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Suzon B, Louis-Sidney F, Abel A, Moinet F, Bagoée C, Henry K, Coco-Viloin I, Cougnaud R, Wolff S, Guilpain P, Rivière S, Flori N, Deligny C, Maria A. [Severe small bowel involvement and chronic intestinal pseudo-obstruction in systemic sclerosis (scleroderma): Pathophysiological, diagnostic and therapeutic basis, including parenteral nutrition]. Rev Med Interne 2024; 45:147-155. [PMID: 38388303 DOI: 10.1016/j.revmed.2024.02.001] [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: 03/04/2023] [Revised: 01/15/2024] [Accepted: 02/03/2024] [Indexed: 02/24/2024]
Abstract
Gastrointestinal involvement in systemic sclerosis can be severe, reaching the critical point of chronic intestinal pseudo-obstruction, secondary to major disorders of small bowel motility. It is associated with some clinical and biological characteristics, in particular the positivity of anti-fibrillarin/U3RNP antibodies. Chronic intestinal pseudo-obstruction (CIPO) is complicated by a small intestinal bacterial overgrowth that requires cyclic antibiotic therapy. CIPO leads to a reduction of the food intake, due to painful symptoms, nausea and vomiting caused by meals, and ultimately to severe malnutrition. Meal splitting is often transiently effective and patients require exogenous nutritional support, mostly parenteral. Systemic sclerosis is not an obstacle to initiation and long-term continuation of parenteral nutrition and central venous catheter implantation is not associated with an increased risk of cutaneous or infectious complications. However, continuation of long-term parenteral nutrition requires monitoring in an expert nutrition center in order to adapt nutritional volumes and intakes and to limit potentially fatal cardiac and hepatobiliary complications. In addition to nutrition, prokinetic treatments, whose side effects must be known, can be associated. Invasive procedures, whose risk-benefit ratio must be carefully assessed, can also be used to treat symptoms exclusively.
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Affiliation(s)
- B Suzon
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique; Unité EpiCliV, Université des Antilles, Fort-de-France, Martinique.
| | - F Louis-Sidney
- Unité EpiCliV, Université des Antilles, Fort-de-France, Martinique; Rhumatologie, CHU de Martinique, Fort-de-France, Martinique
| | - A Abel
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - F Moinet
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - C Bagoée
- Médecine interne et polyvalente, Centre hospitalier territorial Gaston-Bourret, Nouméa, Nouvelle-Calédonie
| | - K Henry
- Maladies infectieuses et tropicales, Centre hospitalier de Cayenne, Cayenne, Guyane
| | - I Coco-Viloin
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - R Cougnaud
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - S Wolff
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - P Guilpain
- Médecine interne et maladies multi-organiques, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France; Institut de médecine régénérative et biothérapies, Inserm U1183, Montpellier, France; Faculté de médecine, Université de Montpellier, Montpellier, France
| | - S Rivière
- Médecine interne et maladies multi-organiques, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France
| | - N Flori
- Centre expert régional de nutrition, ICM, Montpellier, France
| | - C Deligny
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique; Unité EpiCliV, Université des Antilles, Fort-de-France, Martinique
| | - A Maria
- Institut de médecine régénérative et biothérapies, Inserm U1183, Montpellier, France; Faculté de médecine, Université de Montpellier, Montpellier, France; Médecine interne et immuno-oncologie (MedI2O), Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
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Gastrointestinal dysfunction in neuroinflammatory diseases: Multiple sclerosis, neuromyelitis optica, acute autonomic ganglionopathy and related conditions. Auton Neurosci 2021; 232:102795. [PMID: 33740560 DOI: 10.1016/j.autneu.2021.102795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/09/2021] [Accepted: 03/02/2021] [Indexed: 01/25/2023]
Abstract
Disorders of the nervous system can produce a variety of gastrointestinal (GI) dysfunctions. Among these, lesions in various brain structures can cause appetite loss (hypothalamus), decreased peristalsis (presumably the basal ganglia, pontine defecation center/Barrington's nucleus), decreased abdominal strain (presumably parabrachial nucleus/Kolliker-Fuse nucleus) and hiccupping and vomiting (area postrema/dorsal vagal complex). In addition, decreased peristalsis with/without loss of bowel sensation can be caused by lesions of the spinal long tracts and the intermediolateral nucleus or of the peripheral nerves and myenteric plexus. Recently, neural diseases of inflammatory etiology, particularly those affecting the PNS, are being recognized to contribute to GI dysfunction. Here, we review neuroinflammatory diseases that potentially cause GI dysfunction. Among such CNS diseases are multiple sclerosis, neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein associated disorder, and autoimmune encephalitis. Peripheral nervous system diseases impacting the gut include Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, acute sensory-autonomic neuropathy/acute motor-sensory-autonomic neuropathy, acute autonomic ganglionopathy, myasthenia gravis and acute autonomic neuropathy with paraneoplastic syndrome. Finally, collagen diseases, such as Sjogren syndrome and systemic sclerosis, and celiac disease affect both CNS and PNS. These neuro-associated GI dysfunctions may predate or present concurrently with brain, spinal cord or peripheral nerve dysfunction. Such patients may visit gastroenterologists or physicians first, before the neurological diagnosis is made. Therefore, awareness of these phenomena among general practitioners and collaboration between gastroenterologists and neurologists are highly recommended in order for their early diagnosis and optimal management, as well as for systematic documentation of their presentations and treatment.
