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Kaniecki T, Hughes M, McMahan Z. Managing gastrointestinal manifestations in systemic sclerosis, a mechanistic approach. Expert Rev Clin Immunol 2024; 20:603-622. [PMID: 38406978 PMCID: PMC11098704 DOI: 10.1080/1744666x.2024.2320205] [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: 10/31/2023] [Accepted: 02/14/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a connective tissue disease with heterogeneous presentation. Gastrointestinal (GI) complications of SSc are characterized by esophageal reflux, abnormal motility, and microbiome dysbiosis, which impact patient quality of life and mortality. Preventative therapeutics are lacking, with management primarily aimed at symptomatic control. AREAS COVERED A broad literature review was conducted through electronic databases and references from key articles. We summarize the physiology of gastric acid production and GI motility to provide context for existing therapies, detail the current understanding of SSc-GI disease, and review GI medications studied in SSc. Finally, we explore new therapeutic options. We propose a management strategy that integrates data on drug efficacy with knowledge of disease pathophysiology, aiming to optimize future therapeutic targets. EXPERT OPINION SSc-GI complications remain a challenge for patients, clinicians, and investigators alike. Management presently focuses on treating symptoms and minimizing mucosal damage. Little evidence exists to suggest immunosuppressive therapy halts progression of GI involvement or reverses damage, leaving many unanswered questions about the optimal clinical approach. Further research focused on identifying patients at risk for GI progression, and the underlying mechanism(s) that drive disease will provide opportunities to prevent long-term damage, and significantly improve patient quality of life.
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Affiliation(s)
- Timothy Kaniecki
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Hughes
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, US
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Zsuzsanna McMahan
- Division of Rheumatology, UTHealth Houston McGovern Medical School, Houston, TX
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2
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Patel D, Jose F, Baker J, Moshiree B. Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract in Cystic Fibrosis. Curr Gastroenterol Rep 2024; 26:9-19. [PMID: 38057499 DOI: 10.1007/s11894-023-00906-4] [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] [Accepted: 10/26/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF REVIEW To discuss all the various motility disorders impacting people with Cystic Fibrosis (PwCF) and provide diagnostic and management approaches from a group of pediatric and adult CF and motility experts and physiologists with experience in the management of this disease. RECENT FINDINGS Gastrointestinal (GI) symptoms coexist with pulmonary symptoms in PwCF regardless of age and sex. The GI manifestations include gastroesophageal reflux disease, esophageal dysmotility gastroparesis, small bowel dysmotility, small intestinal bacterial overgrowth syndrome, distal idiopathic obstruction syndrome, constipation, and pelvic floor disorders. They are quite debilitating, limiting the patients' quality of life and affecting their nutrition and ability to socialize. This genetic disorder affects many organ systems and is chronic, potentially impacting fertility and future family planning, requiring a multidisciplinary approach. Our review discusses the treatments of motility disorders in CF, their prevalence and pathophysiology. We have provided a framework for clinicians who care for these patients that can help to guide their clinical management.
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Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, SSM Cardinal Glennon Children's Medical Center, Saint Louis University, St Louis, MO, USA
| | - Folashade Jose
- Pediatric Gastroenterology, Hepatology, and Nutrition, Clinical Associate Professor, Levine Childrens Hospital, Carolina Pediatric Gastroenterology, Charlotte, NC, USA
| | | | - Baha Moshiree
- Division of Gastroenterology, Atrium Health Wake Forest Medical University, Charlotte, NC, USA.
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Clarke JO, Ahuja NK. Upper Gastrointestinal Tract: Manifestations of Systemic Sclerosis. SCLERODERMA 2024:477-493. [DOI: 10.1007/978-3-031-40658-4_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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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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Di Nardo G, Zenzeri L, Guarino M, Molfino A, Parisi P, Barbara G, Stanghellini V, De Giorgio R. Pharmacological and nutritional therapy of children and adults with chronic intestinal pseudo-obstruction. Expert Rev Gastroenterol Hepatol 2023; 17:325-341. [PMID: 36939480 DOI: 10.1080/17474124.2023.2193887] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/18/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Chronic intestinal pseudoobstruction (CIPO) is a rare, heterogenous, and severe form of gastrointestinal dysmotility. AREAS COVERED Pertinent literature on pediatric and adult CIPO management has been assessed via PubMed, Scopus, and EMBASE from inception to June 2022. Prokinetics, aimed at restoring intestinal propulsion (e.g. orthopramides and substituted benzamides, acetyl cholinesterase inhibitors, serotonergic agents, and others), have been poorly tested and the available data showed only partial efficacy. Moreover, some prokinetic agents (e.g. orthopramides and substituted benzamides) can cause major side effects. CIPO-related small intestinal bacterial overgrowth requires treatment preferably via poorly absorbable antibiotics to avoid bacterial resistance. Apart from opioids, which worsen gut motility, analgesics should be considered to manage visceral pain, which might dominate the clinical manifestations. Nutritional support, via modified oral feeding, enteral, or parenteral nutrition, is key to halting CIPO-related malnutrition. EXPERT OPINION There have been significant roadblocks preventing the development of CIPO treatment. Nonetheless, the considerable advancement in neurogastroenterology and pharmacological agents cast hopes to test the actual efficacy of new prokinetics via well-designed clinical trials. Adequate dietary strategies and supplementation remain of crucial importance. Taken together, novel pharmacological and nutritional options are expected to provide adequate treatments forthese patients.
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Affiliation(s)
- Giovanni Di Nardo
- NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Letizia Zenzeri
- NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
- Emergency Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Matteo Guarino
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Alessio Molfino
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Pasquale Parisi
- NESMOS Department, Faculty of Medicine & Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Barbara
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria Di Bologna; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Stanghellini
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria Di Bologna; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Suzon B, Rivière S, Schiffmann A, Rivet V, Flori N, Guilpain P, Maria ATJ. Long-term home parenteral nutrition in systemic sclerosis-related intestinal failure is feasible but unveils occult cardiac disease. Nutrition 2023; 110:112009. [PMID: 36965242 DOI: 10.1016/j.nut.2023.112009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/03/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE The aim of this study was to compare safety and efficacy of long-term home parenteral nutrition between patients with systemic sclerosis and intestinal failure (IF) and controls with IF from another etiology. METHODS A retrospective study was conducted in a referral center for systemic sclerosis (SSc) in Montpellier, France. Patients followed between 1985 and 2020 with SSc-related IF were included and compared with control patients with IF from another etiology. The patients included had to be treated for ≥4 wk by home parenteral nutrition (HPN). Primary outcome was occurrence of HPN-related complications. Secondary outcomes included duration of parenteral nutrition, body mass index at 12 mo, and survival. RESULTS Cumulative duration of HPN was 23 397 catheter days. HPN resulted in body mass index increase in both groups. There was no statistical difference regarding catheter-related bloodstream infections and thrombosis between the groups, despite use of immunosuppressive drugs and autologous hematopoietic stem cell transplantation in patients with SSc. However, the patients with SSc had significantly more HPN-related cardiac overload than the controls (P < 0.0001). Overloads occurred in SSc patients with and without cardiac disease, arguing for comprehensive hemodynamic screening in this condition. CONCLUSION Long-term HPN in SSc-related IF is feasible but unveils occult cardiac disease.
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Affiliation(s)
- Benoit Suzon
- Department of Internal Medicine, Martinique University Hospital, Martinique, France; EpiCliV Research Unit, University of the French West Indies, Fort-de-France, Martinique, France
| | - Sophie Rivière
- Department of Internal Medicine and Multi-Organic Diseases, Montpellier University Hospital, Montpellier, France
| | - Auelie Schiffmann
- Department of Internal Medicine and Multi-Organic Diseases, Montpellier University Hospital, Montpellier, France
| | - Valérian Rivet
- Internal Medicine and Clinical Immunopathology, ICUT-Oncopôle, Toulouse, France
| | - Nicolas Flori
- Clinical Nutrition, Gastroenterology and Endoscopy, Montpellier Cancer Institute, Montpellier, France
| | - Philippe Guilpain
- Department of Internal Medicine and Multi-Organic Diseases, Montpellier University Hospital, Montpellier, France; Montpellier University, Medical School, Montpellier, France; Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Alexandre Thibault Jacques Maria
- Montpellier University, Medical School, Montpellier, France; Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France; Internal Medicine & Immuno-Oncology (MedI2O), Montpellier University Hospital, Montpellier, France.
