one EI exam abnormality: barium contrast radiography, upper gastrointestinal endoscopy and 24-hour esophageal pH-monitoring. RESULTS JLS was observed in 56/5881 patients (0.9%), mainly linear morphea subtype. EI was observed in 23/56(41%) of JLS patients. Eight(35%) of 23 EI patients with JLS were symptomatic and presented heartburn(5/8), solid and liquid dysphagia(3/8), nausea and epigastralgia(1/8). The frequency of any cumulative extracutaneous manifestations (calcinosis, arthritis/arthralgia, central nervous system, interstitial pneumonitis, mesangial nephritis and/or arrhythmia) was significantly higher in JLS patients with EI compared to those without this complication (56% vs. 24%, p=0.024). No differences were evidenced in demographic data, JLS subtypes and in each extracutaneous manifestation in both groups (p>0.05). The frequency of methotrexate use was significantly higher in JLS patients with EI compared to those without (52% vs. 12%, p=0.002). Autoantibody profile (antinuclear antibodies, anti-SCL-70, rheumatoid factor, anticentromere, anti-cardiolipin, anti-Ro/SSA and anti-La/SSB) was similar in both groups (p>0.05). CONCLUSIONS Our study demonstrated that EI was frequently observed in JLS patients, mainly in asymptomatic patients with linear subtype. EI occurred in JLS patients with other extracutaneous manifestations and required methotrexate therapy.
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Valões CC, Novak GV, Brunelli JB, Kozu KT, Toma RK, Silva CA. Anormalidades esofágicas na esclerodermia localizada juvenil: associação com outras manifestações extracutâneas? REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Furst DE, Braun-Moscovic Y, Khanna D. Points to consider for clinical trials of the gastrointestinal tract in systemic sclerosis. Rheumatology (Oxford) 2017; 56:v4-v11. [PMID: 28992166 DOI: 10.1093/rheumatology/kex195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Indexed: 12/19/2022] Open
Abstract
The pathogenesis of gastrointestinal tract involvement in SSc is not fully understood. However, gastrointestinal signs and symptoms are very common. Trials to test therapies, with rare exceptions, should be double-blind, randomized trials with either active therapy or placebo as comparators. Trial duration will vary dependent on the anticipated therapy and should usually be 6-24 weeks long, although some motility trials may need to be 52 weeks. As in any well-controlled trial, inclusion and exclusion criteria should encourage relatively uniform patients with sufficiently active disease to discern response, importantly considering disease duration. Previous therapy, co-morbid conditions, potentially confounding and/or concomitant therapy should be considered. Outcome measures should include both objective/semi-objective and subjective measures, although validated measures are not frequent and design needs to consider using only validated measures. Unvalidated measures can be included to validate them for future use. A full analysis plan should be completed before study commencement, including the method to account for missing data.
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Affiliation(s)
- Daniel E Furst
- Department of Rheumatology, Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Yolanda Braun-Moscovic
- B.Shine Rheumatology Unit, Rambam Medical Health Care Campus, Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Institute of Technology, Haifa, Israel
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
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Di Piazza A, Vernuccio F, Costanzo M, Scopelliti L, Picone D, Midiri F, Salvaggi F, Cupido F, Galia M, Salerno S, Lo Casto A, Midiri M, Lo Re G, Lagalla R. The Videofluorographic Swallowing Study in Rheumatologic Diseases: A Comprehensive Review. Gastroenterol Res Pract 2017; 2017:7659273. [PMID: 28706536 PMCID: PMC5494561 DOI: 10.1155/2017/7659273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/11/2017] [Indexed: 02/01/2023] Open
Abstract
Autoimmune connective tissue diseases are a heterogeneous group of pathologies that affect about 10% of world population with chronic evolution in 20%-80%. Inflammation in autoimmune diseases may lead to serious damage to other organs including the gastrointestinal tract. Gastrointestinal tract involvement in these patients may also due to both a direct action of antibodies against organs and pharmacological therapies. Dysphagia is one of the most important symptom, and it is caused by failure of the swallowing function and may lead to aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. The videofluorographic swallowing study is a key diagnostic tool in the detection of swallowing disorders, allowing to make an early diagnosis and to reduce the risk of gastrointestinal and pulmonary complications. This technique helps to identify both functional and structural anomalies of the anatomic chain involved in swallowing function. The aim of this review is to systematically analyze the basis of the pathological involvement of the swallowing function for each rheumatological disease and to show the main features of the videofluorographic study that may be encountered in these patients.
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Affiliation(s)
- Ambra Di Piazza
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | | | - Massimo Costanzo
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Laura Scopelliti
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Dario Picone
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Federico Midiri
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Francesco Salvaggi
- Unit of Colorectal Surgery, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, Second University of Naples, Naples, Italy
| | - Francesco Cupido
- Department of Surgical, Oncologic and Stomatologic Diseases, University of Palermo, Palermo, Italy
| | - Massimo Galia
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Sergio Salerno
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Antonio Lo Casto
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Massimo Midiri
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Giuseppe Lo Re
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Roberto Lagalla
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
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Braun-Moscovici Y, Brun R, Braun M. Systemic Sclerosis and the Gastrointestinal Tract-Clinical Approach. Rambam Maimonides Med J 2016; 7:RMMJ.10258. [PMID: 27824553 PMCID: PMC5101005 DOI: 10.5041/rmmj.10258] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Systemic sclerosis (SSc) is a multisystem disease characterized by functional and structural abnormalities of small blood vessels, fibrosis of the skin and internal organs, immune system activation, and autoimmunity. The gastrointestinal tract is involved in nearly all patients and is a source of significant morbidity and even mortality. The aim of this review is to summarize the pathogenesis and to provide a clinical approach to these patients.