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Intestinal hypomotility in systemic sclerosis: a histological study into the sequence of events. Clin Rheumatol 2020; 40:981-990. [PMID: 32812181 PMCID: PMC7895795 DOI: 10.1007/s10067-020-05325-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/16/2020] [Accepted: 08/04/2020] [Indexed: 10/30/2022]
Abstract
OBJECTIVES The pathogenesis of intestinal involvement in systemic sclerosis (SSc) is thought to be a sequential process (vascular, neuronal, and consecutive muscular impairment), but understanding of the underlying histological changes and how they translate to symptoms, is still lacking. Therefore, we systematically investigated histological characteristics of SSc in the intestines, compared to controls. METHODS Autopsy material from the small bowel and colon was used for histological semiquantitative evaluation of the vasculature, enteric nervous system, interstitial cells of Cajal (ICC), and muscle layers, using a combination of histochemical and immunohistochemical stainings, according to guidelines of the Gastro 2009 International Working Group. RESULTS Vascular changes were most frequently encountered, represented by intima fibrosis in both arteries and small vessels, and represented by venous dilatation. Second, generalized fibrosis of the circular muscle layer was significantly more found in SSc patients than in controls. Third, reduction of submucosal nerve fibers and myenteric neurons was shown in the colon of four SSc patients, which may explain severe symptoms of intestinal dysmotility. The density of myenteric ICC network was decreased in the small bowel of SSc patients. CONCLUSIONS The postulated sequential processes of intestinal involvement in SSc could not be supported by our histological evaluation. The interpatient diversity suggests that parallel processes occur, explaining the variety of histological features and clinical symptoms. Key Points • Histological analysis showed vascular changes, fibrosis in the muscularis propria, and reduction of the ENS and ICC network in the intestines of SSc patients. • Pathophysiological mechanisms leading to intestinal dysmotility in SSc may be parallel rather than sequential. • The interpatient diversity suggests parallel pathophysiological processes, explaining the variety of histological features and clinical symptoms.
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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: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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Furst DE, Braun-Moscovic Y, Khanna D. Points to consider for clinical trials of the gastrointestinal tract in systemic sclerosis. Rheumatology (Oxford) 2017; 56:v4-v11. [PMID: 28992166 DOI: 10.1093/rheumatology/kex195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Indexed: 12/19/2022] Open
Abstract
The pathogenesis of gastrointestinal tract involvement in SSc is not fully understood. However, gastrointestinal signs and symptoms are very common. Trials to test therapies, with rare exceptions, should be double-blind, randomized trials with either active therapy or placebo as comparators. Trial duration will vary dependent on the anticipated therapy and should usually be 6-24 weeks long, although some motility trials may need to be 52 weeks. As in any well-controlled trial, inclusion and exclusion criteria should encourage relatively uniform patients with sufficiently active disease to discern response, importantly considering disease duration. Previous therapy, co-morbid conditions, potentially confounding and/or concomitant therapy should be considered. Outcome measures should include both objective/semi-objective and subjective measures, although validated measures are not frequent and design needs to consider using only validated measures. Unvalidated measures can be included to validate them for future use. A full analysis plan should be completed before study commencement, including the method to account for missing data.