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Lemos MPC, Zucoloto TG, Oliveira MC, de Oliveira GLV. Dysbiosis and Gut Microbiota Modulation in Systemic Sclerosis. J Clin Rheumatol 2022; 28:e568-e573. [PMID: 34030162 DOI: 10.1097/rhu.0000000000001748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Gastrointestinal (GI) involvement is an early manifestation in systemic sclerosis (SSc), affecting more than 90% of patients, and severe GI disease is a marker of poor prognosis and mortality. Recent studies have hypothesized that alterations of the intestinal microbiota, known as dysbiosis, may represent 1 of the possible environmental factors influencing SSc disease status. In addition, specific microorganisms may be associated with SSc pathogenesis, progression, and GI manifestations. Therapeutic approaches aiming to modulate the intestinal microbiota have emerged, as alternatives to treat GI symptoms, and dietary interventions, probiotic administration, and fecal microbiota transplantation are potential therapies for SSc patients. However, given the complexity and variability of pathogenesis and clinical manifestations in SSc, these therapies need to be combined with additional interventions that target other disease components. Here, we summarize studies addressing intestinal dysbiosis in SSc and discuss the potential of microbiota modulators to treat SSc-related GI disorders.
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Keller J, Wedel T, Seidl H, Kreis ME, van der Voort I, Gebhard M, Langhorst J, Lynen Jansen P, Schwandner O, Storr M, van Leeuwen P, Andresen V, Preiß JC, Layer P, Allescher H, Andus T, Bischoff SC, Buderus S, Claßen M, Ehlert U, Elsenbruch S, Engel M, Enninger A, Fischbach W, Freitag M, Frieling T, Gillessen A, Goebel-Stengel M, Gschossmann J, Gundling F, Haag S, Häuser W, Helwig U, Hollerbach S, Holtmann G, Karaus M, Katschinski M, Krammer H, Kruis W, Kuhlbusch-Zicklam R, Lynen Jansen P, Madisch A, Matthes H, Miehlke S, Mönnikes H, Müller-Lissner S, Niesler B, Pehl C, Pohl D, Posovszky C, Raithel M, Röhrig-Herzog G, Schäfert R, Schemann M, Schmidt-Choudhury A, Schmiedel S, Schweinlin A, Schwille-Kiuntke J, Stengel A, Tesarz J, Voderholzer W, von Boyen G, von Schönfeld J. Update S3-Leitlinie Intestinale Motilitätsstörungen: Definition, Pathophysiologie, Diagnostik und Therapie. Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:192-218. [PMID: 35148561 DOI: 10.1055/a-1646-1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus in Hamburg, Hamburg, Deutschland
| | - Thilo Wedel
- Institut für Anatomie, Christian-Albrechts-Universität Kiel, Kiel, Deutschland
| | - Holger Seidl
- Klinik für Gastroenterologie, Hepatologie und Gastroenterologische Onkologie, Isarklinikum München, München, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité, Campus Benjamin Franklin, Berlin, Deutschland
| | - Ivo van der Voort
- Klinik für Innere Medizin - Gastroenterologie und Diabetologie, Jüdisches Krankenhaus Berlin, Deutschland
| | | | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum Bamberg, Bamberg, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, Berlin, Deutschland
| | - Oliver Schwandner
- Abteilung für Proktologie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Martin Storr
- Zentrum für Endoskopie, Gesundheitszentrum Starnberger See, Starnberg
| | - Pia van Leeuwen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, Berlin, Deutschland
| | - Viola Andresen
- Medizinische Klinik, Israelitisches Krankenhaus in Hamburg, Hamburg, Deutschland
| | - Jan C Preiß
- Klinik für Innere Medizin - Gastroenterologie, Diabetologie und Hepatologie, Klinikum Neukölln, Berlin
| | - Peter Layer
- Medizinische Klinik, Israelitisches Krankenhaus in Hamburg, Hamburg, Deutschland
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Chronic intestinal pseudo-obstruction: a case report with review of the literature and practical guidance for the clinician. Acta Gastroenterol Belg 2022; 85:85-93. [PMID: 35304998 DOI: 10.51821/85.1.9704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic Intestinal Pseudo-obstruction (CIPO) is a rare but debilitating and severe form of gastrointestinal dysmotility. The diagnosis is often made very late in the disease course due to its rarity and complexity. Treatment is mainly supportive, as there is no definitive cure. Pharmacologic therapy comprises prokinetics, antibiotics for bacterial overgrowth and pain management. Pain can also be alleviated with intestinal decompression in selected cases. Beside the pharmacologic therapy, nutrition and fluid replacement play a key role. Rarely, intestinal transplantation is necessary in patients with CIPO and intestinal failure. In this review, we describe an advanced CIPO case and provide an update of the clinical and diagnostic features and current management strategies. The goal of our review is to raise awareness around CIPO and to give practical guidance for the clinician.
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Thoreau B, Chaigne B, Renaud A, Mouthon L. Treatment of systemic sclerosis. Presse Med 2021; 50:104088. [PMID: 34718109 DOI: 10.1016/j.lpm.2021.104088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 12/29/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare connective tissue disease characterized by skin and visceral fibrosis, vascular hyperreactivity and obliterative vasculopathy. Some of its complications such as interstitial lung disease (ILD), pulmonary arterial hypertension (PAH) and heart involvement can be life-threatening and are associated with a high mortality and a poor prognosis. Many clinical trials were carried out in order to improve the survival and prognosis of SSc patients. The management of SSc is based on the frequent and regular assessment of the potential organ damage, and if present, the establishment of graduated pharmacological therapeutic strategies, associated with non-pharmacological procedures. Several randomized clinical trials have showed significant positive outcomes regarding some specific involvements. Many advances have been made, especially in the field of targeted therapies and personalized medicine, based on specific characteristics of the patient and the SSc.
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Affiliation(s)
- Benjamin Thoreau
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université de Paris; Service de Médecine Interne, Centre de Référence Maladies Systémiques Autoimmunes Rares d'Ile de France, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Benjamin Chaigne
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université de Paris; Service de Médecine Interne, Centre de Référence Maladies Systémiques Autoimmunes Rares d'Ile de France, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Arthur Renaud
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université de Paris; Service de Médecine Interne, Centre de Compétence Maladies Systémiques Autoimmunes Rares, CHU de Nantes, Nantes, France
| | - Luc Mouthon
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université de Paris; Service de Médecine Interne, Centre de Référence Maladies Systémiques Autoimmunes Rares d'Ile de France, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
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Cuerda C, Pironi L, Arends J, Bozzetti F, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM, Bischoff SC. ESPEN practical guideline: Clinical nutrition in chronic intestinal failure. Clin Nutr 2021; 40:5196-5220. [PMID: 34479179 DOI: 10.1016/j.clnu.2021.07.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults. METHODOLOGY ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure. RESULTS This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.