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Affiliation(s)
- Yolanda Braun-Moscovici
- B. Shine Rheumatology Unit, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Rita Brun
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Marius Braun
- Liver Institute, Beilinson Hospital, Petach Tiqwa, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cancer and scleroderma: a paraneoplastic disease with implications for malignancy screening. Curr Opin Rheumatol 2016; 27:563-70. [PMID: 26352736 DOI: 10.1097/bor.0000000000000222] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Recent data suggest a paraneoplastic mechanism of scleroderma pathogenesis in unique subsets of scleroderma patients. In this article, we review these data, explore potential links between cancer and scleroderma, and propose an approach to malignancy screening in scleroderma. RECENT FINDINGS Emerging data have demonstrated that patients with scleroderma and RNA polymerase III autoantibodies have a significantly increased risk of cancer within a few years of scleroderma onset. Genetic alterations in the gene encoding RNA polymerase III (POLR3A) have been identified, and patients with somatic mutations in POLR3A have evidence of mutation specific T-cell immune responses with generation of cross-reactive RNA polymerase III autoantibodies. These data strongly suggest that scleroderma is a by-product of antitumor immune responses in some patients. Additional epidemiologic data demonstrate that patients developing scleroderma at older ages may also have a short cancer-scleroderma interval, suggestive of paraneoplastic disease. SUMMARY Scleroderma may be a paraneoplastic disease in unique patient subsets. Aggressive malignancy screening in these patients may aid in early cancer detection. Further study is required to determine whether cancer therapy could improve scleroderma outcomes in this patient population.
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Gastrointestinal Manifestations, Malnutrition, and Role of Enteral and Parenteral Nutrition in Patients With Scleroderma. J Clin Gastroenterol 2015; 49:559-64. [PMID: 25992813 DOI: 10.1097/mcg.0000000000000334] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Scleroderma (systemic sclerosis) is an autoimmune disease that can affect multiple organ systems. Gastrointestinal (GI) involvement is the most common organ system involved in scleroderma. Complications of GI involvement including gastroesophageal reflux disease, small intestinal bacterial overgrowth, and chronic intestinal pseudoobstruction secondary to extensive fibrosis may lead to nutritional deficiencies in these patients. Here, we discuss pathophysiology, progression of GI manifestations, and malnutrition secondary to scleroderma, and the use of enteral and parenteral nutrition to reverse severe nutritional deficiencies. Increased mortality in patients with concurrent malnutrition in systemic sclerosis, as well as the refractory nature of this malnutrition to pharmacologic therapies compels clinicians to provide novel and more invasive interventions in reversing these nutritional deficiencies. Enteral and parenteral nutrition have important implications for patients who are severely malnourished or have compromised GI function as they are relatively safe and have substantial retrospective evidence of success. Increased awareness of these therapeutic options is important when treating scleroderma-associated malnutrition.
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Arif T, Masood Q, Singh J, Hassan I. Assessment of esophageal involvement in systemic sclerosis and morphea (localized scleroderma) by clinical, endoscopic, manometric and pH metric features: a prospective comparative hospital based study. BMC Gastroenterol 2015; 15:24. [PMID: 25888470 PMCID: PMC4339256 DOI: 10.1186/s12876-015-0241-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 01/29/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a generalized disorder of unknown etiology affecting the connective tissue of the body. It affects the skin and various internal organs. Gastrointestinal tract involvement is seen in almost 90% of the patients. Esophagus is the most frequently affected part of the gastrointestinal tract. Esophageal motility disturbance classically manifests as a reduced lower esophageal sphincter pressure (LESP) and loss of distal esophageal body peristalsis. Consequently, SSc patients may be complicated by erosive esophagitis and eventually by Barrett's esophagus and esophageal adenocarcinoma. Morphea, also known as localized scleroderma, is characterized by predominant skin involvement, with occasional involvement of subjacent muscles and usually sparing the internal organs. The involvement of esophagus in morphea has been studied very scarcely. The proposed study will investigate the esophageal involvement in the two forms of scleroderma (systemic and localized), compare the same and address any need of upper gastrointestinal evaluation in morphea (localized scleroderma) patients. METHODS 56 and 31 newly and already diagnosed cases of SSc and morphea respectively were taken up for the study. All the patients were inquired about the dyspeptic symptoms (heartburn and/or acid regurgitation and/or dysphagia). Upper gastrointestinal endoscopy, esophageal manometry and 24-hour pH monitoring were done in 52, 47 and 41 patients of SSc; and 28, 25 and 20 patients of morphea respectively. RESULTS Esophageal symptoms were present in 39 cases (69.6%) of SSc which were mild in 22 (39.3%), moderate in 14 (25%), severe in three (5.3%); while only four cases (7.1%) of morphea had esophageal symptoms all of which were mild in severity. Reflux esophagitis was seen in 17 cases (32.7%) of SSc and only two cases (7.14%) of morphea. Manometric abnormalities were seen in 32 cases (68.1%) of SSc and none in morphea. Ambulatory 24-hour esophageal pH monitoring documented abnormal reflux in 33 cases (80.5%) of SSc and no such abnormality in morphea. CONCLUSION While the esophageal involvement is frequent in SSc, no such motility disorder is seen in morphea. Meticulous upper gastrointestinal tract evaluation is justified only in SSc and not in morphea.
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Affiliation(s)
- Tasleem Arif
- Postgraduate Department of Dermatology, STDs & Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India.
- Postgraduate Department of Dermatology, STDs and Leprosy, Jawaharlal Nehru Medical College (JNMC), Aligarh Muslim University (AMU), Aligarh, India.
| | - Qazi Masood
- Postgraduate Department of Dermatology, STDs & Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India.
| | - Jaswinder Singh
- Department of Gastroenterology, SKIMS, Soura, Srinagar, Kashmir, India.
| | - Iffat Hassan
- Postgraduate Department of Dermatology, STDs & Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India.