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Affiliation(s)
- Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Loris Pironi
- Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy
| | - Jann Arends
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | | | - Lyn Gillanders
- Emeritus of Auckland City Hospital, Auckland, New Zealand
| | - Palle Bekker Jeppesen
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Emeritus of Mayo Graduate School of Medicine, Rochester, Minnesota
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | - Stephan C Bischoff
- Department of Nutritional Medicine and Prevention, University of Hohenheim, Stuttgart, Germany
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Nightingale JMD, Paine P, McLaughlin J, Emmanuel A, Martin JE, Lal S, Small Bowel and Nutrition Committee and the Neurogastroenterology and Motility Committee of the British Society of Gastroenterology. The management of adult patients with severe chronic small intestinal dysmotility. Gut 2020; 69:2074-2092. [PMID: 32826308 PMCID: PMC7677490 DOI: 10.1136/gutjnl-2020-321631] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023]
Abstract
Adult patients with severe chronic small intestinal dysmotility are not uncommon and can be difficult to manage. This guideline gives an outline of how to make the diagnosis. It discusses factors which contribute to or cause a picture of severe chronic intestinal dysmotility (eg, obstruction, functional gastrointestinal disorders, drugs, psychosocial issues and malnutrition). It gives management guidelines for patients with an enteric myopathy or neuropathy including the use of enteral and parenteral nutrition.
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Affiliation(s)
| | - Peter Paine
- Gastroenterology, Salford Royal Foundation Trust, Salford, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Salford, UK
| | | | - Joanne E Martin
- Pathology Group, Blizard Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Simon Lal
- Gastroenterology and Intestinal Failure Unit, Salford Royal Foundation Trust, Manchester, UK
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13
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Fecal microbiota transplantation in systemic sclerosis: A double-blind, placebo-controlled randomized pilot trial. PLoS One 2020; 15:e0232739. [PMID: 32437393 PMCID: PMC7241803 DOI: 10.1371/journal.pone.0232739] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 04/03/2020] [Indexed: 01/07/2023] Open
Abstract
Objectives Systemic sclerosis (SSc) is an auto-immune, multi organ disease marked by severe gastrointestinal (GI) involvement and gut dysbiosis. Here, we aimed to determine the safety and efficacy of fecal microbiota transplantation (FMT) using commercially-available anaerobic cultivated human intestinal microbiota (ACHIM) in SSc. Methods Ten patients with SSc were randomized to ACHIM (n = 5) or placebo (n = 5) in a double-blind, placebo-controlled 16-week pilot. All patients had mild to severe upper and lower GI symptoms including diarrhea, distention/bloating and/or fecal incontinence at baseline. Gastroduodenoscopy transfer of ACHIM or placebo was performed at weeks 0 and 2. Primary endpoints were safety and clinical efficacy on GI symptoms assessed at weeks 4 and 16. Secondary endpoints included changes in relative abundance of total, immunoglobulin (Ig) A- and IgM-coated fecal bacteria measured by 16s rRNA sequencing. Results ACHIM side effects were mild and transient. Two placebo controls experienced procedure-related serious adverse events; one developed laryngospasms at week 0 gastroduodenoscopy necessitating study exclusion whilst one encountered duodenal perforation during gastroduodenoscopy at the last study visit (week 16). Decreased bloating, diarrhea and/or fecal incontinence was observed in four of five patients in the FMT group (week 4 or/and 16) and in two of four in the placebo group (week 4 or 16). Relative abundance, richness and diversity of total and IgA-coated and IgM-coated bacteria fluctuated more after FMT, than after placebo. Conclusions FMT of commercially-available ACHIM is associated with gastroduodenoscopy complications but reduces lower GI symptoms by possibly altering the gut microbiota in patients with SSc.
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Zenzeri L, Tambucci R, Quitadamo P, Giorgio V, De Giorgio R, Di Nardo G. Update on chronic intestinal pseudo-obstruction. Curr Opin Gastroenterol 2020; 36:230-237. [PMID: 32073506 DOI: 10.1097/mog.0000000000000630] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Chronic intestinal pseudo-obstruction (CIPO) is the most severe and disabling form of gastrointestinal dysmotility characterized by an impairment of coordinated propulsive activity in the gastrointestinal tract mimicking mechanical intestinal obstruction. Over the last few years, major advances have been made in the diagnostic and therapeutic management of this rare disorder. RECENT FINDINGS The present narrative review aims to summarize the current literature about the management of CIPO focusing on significant novelties about definition, epidemiology, diagnosis, and therapeutic options. The most significant advancement is a consensus on classification and dedicated diagnostic criteria for CIPO in children highlighting the distinctive features between adult and pediatric forms of CIPO (hence pediatric intestinal pseudo-obstruction). Despite no single diagnostic test is pathognomonic of CIPO and no recommended drug treatment is advised to improve gastrointestinal motility, recent reports suggest promising results in both diagnostic testing and therapy that might assist the diagnosis and help the management of patients with CIPO. SUMMARY The articles referenced in this review will help in optimizing the clinical management of this rare and severe disease in adult population.
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Affiliation(s)
- Letizia Zenzeri
- Emergency Pediatric Department, Santobono-Pausilipon Children's Hospital, Naples
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | - Paolo Quitadamo
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples
| | | | | | - Giovanni Di Nardo
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
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15
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Gonzalez Z, McCallum R. Small Bowel Dysmotility, Pseudoobstruction, and Functional Correlation with Histopathology: Lessons Learned. Curr Gastroenterol Rep 2020; 22:14. [PMID: 32078071 DOI: 10.1007/s11894-020-0748-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Small bowel dysmotility is a broad heterogeneous term that encompasses a wide range of gastrointestinal disorders resulting from abnormal gut motility. Chronic intestinal pseudo-obstruction (CIPO) is a severe, rare, and complex small bowel motility disorder at the extreme end of this spectrum. It is characterized by failure of the intestinal tract to propel contents, which results in signs and symptoms of bowel obstruction albeit in the absence of any obstructive lesion(s). In this article, we discuss up-to-date diagnostic techniques, management options, and histopathological findings in CIPO. RECENT FINDINGS We will emphasize the latest diagnostic methodologies and therapeutic options as well as enteric histopathologic abnormalities in patients with CIPO. CIPO continues to be a clinical challenge. Several novel pharmacological agents hold promise including gastrointestinal hormone agonists and prokinetics. Furthermore, histopathologic findings may help guide therapy and provide further prognostic significance. At present, nutritional support, symptom management, and avoidance of long-term complications are the mainstay of treatment in CIPO.
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Affiliation(s)
- Zorisadday Gonzalez
- Department of Gastroenterology, GI Motility Training and Research, Texas Tech University Health Sciences Center El Paso, 4800 Alberta, MSC 41007, El Paso, TX, 79905, USA.
| | - Richard McCallum
- Division of Gastroenterology, Center for Neurogastroenterology and GI Motility, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta, MSC 41007, El Paso, TX, 79905, USA
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16
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Parkman HP, Orthey P, Maurer AH. Gastric Motility. ENCYCLOPEDIA OF GASTROENTEROLOGY 2020:598-612. [DOI: 10.1016/b978-0-12-801238-3.11092-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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17
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Ahmed M, Ahmed S. Functional, Diagnostic and Therapeutic Aspects of Gastrointestinal Hormones. Gastroenterology Res 2019; 12:233-244. [PMID: 31636773 PMCID: PMC6785288 DOI: 10.14740/gr1219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/23/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal (GI) hormones are essential to many physiologic functions in our body. They have many GI and extra-GI functions. Some of the functions of these hormones, which have GI and extra-GI sources, are still unknown. Specific GI hormones can affect the brain to control food intake, while others can proliferate normal and neoplastic tissue when their receptors are expressed in certain neoplasms. GI hormones also have many diagnostic and therapeutic roles. Physiologic and pathophysiologic aspects as well as the diagnostic and therapeutic values of GI hormones are elaborated in this review.