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Savarino E, Furnari M, de Bortoli N, Martinucci I, Bodini G, Ghio M, Savarino V. Gastrointestinal involvement in systemic sclerosis. Presse Med 2014; 43:e279-91. [PMID: 25179275 DOI: 10.1016/j.lpm.2014.03.029] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/18/2014] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis is an autoimmune chronic disease characterised by microvascular, muscular and immunologic abnormalities that lead to progressive and systemic deposition of connective tissue in the skin and internal organs. The gastrointestinal tract is often overlooked by physicians but it is the most affected organ after the skin, from the mouth to the anus. Indeed, 80% of SSc patients may present with gastrointestinal involvement. Gastrointestinal manifestations range from bloating and heartburn to dysphagia and anorectal dysfunction to severe weight loss and malabsorption. However, the gastrointestinal involvement is rarely the direct cause of death, but has great impact on quality of life and leads to several comorbidities that subsequently affect patients' survival. Treatments, including nutritional support and prokinetics provide limited benefits and do not arrest the progressive course of the disease, but earlier detection of gastrointestinal involvement may reduce the risk of complications such as malnutrition.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Irene Martinucci
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Giorgia Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Massimo Ghio
- Division of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Petronovich JJ, Bock JM. Systemic sclerosis and reflux. EAR, NOSE & THROAT JOURNAL 2014; 92:192-4. [PMID: 23599100 DOI: 10.1177/014556131309200410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- John J Petronovich
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
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Smyk DS, Koutsoumpas AL, Mytilinaiou MG, Rigopoulou EI, Sakkas LI, Bogdanos DP. Helicobacter pylori and autoimmune disease: Cause or bystander. World J Gastroenterol 2014; 20:613-629. [PMID: 24574735 PMCID: PMC3921471 DOI: 10.3748/wjg.v20.i3.613] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/26/2013] [Accepted: 12/06/2013] [Indexed: 02/06/2023] Open
Abstract
Helicobacter pylori (H. pylori) is the main cause of chronic gastritis and a major risk factor for gastric cancer. This pathogen has also been considered a potential trigger of gastric autoimmunity, and in particular of autoimmune gastritis. However, a considerable number of reports have attempted to link H. pylori infection with the development of extra-gastrointestinal autoimmune disorders, affecting organs not immediately relevant to the stomach. This review discusses the current evidence in support or against the role of H. pylori as a potential trigger of autoimmune rheumatic and skin diseases, as well as organ specific autoimmune diseases. We discuss epidemiological, serological, immunological and experimental evidence associating this pathogen with autoimmune diseases. Although over one hundred autoimmune diseases have been investigated in relation to H. pylori, we discuss a select number of papers with a larger literature base, and include Sjögrens syndrome, rheumatoid arthritis, systemic lupus erythematosus, vasculitides, autoimmune skin conditions, idiopathic thrombocytopenic purpura, autoimmune thyroid disease, multiple sclerosis, neuromyelitis optica and autoimmune liver diseases. Specific mention is given to those studies reporting an association of anti-H. pylori antibodies with the presence of autoimmune disease-specific clinical parameters, as well as those failing to find such associations. We also provide helpful hints for future research.
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Ghrénassia E, Avouac J, Khanna D, Derk CT, Distler O, Suliman YA, Airo P, Carreira PE, Foti R, Granel B, Berezne A, Cabane J, Ingegnoli F, Rosato E, Caramaschi P, Hesselstrand R, Walker UA, Alegre-Sancho JJ, Zarrouk V, Agard C, Riccieri V, Schiopu E, Gladue H, Steen VD, Allanore Y. Prevalence, correlates and outcomes of gastric antral vascular ectasia in systemic sclerosis: a EUSTAR case-control study. J Rheumatol 2013; 41:99-105. [PMID: 24293584 DOI: 10.3899/jrheum.130386] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To estimate the prevalence, determine the subgroups at risk, and the outcomes of patients with systemic sclerosis (SSc) and gastric antral vascular ectasia (GAVE). METHODS We queried the European League Against Rheumatism Scleroderma Trials and Research (EUSTAR) network for the recruitment of patients with SSc-GAVE. Each case was matched for cutaneous subset and disease duration with 2 controls with SSc recruited from the same center, evaluated at the time the index case made the diagnosis of GAVE. SSc characteristics were recorded at the time GAVE occurred and the last observation was collected to define the outcomes. RESULTS Forty-nine patients with SSc and GAVE were included (24 with diffuse cutaneous SSc) and compared to 93 controls with SSc. The prevalence of GAVE was estimated at about 1% of patients with SSc. By multivariate analysis, patients with SSc-GAVE more frequently exhibited a diminished (< 75%) DLCO value (OR 12.8; 95% CI 1.9-82.8) despite less frequent pulmonary fibrosis (OR 0.2; 95% CI 0.1-0.6). GAVE was also associated with the presence of anti-RNA-polymerase III antibodies (OR 4.6; 95% CI 1.2-21.1). SSc-GAVE was associated with anemia (82%) requiring blood transfusion (45%). Therapeutic endoscopic procedures were performed in 45% of patients with GAVE. After a median followup of 30 months (range 1-113 months), survival was similar in patients with SSc-GAVE compared to controls, but a higher number of scleroderma renal crisis cases occurred (12% vs 2%; p = 0.01). CONCLUSION GAVE is rare and associated with a vascular phenotype, including anti-RNA-polymerase III antibodies, and a high risk of renal crisis. Anemia, usually requiring blood transfusions, is a common complication.
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Affiliation(s)
- Etienne Ghrénassia
- From the Department of Rheumatology A, Paris Descartes University, Cochin Hospital, AP-HP, Paris, France; University of Michigan Scleroderma Program, Ann Arbor, Michigan, USA; Division of Rheumatology, University of Pennsylvania, Philadelphia, USA; Department of Rheumatology, University Hospital Zurich, Switzerland; Rheumatology and Clinical Immunology Unit, Spedali Civili and University of Brescia, Brescia, Italy; Rheumatology Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Rheumatology Unit, Azienda Ospedaliera Universitaria V. Emanuele, Ferrarotto, S. Bambino, Catania, Italy; Service de Médecine Interne, Centre Hospitalier Nord, Marseille, France; Service de Médecine Interne, University Hospital Centre (CHU) Cochin; Service de Médecine Interne, CHU Saint-Antoine, Paris, France; Division of Rheumatology, Istituto Gaetano Pini, University of Milan, Italy; Department of Clinical Medicine, Clinical Immunology Unit, Sapienza University of Rome, Rome, Italy; Rheumatology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italia; Department of Rheumatology, Lund University, Lund, Sweden; Department of Rheumatology, Basel University, Basel, Switzerland; Sección de Reumatología, Hospital Dr Peset, Valencia, Spain; Médecine interne, Hôpital Beaujon, Clichy, France; Internal Medicine, Hôtel-Dieu Hospital, CHU Nantes, Nantes, France; Rheumatologic Unit, Department of Internal Medicine and Clinical Specialties, Sapienza University of Rome, Rome, Italy; and Department of Medicine, Georgetown University Medical Center, Washington DC, USA
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Acupuncture-based modalities: novel alternative approaches in the treatment of gastrointestinal dysmotility in patients with systemic sclerosis. Explore (NY) 2013; 10:44-52. [PMID: 24439095 DOI: 10.1016/j.explore.2013.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The gastrointestinal (GI) dysmotility of systemic sclerosis (SSc, scleroderma) patients requires careful evaluation and intervention. The lack of effective prokinetic drugs motivate researchers to search for alternative treatments. OBJECTIVES We present an overview of the pathophysiology of SSc GI dysmotility and the advances in its management, with particular focus on acupuncture-related modalities and innovative therapies. DATA SOURCES Original research articles were identified based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline methodology. We have searched the MEDLINE database using Medical Subject Heading (MeSH) for all English and non-English articles with an English abstract from 2005 to October 2012. RESULTS Only four original articles of various study designs were found studying Complementary and Alternative Medicine (CAM) therapies for SSc patients. Despite the small patient study numbers, CAM treatments, acupressure, and transcutaneous electroacupuncture, showed self-reported and physiologic evidence of improvement of GI functioning and/or symptoms in SSc patients. CONCLUSIONS CAM therapies include experimental modalities with the potential to offer relief of symptoms from GI dysmotility. Larger studies are needed to investigate their optimal use in patient subsets to tailor therapies to patient needs.
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Petronovich JJ, Bock JM. Systemic Sclerosis and Reflux. EAR, NOSE & THROAT JOURNAL 2013. [DOI: 10.1177/014556131309200510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- John J. Petronovich
- From the Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - Jonathan M. Bock
- From the Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
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26
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Noaiseh G, Li S, Derk CT. Management of gastrointestinal manifestations in systemic sclerosis (scleroderma). ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Turesson C, Matteson EL. Malignancy as a comorbidity in rheumatic diseases. Rheumatology (Oxford) 2012; 52:5-14. [DOI: 10.1093/rheumatology/kes189] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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28
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Horowitz DP, Halmos B, Poneros J, Sonett J, Remotti H, Burri RJ. Management of Esophageal Squamous Cell Carcinoma with Definitive Chemoradiotherapy in a Patient with Scleroderma: Case Report and Review of the Literature. J Gastrointest Cancer 2012; 43 Suppl 1:S156-60. [PMID: 22585471 DOI: 10.1007/s12029-012-9393-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- David P Horowitz
- Department of Radiation Oncology, Columbia University Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Balazs Halmos
- Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - John Poneros
- Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Joshua Sonett
- Department of Surgery, Columbia University Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Helen Remotti
- Department of Pathology, Columbia University Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Ryan J Burri
- Winter Park Cancer Center, Winter Park, FL, USA.
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Vischio J, Saeed F, Karimeddini M, Mubashir A, Feinn R, Caldito G, Striegel K, Rothfield N. Progression of esophageal dysmotility in systemic sclerosis. J Rheumatol 2012; 39:986-91. [PMID: 22382346 DOI: 10.3899/jrheum.110923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To longitudinally evaluate esophageal dysmotility (ED) in patients with limited cutaneous systemic sclerosis (lcSSc) and diffuse cutaneous systemic sclerosis (dcSSc). METHODS We performed a retrospective review of all adult patients with SSc seen between 1995 and 2008. Patients were included if they had undergone 2 or more esophageal transit scintigraphy (ETS) studies at least 1 year apart. Data from 382 ETS studies of 102 patients with SSc were analyzed. Eighty patients had lcSSc and 22 patients had dcSSc. A grading system was used to quantify the degree of esophageal dysfunction, ranging from grade 0 (normal) to grade 3 (severe hypomotility). Change in esophageal motility over time was evaluated and compared between the limited and diffuse subtypes. RESULTS Sixty-eight patients (66.7%) had an abnormal ETS study at any time. Of patients with dcSSc, 95.4% had an abnormal ETS study, compared to 58.5% of patients with lcSSc. dcSSc and regurgitation were independent risk factors for ED. There was no association between the presence of anticentromere antibodies or antitopoisomerase (anti-Scl-70) antibodies and an abnormal ETS study. Esophageal motility in patients with dcSSc worsened in 96% of cases compared with only 58.8% in those with lcSSc. CONCLUSION ED is more frequent in patients with dcSSc than in those with lcSSc, and is more likely to deteriorate over time. Given the potential associated risks of erosive esophagitis, Barrett's esophagus, and esophageal cancer in patients with SSc, routine screening and monitoring for ED is advised.