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Affiliation(s)
- Monjur Ahmed
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Both authors contributed equally to write the manuscript
| | - Sarah Ahmed
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Both authors contributed equally to write the manuscript
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18
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19
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Downes TJ, Cheruvu MS, Karunaratne TB, De Giorgio R, Farmer AD. Pathophysiology, Diagnosis, and Management of Chronic Intestinal Pseudo-Obstruction. J Clin Gastroenterol 2018; 52:477-489. [PMID: 29877952 DOI: 10.1097/mcg.0000000000001047] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chronic intestinal pseudo-obstruction (CIPO) is a rare disorder characterized by an impairment of coordinated propulsive activity in the gastrointestinal (GI) tract, which clinically mimics mechanical intestinal obstruction. CIPO is the most severe and debilitating form of GI dysmotility. CIPO may be primary or be secondary to pathology at any level of the brain-gut axis as well as systemic disease. The clinical features of CIPO are pleomorphic and largely depend on the site and extent of the segment of the GI tract involved. The diagnostic approach includes the need for investigations to exclude mechanical GI obstruction, screening for causes of secondary CIPO and the identification of the disease phenotype as well as the prompt recognition and treatment of complications such as malnutrition and small intestinal bacterial overgrowth. In managing this disorder, a holistic, multidisciplinary approach is needed with judicious use of pharmacotherapeutic agents. While currently there are no specific therapeutic modalities for CIPO, treatment is largely directed at maintaining adequate nutrition and electrolyte balance and enhancing coordinated GI motility. Surgery should be avoided unless advisable for carefully selected patients and may include stoma formation. This narrative review provides a concise overview of the literature on this rare, severe and complex disorder, and highlights the need and areas for further research to improve both diagnostics and therapeutics.
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Affiliation(s)
- Thomas J Downes
- Department of Gastroenterology, University Hospitals of the North Midlands, Stoke-on-Trent, Staffordshire
| | - Manikandar S Cheruvu
- Department of Gastroenterology, University Hospitals of the North Midlands, Stoke-on-Trent, Staffordshire
| | - Tennekoon B Karunaratne
- Department of Medical and Surgical Sciences, St.Orsola-Malpighi Hospital, University of Bologna, Bologna
| | - Roberto De Giorgio
- Department of Medical Sciences, Nuovo Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Adam D Farmer
- Department of Gastroenterology, University Hospitals of the North Midlands, Stoke-on-Trent, Staffordshire.,Centre for Trauma and Neuroscience, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London.,Institute of Applied Clinical Science, University of Keele, Keele, UK
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20
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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21
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Sakkas LI, Simopoulou T, Daoussis D, Liossis SN, Potamianos S. Intestinal Involvement in Systemic Sclerosis: A Clinical Review. Dig Dis Sci 2018; 63:834-844. [PMID: 29464583 DOI: 10.1007/s10620-018-4977-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 02/10/2018] [Indexed: 12/16/2022]
Abstract
Systemic sclerosis (SSc) is a chronic systemic disease characterized by microvasculopathy, autoantibodies, and extensive fibrosis. Intestinal involvement is frequent in SSc and represents a significant cause of morbidity. The pathogenesis of intestinal involvement includes vascular damage, nerve dysfunction, smooth muscle atrophy, and fibrosis, causing hypomotility, which leads to small intestinal bacterial overgrowth (SIBO), malabsorption, malnutrition, diarrhea, pseudo-obstruction, constipation, pneumatosis intestinalis, and fecal incontinence. Manifestations are often troublesome and reduce quality of life and life expectancy. Assessment of intestinal involvement includes screening for small intestine hypomotility, malnutrition, SIBO, and anorectal dysfunction. Current management of intestinal manifestations is largely inadequate. Patients with diarrhea are managed with low-fat diet, medium-chain triglycerides, avoidance of lactulose and fructose, and control of bacterial overgrowth with antibiotics for SIBO. In diarrhea/malabsorption, bile acid sequestrant and pancreatic enzyme supplementation may help, and nutritional support is needed. General measures are applied for constipation, and intestine rest plus antibiotics for pseudo-obstruction. Fecal incontinence is managed with measures for associated SIBO, or constipation, and with behavioral therapies. Pneumatosis intestinalis is usually an incidental finding that does not require any specific treatment. Immunomoduation should be considered early in intestinal involvement. Multidisciplinary approach of intestinal manifestations in SSc by gastroenterologists and rheumatologists is required for optimum management.
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Affiliation(s)
- Lazaros I Sakkas
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110, Larissa, Greece.
| | - Theodora Simopoulou
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110, Larissa, Greece
| | - Dimitrios Daoussis
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, School of Health Sciences, University of Patras, Patras, Greece
| | - Stamatis-Nick Liossis
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, School of Health Sciences, University of Patras, Patras, Greece
| | - Spyros Potamianos
- Department of Gastroenterology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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22
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McFarlane IM, Bhamra MS, Kreps A, Iqbal S, Al-Ani F, Saladini-Aponte C, Grant C, Singh S, Awwal K, Koci K, Saperstein Y, Arroyo-Mercado FM, Laskar DB, Atluri P. Gastrointestinal Manifestations of Systemic Sclerosis. ACTA ACUST UNITED AC 2018; 8. [PMID: 30057856 PMCID: PMC6059963 DOI: 10.4172/2161-1149.1000235] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibroproliferative alterations of the microvasculature leading to fibrosis and loss of function of the skin and internal organs. Gastrointestinal manifestations of SSc are the most commonly encountered complications of the disease affecting nearly 90% of the SSc population. Among these complications, the esophagus and the anorectum are the most commonly affected. However, this devastating disorder does not spare any part of the gastrointestinal tract (GIT), and includes the oral cavity, esophagus, stomach, small and large bowels as well as the liver and pancreas. In this review, we present the current understanding of the pathophysiologic mechanisms of SSc including vasculopathy, endothelial to mesenchymal transformation as well as the autoimmune pathogenetic pathways. We also discuss the clinical presentation and diagnosis of each part of the GIT affected by SSc. Finally, we highlight the latest developments in the management of this disease, addressing the severe malnutrition that affects this vulnerable patient population and ways to assess and improve the nutritional status of the patients.
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Affiliation(s)
- Isabel M McFarlane
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Manjeet S Bhamra
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Alexandra Kreps
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Sadat Iqbal
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Firas Al-Ani
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Carla Saladini-Aponte
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Christon Grant
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Soberjot Singh
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Khalid Awwal
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Kristaq Koci
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Yair Saperstein
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Fray M Arroyo-Mercado
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Derek B Laskar
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Purna Atluri
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
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23
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Kirby DF, Raheem SA, Corrigan ML. Nutritional Interventions in Chronic Intestinal Pseudoobstruction. Gastroenterol Clin North Am 2018; 47:209-218. [PMID: 29413013 DOI: 10.1016/j.gtc.2017.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although chronic intestinal pseudo-obstruction (CIPO) is a rare disorder, it presents a wide spectrum of severity that ranges from abdominal bloating to severe gastrointestinal dysfunction. In the worst cases, patients may become dependent upon artificial nutrition via parenteral nutrition or choose to have an intestinal transplant. However, whatever the severity, a patient's quality of life can be seriously compromised. This article defines the disorder and discusses the spectrum of disease and challenges to providing adequate nutrition to help improve a patient's quality of life.