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Affiliation(s)
- John Vischio
- Department of Medicine, Division of Rheumatology, University of Connecticut Health Center, Farmington, Connecticut 06030, USA
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30
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Lahcene M, Oumnia N, Matougui N, Boudjella M, Tebaibia A, Touchene B. Esophageal involvement in scleroderma: clinical, endoscopic, and manometric features. ISRN RHEUMATOLOGY 2011; 2011:325826. [PMID: 22389793 PMCID: PMC3263742 DOI: 10.5402/2011/325826] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 07/06/2011] [Indexed: 01/01/2023]
Abstract
Aim. To evaluate characteristics of esophageal involvement in scleroderma. Methods. The study was prospective and concerned 194 patients with a definite systemic sclerosis. Gastroesophageal endoscopy and esophageal manometry were performed in all the cases. Results. Symptoms were present in 118 cases (60.8%); they were signs of GERD or dysphagia, respectively, in 94 (48.4%) and 91 patients (46.9%). Reflux esophagitis was found in 73 cases (37.6%); it was mild or moderate in 47 cases (24.2%) and severe or complicated in the remaining cases. Manometry revealed a lower esophageal sphincter incompetence and esophageal motor disorders, respectively, in 118 (60.8%) and 157 cases (80.9%). Presence of these late was not related to age, duration, or skin extension of the disease, but with clinical complaint and/or mucosal damage. Conclusion. Esophageal involvement is frequent during scleroderma. Manometry is the most sensible examination and could be a screening procedure.
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Affiliation(s)
- M Lahcene
- Department of Internal Medicine, Kouba Hospital, Algiers, Algeria
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31
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Belloli L, Carlo-Stella N, Ughi N, Marasini B. Cancer in Italian Patients with Systemic Sclerosis. EUR J INFLAMM 2011. [DOI: 10.1177/1721727x1100900215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The association between cancer and systemic sclerosis (SSc) is known, although the underlying mechanisms remain unclear and epidemiological data is conflicting. Since no data exist on cancer in Italian SSc, we examined the frequency and characteristics of cancer in an Italian cohort of SSc patients to examine whether clinical and/or laboratory SSc-specific features represent a risk for developing malignancies in these patients. A retrospective chart review was carried out of 112 Italian SSc patients of whom 109 were women 3 and were men, aged 63±13 years; 81 patients had limited SSc, 25 had diffuse SSc and 6 had sine scleroderma SSc. Fifteen cancers were found in 14 patients. The majority (60%) occurred after SSc onset (average 16 years), 40% occurred before the onset of SSc (average 14 years). The most frequent was breast cancer (prevalence: 4.5%, relative prevalence:33.3%), followed by uterine cancer and lymphomas (prevalence: 2.7%, relative prevalence: 20% each). Lung cancer was not observed. Cancers were unrelated with SSc type, autoantibodies, organ involvement and treatments. In conclusion, clinical features do not seem to be linked with the risk of developing cancer in SSc patients. Interestingly, and in contrast with published data, no lung cancer was present in our patients, although lung involvement was observed in the majority of them. This finding, consistent with a lower prevalence of lung cancer in the Italian female general population, and the absence of associations between SSc-specific features and cancer, suggests that genetic and environmental factors might play a pivotal role in cancer risk in these patients.
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Affiliation(s)
- L. Belloli
- Rheumatology Unit, IRCCS Istituto Clinico Humanitas, Università degli Studi di Milano, Milan, Italy
| | - N. Carlo-Stella
- Rheumatology Unit, IRCCS Istituto Clinico Humanitas, Università degli Studi di Milano, Milan, Italy
| | - N. Ughi
- Rheumatology Unit, IRCCS Istituto Clinico Humanitas, Università degli Studi di Milano, Milan, Italy
| | - B. Marasini
- Rheumatology Unit, IRCCS Istituto Clinico Humanitas, Università degli Studi di Milano, Milan, Italy
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Wipff J, Coriat R, Masciocchi M, Caramaschi P, Derk CT, Hachulla E, Riccieri V, Mouthon L, Krasowska D, Ananyeva LP, Kahan A, Matucci-Cerinic M, Chaussade S, Allanore Y. Outcomes of Barrett's oesophagus related to systemic sclerosis: a 3-year EULAR Scleroderma Trials and Research prospective follow-up study. Rheumatology (Oxford) 2011; 50:1440-4. [PMID: 21415021 DOI: 10.1093/rheumatology/ker110] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Barrett's oesophagus (BE) is the major risk factor for oesophageal adenocarcinoma (EAC). SSc is associated with an increased risk of BE related to chronic reflux. The aim of this study is to determine the outcomes of BE and estimate the EAC risk in SSc patients over a 3-year prospective study. METHODS SSc patients were recruited through EUSTAR network centres. Inclusion criterion was a recent histological finding of BE. The patients were then prospectively followed and, as recommended, a second oesophageal endoscopy was performed according to the presence of BE-related dysplasia at baseline. RESULTS A total of 50 SSc patients with BE (40 without and 10 with dysplasia) were included and 46 completed the follow-up (138 patient-years). During the 3-year follow-up, 4 of the 46 BE patients (3% per year) were diagnosed with high-grade dysplasia/EAC, of which one developed cardial EAC. EAC incidence in the BE subgroup with dysplasia increased to 4% per year compared with the absence of EAC cases in the BE subgroup without dysplasia at baseline. CONCLUSION Our results, in accordance with previous published data suggesting an increased risk of EAC or cardial adenocarcinoma in SSc, highlight the need for accurate follow-up of BE SSc patients at risk of developing adenocarcinoma.
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Affiliation(s)
- Julien Wipff
- Rheumatology A Department, Paris Descartes University, Cochin Hospital, AP-HP, Paris, France.
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Pathogenesis of systemic sclerosis. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00139-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Radić M, Kaliterna DM, Radić J. Helicobacter pylori infection and systemic sclerosis-is there a link? Joint Bone Spine 2010; 78:337-40. [PMID: 21145276 DOI: 10.1016/j.jbspin.2010.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 10/08/2010] [Indexed: 12/11/2022]
Abstract
Over the last 20 years, increasing evidence has accumulated to implicate infectious agents in the etiology of systemic sclerosis (SSc) and Raynaud's phenomenon. Infection rates in patients with SSc compared with those in control populations do not provide clear support for any specific pathogen. However, increased antibody titers, a preponderance of specific strains in patients with SSc, and evidence of molecular mimicry inducing autoimmune responses suggest mechanisms by which infectious agents may contribute to the development and progression of SSc. Helicobacter pylori (H. pylori) has been associated with diseases such as autoimmune gastritis, Sjögren's syndrome, atherosclerosis, immune thrombocytopenia purpura, inflammatory bowel diseases and autoimmune pancreatitis, in each of which it seems to play a pathogenetic, but it has also been suggested that it may help to protect against the development of autoimmune gastritis, multiple sclerosis, systemic lupus erythemathosus and inflammatory bowel diseases. A systematic literature search was carried out in MEDLINE, EMBASE, Cochrane Library and ACR/EULAR meeting abstracts. We hypotheses that H. pylori infection might play a critical role in the pathogenesis of SSc. Here we review studies examining the potential involvement of H. pylori infection in SSc.
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Affiliation(s)
- Mislav Radić
- Department of Rheumatology, University Hospital, Split, Croatia.
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35
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Laoubi K, Allanore Y, Chaussade S, Kahan A, Wipff J. Estomac pastèque au cours de la sclérodermie systémique. ACTA ACUST UNITED AC 2010; 35:250-3. [DOI: 10.1016/j.jmv.2010.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 03/08/2010] [Indexed: 01/24/2023]
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Tiev KP, Cabane J. Digestive tract involvement in systemic sclerosis. Autoimmun Rev 2010; 11:68-73. [PMID: 20601200 DOI: 10.1016/j.autrev.2010.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2010] [Indexed: 01/17/2023]
Affiliation(s)
- Kiet Phong Tiev
- Department of Internal Medicine, Saint-Antoine Hospital, AP-HP, Pierre & Marie Curie University (Paris VI), 184 rue du Faubourg Saint Antoine, Paris Cedex 12, France
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Calderaro DC, de Carvalho MAP, Moretzsohn LD. Esophageal manometry in 28 systemic sclerosis Brazilian patients: findings and correlations. Dis Esophagus 2009; 22:700-4. [PMID: 19664079 DOI: 10.1111/j.1442-2050.2009.01000.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Systemic sclerosis (SSc) is a multisystem disease of unknown etiology. Esophageal involvement affects 50-90% of patients and is characterized by abnormal motility and hypotonic lower esophageal sphincter. Data on the association of esophageal abnormalities and age, gender, SSc subset or duration, autoantibody profile, esophageal symptoms, and medication are lacking or conflicting. The aim of this study was the evaluation of these associations in Brazilian sclerodermic patients from the Rheumatology Division, Clinics Hospital, Federal University, Minas Gerais. They underwent medical records review, clinical interview, and esophageal manometry. The normal cutoff level for lower esophageal sphincter pressure was 14 mmHg. Abnormal peristalsis occurred when less than 80% of peristaltic waves were propagated. P-values less than 0.05 were considered significant. Twenty-eight patients were included: 71% were women. The population presented medium age and disease duration of 46 years and 12 years, respectively. Cutaneous diffuse SSc occurred in 39% and its limited form in 61%. Dysphagia, pyrosis, and regurgitation occurred, respectively, in 71%, 43%, and 61% of patients. Lower esophageal sphincter pressure and number of peristaltic waves-propagated medias were, respectively, 17.2 mmHg and 2.3. SSc-related manometric abnormalities were present in 86% of patients. Manometry revealed distal esophageal body hypomotility, hypotonic lower esophageal sphincter, or both, respectively, in 82%, 39%, and 36% of patients. One patient presented the manometric pattern of esophageal achalasia. Male patients more frequently presented hypotonic inferior esophageal sphincter. Manometric findings have had no relationship with the other variables. Nifedipine use did not influence manometric findings.
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Affiliation(s)
- D C Calderaro
- Rheumatology Division of the Department of Musculoskeletal System, Clinics Hospital, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
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Forbes A, Marie I. Gastrointestinal complications: the most frequent internal complications of systemic sclerosis. Rheumatology (Oxford) 2009; 48 Suppl 3:iii36-9. [PMID: 19487222 DOI: 10.1093/rheumatology/ken485] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Manifestations of SSc in the gastrointestinal (GI) tract are common, occurring in 50-90% of patients. They typically result from the fibrosis that characterizes this disease. Manifestations of SSc can affect many sites within the GI tract, and patients may experience substantial dysfunction in the processes of motility, digestion, absorption and excretion. Oesophageal dysfunction is the most common GI manifestation, but patients may also experience dysfunction of the stomach, small intestine, colon and rectum, each of which can be responsible for severe and distressing symptoms. At present, few specific therapeutic options are available for the treatment of these patients, but relief of symptoms is often possible with appropriate knowledge and support. It is therefore particularly important to identify, monitor and manage these patients carefully, with a view to minimizing further degeneration and maximizing quality of life.
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Affiliation(s)
- A Forbes
- Department of Gastroenterology and Nutrition, University College Hospital, London, UK.
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39
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Marasini B, Conciato L, Belloli L, Massarotti M. Systemic Sclerosis and Cancer. Int J Immunopathol Pharmacol 2009; 22:573-8. [DOI: 10.1177/039463200902200303] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
To review recent advances and current controversies on the association between systemic sclerosis (SSc) and cancer, PUBMED was searched from 1966 to the present using the terms: systemic sclerosis, cancer, morphoea, sclerotic diseases. Malignancies, mainly in lung and breast, coexist with idiopathic SSc or with SSc-like disorders, but not with localized forms of scleroderma (morphoea), with the exception of squamous cell carcinoma in patients with pansclerotic morphoea and skin ulcers. The mechanisms connecting SSc and malignancies are unknown. The occurrence of different cancer types with SSc or SSc-like disorders suggest different underlying mechanisms, including altered immune response, common genetic and environmental links, disease-dependent factors, tumor-derived biologic substances and therapies. The process of sclerosis itself may favour cancer in certain sites, and a reaction between T cells and neoantigens formed during irradiation has been suggested to explain the frequent development of morphoea after breast irradiation. Radiotherapy, especially when used for breast cancer, may trigger idiopathic SSc or morphoea and influence the severity of preexisting SSc, with the consequence that SSc is considered a relative contraindication to breast radiotherapy. In conclusion, cancer and SSc may be associated, but it is still controversial as to whether there is a causal relationship. Continuing interest in these associations, in particular in the different modalities of associations, may help to understand the underlying biological mechanisms and to identify patients at risk.