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Affiliation(s)
- Donald F Kirby
- Intestinal Transplant Program, Center for Human Nutrition, Cleveland Clinic, 9500 Euclid Avenue/A51, Cleveland, OH 44195, USA.
| | - Sulieman Abdal Raheem
- Center for Human Nutrition, Cleveland Clinic, 9500 Euclid Avenue/A51, Cleveland, OH 44195, USA
| | - Mandy L Corrigan
- Home Nutrition Support and Center for Gut Rehabilitation and Transplant, Center for Human Nutrition, Cleveland Clinic, 9500 Euclid Avenue/A100, Cleveland, OH 44195, USA
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24
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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: 0.8] [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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25
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Kowal-Bielecka O, Fransen J, Avouac J, Becker M, Kulak A, Allanore Y, Distler O, Clements P, Cutolo M, Czirjak L, Damjanov N, Del Galdo F, Denton CP, Distler JHW, Foeldvari I, Figelstone K, Frerix M, Furst DE, Guiducci S, Hunzelmann N, Khanna D, Matucci-Cerinic M, Herrick AL, van den Hoogen F, van Laar JM, Riemekasten G, Silver R, Smith V, Sulli A, Tarner I, Tyndall A, Welling J, Wigley F, Valentini G, Walker UA, Zulian F, Müller-Ladner U. Update of EULAR recommendations for the treatment of systemic sclerosis. Ann Rheum Dis 2017; 76:1327-1339. [PMID: 27941129 DOI: 10.1136/annrheumdis-2016-209909] [Citation(s) in RCA: 725] [Impact Index Per Article: 90.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/22/2016] [Accepted: 10/09/2016] [Indexed: 12/16/2022]
Abstract
The aim was to update the 2009 European League against Rheumatism (EULAR) recommendations for the treatment of systemic sclerosis (SSc), with attention to new therapeutic questions. Update of the previous treatment recommendations was performed according to EULAR standard operating procedures. The task force consisted of 32 SSc clinical experts from Europe and the USA, 2 patients nominated by the pan-European patient association for SSc (Federation of European Scleroderma Associations (FESCA)), a clinical epidemiologist and 2 research fellows. All centres from the EULAR Scleroderma Trials and Research group were invited to submit and select clinical questions concerning SSc treatment using a Delphi approach. Accordingly, 46 clinical questions addressing 26 different interventions were selected for systematic literature review. The new recommendations were based on the available evidence and developed in a consensus meeting with clinical experts and patients. The procedure resulted in 16 recommendations being developed (instead of 14 in 2009) that address treatment of several SSc-related organ complications: Raynaud's phenomenon (RP), digital ulcers (DUs), pulmonary arterial hypertension (PAH), skin and lung disease, scleroderma renal crisis and gastrointestinal involvement. Compared with the 2009 recommendations, the 2016 recommendations include phosphodiesterase type 5 (PDE-5) inhibitors for the treatment of SSc-related RP and DUs, riociguat, new aspects for endothelin receptor antagonists, prostacyclin analogues and PDE-5 inhibitors for SSc-related PAH. New recommendations regarding the use of fluoxetine for SSc-related RP and haematopoietic stem cell transplantation for selected patients with rapidly progressive SSc were also added. In addition, several comments regarding other treatments addressed in clinical questions and suggestions for the SSc research agenda were formulated. These updated data-derived and consensus-derived recommendations will help rheumatologists to manage patients with SSc in an evidence-based way. These recommendations also give directions for future clinical research in SSc.
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Affiliation(s)
- Otylia Kowal-Bielecka
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Jaap Fransen
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jerome Avouac
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Mike Becker
- University Hospital Charité, Berlin, Germany
- University Hospital Zurich, Zurich, Switzerland
| | - Agnieszka Kulak
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Yannick Allanore
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | | | - Philip Clements
- University of California at Los Angeles, Los Angeles, California, USA
| | - Maurizio Cutolo
- Research Laboratories and Clinical Division of Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino, Genova, Italy
| | - Laszlo Czirjak
- Department of Rheumatology and Immunology, Medical Center, University of Pecs, Pecs, Hungary
| | | | | | | | | | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescence Rheumatology, Hamburg, Germany
| | | | | | - Daniel E Furst
- University of California at Los Angeles, Los Angeles, California, USA
| | | | | | - Dinesh Khanna
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - Ariane L Herrick
- University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester, UK
| | | | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Richard Silver
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vanessa Smith
- Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratories and Clinical Division of Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino, Genova, Italy
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26
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Di Nardo G, Di Lorenzo C, Lauro A, Stanghellini V, Thapar N, Karunaratne TB, Volta U, De Giorgio R. Chronic intestinal pseudo-obstruction in children and adults: diagnosis and therapeutic options. Neurogastroenterol Motil 2017; 29. [PMID: 27683196 DOI: 10.1111/nmo.12945] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) represents the most severe form of gastrointestinal dysmotility with debilitating and potentially lethal consequences. Symptoms can be non-specific, and result in this condition being diagnosed incorrectly or too late with consequences for morbidity and even mortality. PURPOSE The present article aims to provide pediatric and adult gastroenterologists with an up to date review about clinical features, diagnosis and therapeutic options for CIPO. Although pediatric and adult CIPO share many clinical aspects distinctive features can be identified. There is no single diagnostic test or pathognomonic finding of CIPO, thus a stepwise approach including radiology, endoscopy, laboratory, manometry, and histopathology should be considered in the diagnostic work-up. Treatment of patients with CIPO is challenging and requires a multidisciplinary effort with participation of appropriately experienced gastroenterologists, pathologists, dieticians, surgeons, psychologists, and other subspecialists based on the presence of comorbidities. Current treatment options invariably involve surgery and specialized nutritional support, especially in children. Medical therapies are mainly aimed to avoid complications such as sepsis or intestinal bacterial overgrowth and, where possible, restore intestinal propulsion. More efficacious therapeutic options are eagerly awaited for such difficult patients.
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Affiliation(s)
- G Di Nardo
- Pediatric Unit, Orvieto Hospital, Orvieto, Italy
- Pediatric Gastroenterology Unit, International Hospital Salvator Mundi, Rome, Italy
| | - C Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - A Lauro
- Liver and Multiorgan Transplant Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - V Stanghellini
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - N Thapar
- Department of Gastroenterology, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - T B Karunaratne
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - U Volta
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - R De Giorgio
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
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Pellar RE, Pope JE. Evidence-based management of systemic sclerosis: Navigating recommendations and guidelines. Semin Arthritis Rheum 2016; 46:767-774. [PMID: 28088339 DOI: 10.1016/j.semarthrit.2016.12.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Systemic sclerosis (SSc) is a rare heterogeneous connective tissue disease. Recommendations addressing the major issues in the management of SSc including screening and treatment of organ complications are needed. METHODS The updated European League Against Rheumatism/European Scleroderma Trial and Research (EULAR/EUSTAR) and the British Society of Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) guidelines were compared and contrasted. RESULTS The updated EULAR/EUSTAR guidelines focus specifically on the management of SSc features and include data on newer therapeutic modalities and mention a research agenda. These recommendations are pharmacologic, with few guidelines regarding investigations and non-pharmacologic management. Recommendations from BSR/BHPR are similar to the organ manifestations mentioned in the EULAR/EUSTAR recommendations, and expand on several domains of treatment, including general measures, non-pharmacologic treatment, cardiac involvement, calcinosis, and musculoskeletal features. The guidelines usually agree with one another. Limitations include the lack of guidance for combination or second-line therapy, algorithmic suggestions, the absence of evidence-based recommendations regarding the treatment of specific complications (i.e., gastric antral ectasia and erectile dysfunction). Consensus for when to treat interstitial lung disease in SSc is lacking. There are differences between Europe and North American experts due to access and indications for certain therapies. CONCLUSIONS Care gaps in SSc have been demonstrated so the EULAR/EUSTAR and BSR/BHP guidelines can promote best practices. Certain complications warrant active investigation to further improve outcomes in SSc and future updates of these recommendations. Care gaps in SSc have been demonstrated so the EULAR/EUSTAR and BSR/BHP guidelines can promote best practices. Certain complications warrant active investigation to further improve outcomes in SSc.
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Affiliation(s)
| | - Janet Elizabeth Pope
- Department of Medicine, University of Western Ontario, London, ON, Canada; St Joseph Health Care, London, ON, Canada.
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28
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[Systemic sclerosis : What is currently available for treatment?]. Internist (Berl) 2016; 57:1155-1163. [PMID: 27796473 DOI: 10.1007/s00108-016-0148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic sclerosis (scleroderma) is a rheumatologic disease characterised not only by inflammation/autoimmunity, but also by tissue fibrosis and vascular lesions. The therapeutic approach to patients is dictated by the organ involvement and includes treatment of vascular and fibrotic disease features beyond mere immunosuppression. Fibrotic features in particular, are still inadequately treated, whereas many drugs have been tested for vascular complications within recent years. In this review, the currently available treatment options for this rare disease are presented. Therapy options in systemic sclerosis have changed over the past 10 years and this trend will also continue in the future.