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Affiliation(s)
- B. Marasini
- Rheumatology Unit, IRCCS Istituto Clinico Humanitas, University of Milan, Milan, Italy
| | - L. Conciato
- Rheumatology Unit, IRCCS Istituto Clinico Humanitas, University of Milan, Milan, Italy
| | - L. Belloli
- Rheumatology Unit, IRCCS Istituto Clinico Humanitas, University of Milan, Milan, Italy
| | - M. Massarotti
- Rheumatology Unit, IRCCS Istituto Clinico Humanitas, University of Milan, Milan, Italy
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40
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Russo S, Lo Re G, Galia M, Reginelli A, Lo Greco V, D'Agostino T, La Tona G, Coppolino F, Grassi R, Midiri M, Lagalla R. Videofluorography swallow study of patients with systemic sclerosis. Radiol Med 2009; 114:948-59. [PMID: 19562267 DOI: 10.1007/s11547-009-0416-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 07/31/2008] [Indexed: 12/21/2022]
Abstract
PURPOSE This study was undertaken to evaluate the role of the videofluorographic (VFG) swallow study in patients with systemic sclerosis. MATERIALS AND METHODS Over a 23-month period, 45 women (mean age 58 years, range 27-76 years) with a known diagnosis of systemic sclerosis and a history of dysphagia underwent a dynamic and morphological study of the oral, pharyngeal and oesophageal phases of swallowing with videofluorography. All examinations were performed with a remote-controlled digital C-arm device with 16-in image intensifier, 0.6- to 1.2-mm focal spot range and maximum tube voltage of 150 kVp in fluorography and 120 kVp in fluoroscopy. Cineradiographic sequences were acquired for the swallow study with 12 images per second and matrix 512 x 512 after the ingestion of boluses of high-density (250% weight/volume) barium. The evaluation of oesophageal peristalsis was documented with digital cineradiographic sequences with six images per second in the upright and supine positions during the swallowing of barium (60% weight/volume), and the water siphon test was performed with the patient in the supine position to evaluate the presence of gastro-oesophageal reflux disease (GORD). All patients subsequently underwent laryngoscopy, endoscopy and pH monitoring, and the data thus obtained were processed and compared. RESULTS The VFG swallow study identified alterations of epiglottal tilting associated with intraswallowing laryngeal penetration in 26 patients (57.8%), pooling of contrast agent in the valleculae and pyriform sinuses in 23 (51.1%) and radiographic signs of nonspecific hypertrophy of the lingual and/or palatine tonsils in 18 (40%). The study of the oesophageal phase revealed the presence of altered peristalsis in all patients, and in particular, 36 patients (80%) showed signs of atony. Altered oesophageal clearing mechanisms were evident in all 45 patients, sliding hiatus hernia in 43 (93%) and GORD in 44 (97%). CONCLUSIONS Our study demonstrated that in patients with systemic sclerosis, there is no primary alteration of the oral or pharyngeal phase of swallowing. In addition, alterations of epiglottal tilting associated with laryngeal penetration of contrast agent were found to be secondary to chronic GORD. Indeed, in 40% of patients, radiographic signs were found that indicated nonspecific hypertrophy of the lingual tonsil and/or palatine tonsils and nonspecific signs of chronic pharyngeal inflammation, and GORD was identified in 93% of patients, which in 40% of cases extended to the proximal third of the oesophagus. The data obtained were confirmed in 85% of cases with pH monitoring and in all cases with laryngoscopy.
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Affiliation(s)
- S Russo
- Dipartimento Biotecnologie Mediche e Medicine Legale, Università degli Studi di Palermo, Via M. Cefalu' 11, S. Flavia Palermo, 90017 Palermo, Italy.
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41
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Lidia Vera-Lastra O. [Systemic sclerosis and the gastrointestinal tract. Diagnostic and therapeutic approach]. ACTA ACUST UNITED AC 2008; 2 Suppl 3:S24-30. [PMID: 21794384 DOI: 10.1016/s1699-258x(06)73104-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In systemic sclerosis esophagus is affected in 90% followed by anal and rectal involvement (50-70%), stomach (40-70%), colon (10-50%) and small bowel (40%). The main clinical findings are esophagic: dysphagia and sign of gastroesophageal reflux and its complications. Gastric symptomatology is a consequence of gastroparesis (postprandial fullness, nausea). Intestinal affection produces hypomotility (abdominal distention, deficient intestinal absorption, bacterial overgrowth). In colon there are diverticula, intestinal constipation, and fecal incontinence. For the diagnosis of GIT involvement the following are useful: studies of digestive tract with contrast media, endoscopy of upper GIT; gastric emptying; pH metry; esophageal and rectal manometry, as well as test to investigate deficient intestinal absorption syndrome. The prokinetic are a cornerstone for the treatment of hypomotility of GIT, along with pump proton inhibitors for the esophageal alteration and antibiotics for bacterial overgrowth.