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Ambartsumyan L, Flores A, Nurko S, Rodriguez L. Utility of Octreotide in Advancing Enteral Feeds in Children with Chronic Intestinal Pseudo-Obstruction. Paediatr Drugs 2016; 18:387-92. [PMID: 27520652 DOI: 10.1007/s40272-016-0189-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Chronic intestinal pseudo-obstruction (CIPO) is a challenging disorder with high morbidity and mortality due to limited effective therapies that improve enteral tolerance. We aimed to present our experience using octreotide in children with CIPO and evaluate factors predicting therapy response. METHODS The study population included total parenteral nutrition (TPN)-dependent children with CIPO receiving octreotide at a tertiary care center. Octreotide response was defined as an enteral feeding increase of ≥10 cc/kg/day. RESULTS A total of 16 children were included (median age 5 years, range 1-18; 88 % female). We observed an overall feed increase in 11/16 (69 %) subjects and 7/16 (44 %) were considered responders: three tolerated >65 cc/kg/day (discontinued TPN), one tolerated >30 cc/kg/day (decreased TPN) and three patients tolerated 10-12 cc/kg/day. We found an association between therapeutic octreotide response and both the presence of octreotide-induced intestinal phase III of the migrating motor complex (MMC) as well as a higher median increase in intestinal motility index after octreotide challenge during the antroduodenal manometry (p = 0.03 and <0.01, respectively). We did not find an association between octreotide response and age, presence of ileostomy, and colonic manometry testing parameters. Side effects were observed in four patients: an allergic reaction and hyperglycemia requiring octreotide discontinuation, hypertension that responded to dose reduction, and cholecystitis (gallstones) with octreotide successfully restarted after cholecystectomy. CONCLUSIONS Octreotide is safe and effective in improving enteral tolerance in TPN-dependent children with CIPO and the antroduodenal manometry may be helpful in predicting octreotide response. Prospective studies are needed to evaluate the safety and efficacy of octreotide in children with CIPO.
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Affiliation(s)
- Lusine Ambartsumyan
- Division of Gastroenterology, Department of Medicine, Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.,Division of Gastroenterology, Seattle Children's Hospital, Seattle, WA, USA
| | - Alejandro Flores
- Division of Gastroenterology, Department of Medicine, Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Samuel Nurko
- Division of Gastroenterology, Department of Medicine, Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Leonel Rodriguez
- Division of Gastroenterology, Department of Medicine, Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
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30
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Emmanuel A. Current management of the gastrointestinal complications of systemic sclerosis. Nat Rev Gastroenterol Hepatol 2016; 13:461-72. [PMID: 27381075 DOI: 10.1038/nrgastro.2016.99] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic sclerosis is a multisystem autoimmune disorder that involves the gastrointestinal tract in more than 90% of patients. This involvement can extend from the mouth to the anus, with the oesophagus and anorectum most frequently affected. Gut complications result in a plethora of presentations that impair oral intake and faecal continence and, consequently, have an adverse effect on patient quality of life, resulting in referral to gastroenterologists. The cornerstones of gastrointestinal symptom management are to optimize symptom relief and monitor for complications, in particular anaemia and malabsorption. Early intervention in patients who develop these complications is critical to minimize disease progression and improve prognosis. In the future, enhanced therapeutic strategies should be developed, based on an ever-improving understanding of the intestinal pathophysiology of systemic sclerosis. This Review describes the most commonly occurring clinical scenarios of gastrointestinal involvement in patients with systemic sclerosis as they present to the gastroenterologist, with recommendations for the suggested assessment protocol and therapy in each situation.
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Affiliation(s)
- Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, 235 Euston Road, London NW1 2BU, UK
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31
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Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307. [PMID: 26944585 DOI: 10.1016/j.clnu.2016.01.020] [Citation(s) in RCA: 490] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. METHODS The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. RESULTS The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CONCLUSIONS CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lyn Gillanders
- Nutrition Support Team, Auckland City Hospital, (AuSPEN) Auckland, New Zealand
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA; Oley Foundation for Home Parenteral and Enteral Nutrition, Albany, NY, USA
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
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A Case of Dermatomyositis and Anti-EJ Autoantibody with Chronic Intestinal Pseudoobstruction Successfully Treated with Octreotide. Case Rep Rheumatol 2016; 2016:9510316. [PMID: 27885350 PMCID: PMC5112325 DOI: 10.1155/2016/9510316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 10/10/2016] [Indexed: 11/28/2022] Open
Abstract
Chronic intestinal pseudoobstruction (CIPO) is a serious complication in patients with connective tissue disease (CTD) and is sometimes life-threatening or fatal despite intensive medical treatment. Here, we report a patient with dermatomyositis (DM) and anti-EJ autoantibody who developed CIPO that was improved by octreotide. Because her abdominal pain and bloatedness were so severe and persistent, we introduced octreotide to relieve symptoms. In this case, continuous intravenous administration as well as long-acting subcutaneous injection of octreotide was effective for treating CIPO.
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Zulian F. Systemic Sclerodermas. TEXTBOOK OF PEDIATRIC RHEUMATOLOGY 2016:384-405.e9. [DOI: 10.1016/b978-0-323-24145-8.00027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Becker MO, Riemekasten G. Risk factors for severity and manifestations in systemic sclerosis and prediction of disease course. Expert Rev Clin Immunol 2015; 12:115-35. [PMID: 26558747 DOI: 10.1586/1744666x.2016.1115717] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Systemic sclerosis (SSc, or scleroderma) is a rheumatic disease with distinct features that encompass autoimmunity, vascular lesions (vasculopathy) and tissue fibrosis. The disease has a high morbidity and mortality compared with other rheumatic diseases. This review discusses risk factors and markers that predict the disease course and the occurrence of disease manifestations, with an emphasis on major organ involvement. In addition, risk factors will be described that are associated with mortality in SSc patients. The review addresses the impact of recent developments on screening, diagnosis and risk stratification as well as the need for further research where data are lacking.
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Affiliation(s)
- Mike O Becker
- a Department of Rheumatology and Clinical Immunology , University Hospital Charité Berlin , Berlin , Germany
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35
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Valenzuela A, Li S, Becker L, Fernandez-Becker N, Khanna D, Nguyen L, Chung L. Intestinal pseudo-obstruction in patients with systemic sclerosis: an analysis of the Nationwide Inpatient Sample. Rheumatology (Oxford) 2015; 55:654-8. [PMID: 26615031 DOI: 10.1093/rheumatology/kev393] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Intestinal pseudo-obstruction is a rare gastrointestinal complication in patients with SSc without large studies examining its prevalence or outcomes. We aimed to compare outcomes in SSc patients with intestinal pseudo-obstruction to patients with intestinal pseudo-obstruction secondary to other causes, and SSc patients without intestinal pseudo-obstruction. METHODS This is a case-control study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample for the period 2002-2011. We included patients with the previously validated International Classification of Diseases-Clinical Modification-9 code 710.1 for SSc in combination with codes for intestinal pseudo-obstruction, and determined length of hospitalization and the risks for surgical procedures, use of total parenteral nutrition (TPN) and in-hospital mortality. RESULTS A total of 193 610 SSc hospitalizations occurred in the USA between 2002 and 2011, of which 5.4% (n = 10 386) were associated with a concurrent intestinal pseudo-obstruction diagnosis (cases). In-hospital mortality was 7.3%. In multivariate analyses, cases were more likely to die during the inpatient stay and to receive TPN than patients with idiopathic intestinal pseudo-obstruction (control group 1), patients with intestinal pseudo-obstruction and diabetes (control group 2), and SSc patients without intestinal pseudo-obstruction (control group 3). Cases had longer in-hospital stay than control groups 2 and 3, and were less likely to undergo surgical procedures than control groups 1 and 2. CONCLUSION Intestinal pseudo-obstruction is a rare cause of hospitalization in patients with SSc, but is associated with high in-hospital mortality in comparison with other SSc patients and those with intestinal pseudo-obstruction secondary to other causes.
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Affiliation(s)
| | | | - Laren Becker
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA and
| | - Nielsen Fernandez-Becker
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA and
| | - Dinesh Khanna
- Department of Internal medicine, University of Michigan, Ann Arbor, MI, USA
| | - Linda Nguyen
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA and
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36
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Abstract
The gastrointestinal tract, affecting more than 90% of patients, is the internal organ most frequently involved in systemic sclerosis. Any part of the gastrointestinal tract can be affected, from the mouth to the anus. Patients often experience reduced quality of life and impaired social life. Although only 8% have severe gastrointestinal involvement, mortality is high in those patients. Recent studies on the pathophysiology of the disease highlight new mechanisms to explain gastrointestinal dysmotility, but treatment remains symptomatic. This article reviews the pathophysiology of the gastrointestinal tract and discusses the investigation and management of the disease.
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Affiliation(s)
- Genevieve Gyger
- Division of Rheumatology, Jewish General Hospital, McGill University, Suite A725, 3755 Cote St Catherine Road, Montreal, Quebec H3T 1E2, Canada.
| | - Murray Baron
- Division of Rheumatology, Jewish General Hospital, McGill University, Suite A725, 3755 Cote St Catherine Road, Montreal, Quebec H3T 1E2, Canada
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Nagaraja V, McMahan ZH, Getzug T, Khanna D. Management of gastrointestinal involvement in scleroderma. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015; 1:82-105. [PMID: 26005632 DOI: 10.1007/s40674-014-0005-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastrointestinal tract (GIT) commonly affects patients with systemic sclerosis (SSc). The GI involvement is quite heterogeneous varying from asymptomatic disease to significant dysmotility causing complications like malabsorption, weight loss and severe malnutrition. This review focuses on the management of GI involvement in SSc and has been categorized based on the segment of GIT involved. A brief discussion on the role of patient reported outcome measures in SSc-GI involvement has also been incorporated.
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Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | | | - Terri Getzug
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
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Patcharatrakul T, Gonlachanvit S. Technique of functional and motility test: how to perform antroduodenal manometry. J Neurogastroenterol Motil 2013; 19:395-404. [PMID: 23875108 PMCID: PMC3714419 DOI: 10.5056/jnm.2013.19.3.395] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 06/25/2013] [Indexed: 12/13/2022] Open
Abstract
Antroduodenal manometry is one of the methods to evaluate stomach and duodenal motility. This test is a valuable diagnostic tool for gastrointestinal motility disorders especially small intestinal pseudo-obstruction which is difficult to make definite diagnosis by clinical manifestations or radiologic findings. Manometric findings that have no evidence of mechanical obstruction and suggestive of pseudo-obstruction with neuropathy or myopathy can avoid unnecessary surgery and the treatment can be directly targeted. Moreover, among patients who have clinically suspected small intestinal pseudo-obstruction but with normal manometric findings, the alternative diagnosis including psychiatric disorder or other organic disease should be considered. The application of this test to the patients with functional gastrointestinal symptoms especially to find the association of motor abnormalities to the symptom has less impressive yield. Antroduodenal manometry is now readily available only in some tertiary care centers. The aim of this review is to describe the antroduodenal manometry technique, interpretation and clinical utility.
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Affiliation(s)
- Tanisa Patcharatrakul
- Gastrointestinal Motility Research Unit, Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand. ; King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Abstract
Gastrointestinal involvement (GI) is increasingly recognized as a major cause of both morbidity and mortality in systemic sclerosis (SSc). GI complications are common, second only to skin involvement, and affect up to 90% of patients. Although treatment modalities have changed little for upper gut symptoms such as GI reflux, there are emerging treatment modalities for the common lower gut symptoms (constipation and fecal incontinence), which will be reviewed. The important link between reflux and interstitial lung disease in SSc is also addressed. The aim of this review is to help the clinician understand and manage GI symptoms in SSc.
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Affiliation(s)
- Shamaila Butt
- Gastrointestinal Physiology unit, University College Hospital, London, UK.
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40
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Sampaio-Barros PD, Zimmermann AF, Souza Müller CD, Lobato Borges CT, Medeiros Freire EA, Maretti GB, Marques Neto JF, Fonseca Salgado MC, da Cunha Sauma MDFL, de Azevedo MNL, Fontenelle S, Kayser C. Recomendações sobre diagnóstico e tratamento da esclerose sistêmica. REVISTA BRASILEIRA DE REUMATOLOGIA 2013. [DOI: 10.1590/s0482-50042013000300004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Affiliation(s)
| | - Brian E. Lacy
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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42
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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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Amiot A, Joly F, Cazals-Hatem D, Merrouche M, Jouet P, Coffin B, Bouhnik Y. Prognostic yield of esophageal manometry in chronic intestinal pseudo-obstruction: a retrospective cohort of 116 adult patients. Neurogastroenterol Motil 2012; 24:1008-e542. [PMID: 22762287 DOI: 10.1111/j.1365-2982.2012.01973.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) refers to a wide and heterogeneous group of neuromuscular disorders, which classically involve the small intestine. However, further investigation is required to determine if motility disturbances involve all parts of the gastrointestinal (GI) tract. METHODS Medical records and follow-up examinations of 116 adult CIPO patients [70F, median age 28 (0-79) years] were reviewed and performed at our institution since 1980. Manometry (esophageal, small bowel and anorectal) and gastric emptying scintigraphy reports were retrieved and analyzed. Survival, home parenteral nutrition requirement, and the inability to maintain sufficient oral feeding was analyzed using univariate and multivariate analysis. KEY RESULTS The median follow-up time was 6 (0.1-30) years. In all, 90% of patients who underwent at least one motility test, with the exception of small bowel manometry, exhibited at least one abnormal pattern. Esophageal manometry was abnormal in 73% of the cases, including 51% with severe ineffective esophageal motility. Anorectal manometry was abnormal in 59% of the cases, including only 17% with severe abnormalities. Gastric emptying was abnormal in 61% of the cases. Only esophageal motor disorders had significant predicting values for survival, home parenteral nutrition requirement, and an inability to maintain sufficient oral feeding. CONCLUSIONS & INFERENCES Our study showed that CIPO was associated with a diffuse involvement of all parts of the GI tract and was not restricted to the small intestine in 90% of the cases studied. Esophageal manometry had a significant prognostic yield and should be systematically performed in CIPO patients.
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Affiliation(s)
- A Amiot
- Department of Gastroenterology and Nutrition Support, Beaujon Hospital, APHP, Clichy, France. aurelien.amiot.aphp.fr
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44
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Harrison E, Herrick AL, McLaughlin JT, Lal S. Malnutrition in systemic sclerosis. Rheumatology (Oxford) 2012; 51:1747-56. [PMID: 22850183 DOI: 10.1093/rheumatology/kes160] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
SSc is a chronic multi-system disease with wide-reaching consequences. Gastrointestinal features are present in over 90% of cases and these, together with other disease manifestations, may lead to nutritional decline. This produces substantial morbidity, including reliance on enteral support and even parenteral nutrition-dependent intestinal failure. These complications carry an associated mortality. Up to 18% of patients with SSc are reported to be at high risk of malnutrition [as assessed by Malnutrition Universal Screening Tool (MUST) criteria], with risk increasing with disease severity. Little is known about this decline, its rate of progression and how it affects the individual. Few case series report on nutritional interventions. Most current interventions are based on experience in other diseases. The development of specialist knowledge of SSc-related gastrointestinal disease management and nutritional screening and interventions is required. This paper reviews current knowledge relating to malnutrition and its management in SSc.