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Affiliation(s)
- Olga Lidia Vera-Lastra
- Departamento de Medicina Interna. Hospital de Especialidades Antonio Fraga Mouret. Centro Médico Nacional La Raza. IMSS. México DF. México
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Abstract
The pathogenic process of systemic sclerosis targets the skin and internal organs, and involves sequential or concomitant abnormalities in blood vessel function, in immunity and inflammation, and in subsequent fibroblast activation. These characteristics are disease-specific and may partly explain the unresolved therapeutic strategies. These latter must take into account not only the broad biological abnormalities but also the complexities of the disturbances throughout the duration of the disease. However, recent epidemiological data have suggested a decrease in excess mortality, which may be mostly due to the use of cardiovascular drugs. Indeed, the prognoses of the kidney, heart and pulmonary vascular involvements have been improved. Nevertheless and despite several trials, pulmonary fibrosis remains a challenge with no clear efficacy of the regimen of immunosuppressors that have been investigated. This article deals with current and possible future therapeutic options.
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Affiliation(s)
- Yannick Allanore
- Paris Descartes University, Medical Faculty, Department of Rheumatology A, Cochin Hospital, AP-HP and INSERM U781, Necker Hospital, Paris, France.
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Abstract
Barrett's esophagus, or the presence of specialized intestinal mucosa in the esophagus that has a malignant potential, has experienced a rapid increase in diagnosis and prevalence over the past few decades. Once thought to progress to adenocarcinoma in an orderly sequence of increasing dysplasia, recent data suggest the process can be more random. In combination with targeted surveillance endoscopy, recent improvements in technology have aided endoluminal therapy in becoming a cost-effective adjunct to medication. When used in combination, in particular, these ablative therapies have become suitable, if not preferable, alternatives to surgery in many patients.
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Affiliation(s)
- Michael S Smith
- Assistant Professor of Medicine, Temple University School of Medicine, Section of Gastroenterology, 3401 North Broad Street, 8PP, Zone "C", Philadelphia, PA 19140, USA.
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Domsic R, Fasanella K, Bielefeldt K. Gastrointestinal manifestations of systemic sclerosis. Dig Dis Sci 2008; 53:1163-74. [PMID: 17934861 DOI: 10.1007/s10620-007-0018-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 09/07/2007] [Indexed: 12/12/2022]
Abstract
Systemic sclerosis is a chronic disorder of connective tissue that affects the gastrointestinal tract in more than 80% of patients. Changes in neuromuscular function with progressive fibrosis of smooth muscle within the muscularis propria impair normal motor function, which may secondarily alter transit and nutrient absorption. Esophageal manifestations with gastroesophageal reflux and dysphagia are the most common visceral manifestation of the disease, often requiring more intense acid-suppressive medication. Gastric involvement may lead to gastroparesis, which can be found in up to 50% of patients. Severe small bowel disease can present as chronic intestinal pseudo-obstruction with distended loops of small intestine, bacterial overgrowth, impaired absorption and progressive development of nutritional deficiencies. While not studied as extensively, systemic sclerosis often also affects colorectal function resulting in constipation, diarrhea or fecal incontinence. Nutritional support and prokinetics have been used with some success to manage gastric and small or large bowel involvement in patients with systemic sclerosis. Despite advances in management, significant gastrointestinal manifestations of systemic sclerosis still carry a poor prognosis with a five-year mortality exceeding 50%.
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Affiliation(s)
- Robyn Domsic
- Division of Rheumatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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46
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Saar P, Schmeiser T, Tarner IH, Müller-Ladner U. [Gastrointestinal involvement in systemic sclerosis. An underestimated complication]. Hautarzt 2008; 58:844-50. [PMID: 17726594 DOI: 10.1007/s00105-007-1380-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Systemic sclerosis (SSc) belongs to the family of autoimmune connective tissue diseases and is still a challenge to every practicing physician. The disorder is characterized by progressing fibrosis of the skin and internal organs, abnormal activation of the immune system, and distinct changes in microcirculation. Although it is rare--with a prevalence of about 20:100000--patients need to be cared for in a daily setting. In general thickening of the skin is the first sign of the disease, so dermatologists are most frequently consulted first. Two subtypes exist, limited and diffuse forms. Both entities usually involve internal organs, and therefore interdisciplinary cooperation is mandatory. The increased morbidity and mortality depend predominantly on the grade of involvement of the affected organs. Therefore it is essential to diagnose systemic sclerosis early and to identify and monitor all complications closely. In this respect gastrointestinal involvement is frequently neglected, owing to its primarily non-life-threatening character, resulting in substantially delayed therapy.
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Affiliation(s)
- P Saar
- Abt. für Rheumatologie und klinische Immunologie, Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie der Justus-Liebig-Universität Giessen, Kerckhoff-KlinikBad Nauheim, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.
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48
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Abstract
Motor abnormalities of the oesophagus are characterised by a chronic impairment of the neuromuscular structures that co-ordinate oesophageal function. The best-defined entity is achalasia, which is discussed in a separate chapter. Other motor disorders with clinical relevance include diffuse oesophageal spasm, oesophageal dysmotility associated with scleroderma, and ineffective oesophageal motility. These non-achalasic motor disorders have variable prevalence but they could be associated with invalidating symptoms such as dysphagia, chest pain and gastro-oesophageal reflux disease. New oesophageal diagnostic techniques, including high-resolution manometry, high-frequency intraluminal ultrasound and intraluminal impedance, allow (1) better definition of peristalsis and sphincter function, (2) assessment of changes in oesophageal wall thickness, and (3) evaluation of pressure gradients within the oesophagus and across the sphincters that can produce normal or abnormal patterns of bolus transport. This chapter discusses recent advances in physiology, pathophysiology, diagnosis and treatment of non-achalasic oesophageal motor disorders.
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Affiliation(s)
- Daniel Sifrim
- Centre for Gastroenterological Research, Catholic University of Leuven, Faculty of Medicine, Belgium.
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49
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50
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Marie I. Barrett's oesophagus in systemic sclerosis: author's reply. Aliment Pharmacol Ther 2007; 25:858-9. [PMID: 17373926 DOI: 10.1111/j.1365-2036.2007.03264.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- I Marie
- Department of Internal Medicine, Rouen University Hospital, Rouen cedex, France
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