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Affiliation(s)
- Elizabeth Harrison
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK.
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45
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Gyger G, Baron M. Gastrointestinal manifestations of scleroderma: recent progress in evaluation, pathogenesis, and management. Curr Rheumatol Rep 2012; 14:22-9. [PMID: 22105546 DOI: 10.1007/s11926-011-0217-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastrointestinal (GI) involvement is frequent in scleroderma (systemic sclerosis [SSc]) and is the most frequent internal complication of the disease. Patients with GI involvement have impaired quality of life, and their prognosis may be one of severe impairment. Unfortunately, GI involvement is often noticed when severe complications have already occurred, is irreversible, and is difficult to manage. The past 2 to 3 years have been rich in exciting studies that we hope will help identify, prevent, treat, and monitor disease progression. Recent studies on the pathophysiology of GI tract disease could lead to advances in the treatment of GI tract involvement. The importance of treating gastroesophageal reflux (GER) has been reinforced by studies showing GER damage in almost all SSc patients, and the fact that GER damage is reversible if early treatment with proton pump inhibitors is introduced. Moreover, recent data showing a link between GER and interstitial lung disease in SSc underscore the importance of aggressive GER treatment in SSc patients. A novel lung pattern possibly related to GER also has been described. New, exciting data on gastric vascular antral ectasia have been published. Finally, malnutrition in SSc patients has been highlighted, and anorectal involvement has been emphasized.
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Affiliation(s)
- Genevieve Gyger
- Division of Rheumatology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
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46
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Gyger G, Baron M. Gastrointestinal manifestations of scleroderma: recent progress in evaluation, pathogenesis, and management. Curr Rheumatol Rep 2012. [PMID: 22105546 DOI: 10.1007/s11926-011-0217-3.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Gastrointestinal (GI) involvement is frequent in scleroderma (systemic sclerosis [SSc]) and is the most frequent internal complication of the disease. Patients with GI involvement have impaired quality of life, and their prognosis may be one of severe impairment. Unfortunately, GI involvement is often noticed when severe complications have already occurred, is irreversible, and is difficult to manage. The past 2 to 3 years have been rich in exciting studies that we hope will help identify, prevent, treat, and monitor disease progression. Recent studies on the pathophysiology of GI tract disease could lead to advances in the treatment of GI tract involvement. The importance of treating gastroesophageal reflux (GER) has been reinforced by studies showing GER damage in almost all SSc patients, and the fact that GER damage is reversible if early treatment with proton pump inhibitors is introduced. Moreover, recent data showing a link between GER and interstitial lung disease in SSc underscore the importance of aggressive GER treatment in SSc patients. A novel lung pattern possibly related to GER also has been described. New, exciting data on gastric vascular antral ectasia have been published. Finally, malnutrition in SSc patients has been highlighted, and anorectal involvement has been emphasized.
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Affiliation(s)
- Genevieve Gyger
- Division of Rheumatology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
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OMAIR MOHAMMEDA, LEE PETER. Effect of Gastrointestinal Manifestations on Quality of Life in 87 Consecutive Patients with Systemic Sclerosis. J Rheumatol 2012; 39:992-6. [DOI: 10.3899/jrheum.110826] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective.To assess the effect of gastrointestinal (GI) manifestation on the quality of life in patients with systemic sclerosis (SSc).Methods.The University of California, Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2 questionnaire was completed by 87 consecutive patients with SSc attending the scleroderma clinic at a single center. Their clinical features and current therapies were recorded; 100 patients with rheumatologic disorders other than SSc were used as controls. Individual scores were compared between SSc and controls, and between SSc subgroups.Results.Of 87 patients, 76 (90%) were women. Median age was 55 years and disease duration 105 months. Thirty-three (38%) had diffuse and 54 (62%) had limited SSc. Patients with SSc had a higher score than controls in all domains (p < 0.05). Numbers of patients who responded positively to individual questionnaire components are as follows: any GI symptom 86 (99%), reflux 77 (89%), distension 73 (84%), soilage 19 (22%), diarrhea 44 (51%), constipation 51 (59%), well-being 43 (49%), and social 43 (49%). There was no difference between the scores of patients with diffuse and limited disease subtypes. The use of calcium channel blockers did not significantly increase the constipation score (p = 0.99). Patients who responded positively to the reflux, distension, diarrhea, and constipation domains had lower scores in the well-being and social domains.Conclusion.GI manifestations, especially fecal incontinence (affecting 22% of patients), have a negative influence on the quality of life of patients with SSc. There was no difference between SSc disease subtypes.
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Joly F, Amiot A, Messing B. Nutritional support in the severely compromised motility patient: when and how? Gastroenterol Clin North Am 2011; 40:845-51. [PMID: 22100122 DOI: 10.1016/j.gtc.2011.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The management of CIPO remains difficult and requires a multidisciplinary approach. In adult patients with CIPO on HPN, the 10-year survival rate was 68%. Long-term HPN dependence does not seem to be associated with a significant increase in mortality and morbidity. HPN could be a safe and efficient approach to the management of intestinal failure caused by CIPO, with restoring oral intake and lowering hospitalization frequency as major goals of treatment.
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Affiliation(s)
- Francisca Joly
- Department of Gastroenterology and Nutrition Support, Beaujon Hospital, René Diderot University of Paris, 100 bd Général Leclerc 92100, Clichy, France.
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De Giorgio R, Cogliandro RF, Barbara G, Corinaldesi R, Stanghellini V. Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy. Gastroenterol Clin North Am 2011; 40:787-807. [PMID: 22100118 DOI: 10.1016/j.gtc.2011.09.005] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CIPO is the very “tip of the iceberg” of functional gastrointestinal disorders, being a rare and frequently misdiagnosed condition characterized by an overall poor outcome. Diagnosis should be based on clinical features, natural history and radiologic findings. There is no cure for CIPO and management strategies include a wide array of nutritional, pharmacologic, and surgical options which are directed to minimize malnutrition, promote gut motility and reduce complications of stasis (ie, bacterial overgrowth). Pain may become so severe to necessitate major analgesic drugs. Underlying causes of secondary CIPO should be thoroughly investigated and, if detected, treated accordingly. Surgery should be indicated only in a highly selected, well characterized subset of patients, while isolated intestinal or multivisceral transplantation is a rescue therapy only in those patients with intestinal failure unsuitable for or unable to continue with TPN/HPN. Future perspectives in CIPO will be directed toward an accurate genomic/proteomic phenotying of these rare, challenging patients. Unveiling causative mechanisms of neuro-ICC-muscular abnormalities will pave the way for targeted therapeutic options for patients with CIPO.
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Lee BH, Kim N, Kang SB, Lee KH, Oh JC, Kim SM, Park YS, Lee DH. Two Cases of Chronic Idiopathic Intestinal Pseudo-obstruction with Different Clinical Features. J Neurogastroenterol Motil 2010; 16:83-9. [PMID: 20535331 PMCID: PMC2879827 DOI: 10.5056/jnm.2010.16.1.83] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 12/30/2009] [Indexed: 01/27/2023] Open
Abstract
Chronic intestinal pseudo-obstruction (CIPO) is a rare disorder characterized by a severe impairment of gastrointestinal propulsion in the absence of mechanical obstruction. We experienced a case of chronic pseudo-obstruction in the initial phase mimicking acute pseudo-obstruction, which was treated medically. This ongoing case was compared to another recurrent and intractable case successfully treated with surgery and diagnosed as hypoganglionosis. These two cases showed different clinical features and therapeutic approaches for CIPO; one with the first episode of CIPO mimicking Ogilvie's syndrome; the other with recurrent episodes of CIPO with typical features. In conclusion, CIPO is a difficult disorder with various clinical manifestations and different treatment modalities, therefore individualized diagnostic and therapeutic approaches are needed.
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Affiliation(s)
- Byoung Hwan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
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