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Affiliation(s)
- Daniel E Furst
- Department of Rheumatology, Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Yolanda Braun-Moscovic
- B.Shine Rheumatology Unit, Rambam Medical Health Care Campus, Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Institute of Technology, Haifa, Israel
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
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Abstract
In patients with systemic sclerosis (SSc), gastrointestinal (GI) tract involvement is almost universal. Any segment of the GI tract from mouth to anus can be involved, and GI symptoms are a frequent cause of morbidity. In severe cases, GI tract involvement can progress to the point of malnutrition requiring parenteral nutrition. GI tract involvement in SSc contributes to disease-related mortality although mostly as a co-morbidity rather than direct cause of death. The review is intended to help address challenges in the assessment and treatment of GI tract involvement in SSc.
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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: 2.3] [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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Saigusa S, Inoue Y, Ohi M, Imaoka H, Uratani R, Kobayashi M, Kusunoki M. Distinguishing between limited systemic scleroderma-associated pseudo-obstruction and peritoneal dissemination. Surg Case Rep 2016; 1:21. [PMID: 26943389 PMCID: PMC4747929 DOI: 10.1186/s40792-014-0010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 12/22/2014] [Indexed: 11/10/2022] Open
Abstract
A 78-year-old woman receiving treatment for limited systemic scleroderma (SSc) underwent high anterior resection and partial liver resections for rectosigmoid colon cancer with multiple liver metastases. A year after surgery, an abdominal computed tomography (CT) demonstrated suspicion for peritoneal dissemination with an increase in ascites, and (18)F-fluorodeoxy glucose-positron emission tomography-CT was suggestive of carcinomatosis. We began to decompress the small intestine and administer octreotide. However, the intestinal obstruction did not improve. Although intestinal pseudo-obstruction caused by limited SSc was considered as a differential diagnosis, we performed an exploratory laparotomy because the possibility of peritoneal dissemination-associated obstruction could not be excluded. We observed a moderate amount of serous ascites and dilatation of the small intestine that was white in color, hard, and with limited contractility. There was no evidence of peritoneal dissemination nor of mechanical obstruction. Our experience thus shows the difficulty of distinguishing SSc-associated intestinal pseudo-obstruction from peritoneal dissemination.
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Affiliation(s)
- Susumu Saigusa
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Yasuhiro Inoue
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Masaki Ohi
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Hiroki Imaoka
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Ryo Uratani
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Minako Kobayashi
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
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Menys A, Butt S, Emmanuel A, Plumb AA, Fikree A, Knowles C, Atkinson D, Zarate N, Halligan S, Taylor SA. Comparative quantitative assessment of global small bowel motility using magnetic resonance imaging in chronic intestinal pseudo-obstruction and healthy controls. Neurogastroenterol Motil 2016; 28:376-83. [PMID: 26661570 DOI: 10.1111/nmo.12735] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 10/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) is characterized by dilatation of the bowel lumen and abnormal motility. In this study, we aimed to quantify small bowel dysmotility in CIPO using a validated pan-intestinal motility assessment technique based on motion capture magnetic resonance imaging (MRI) compared to normal controls. In addition, we explored if motility responses of CIPO patients to neostigmine challenge differed from healthy volunteers. METHODS Twenty healthy volunteers (mean age 28, range 22-48) and 11 CIPO patients (mean age 47, range 19-90) underwent MRI enterography to capture global small bowel motility. Eleven controls and seven CIPO patients further underwent a randomized placebo-controlled crossover study of either intravenous neostigmine (0.5 mg) or saline with motility MRI repeated at a mean of 3 weeks. Motility was quantified in regions of interest placed to encompass the whole small bowel volume using a validated, postprocessing technique to give a global motility index in arbitrary units (AU). Baseline and stimulated motility was compared using Wilcoxon rank-sum paired T-tests. KEY RESULTS Baseline global small bowel motility was significantly lower in CIPO patients compared to controls (mean 0.25 AU vs 0.35 AU, p < 0.001). Motility in both groups increased significantly after neostigmine (0.06 AU increase, p = 0.016 in CIPO and 0.06 AU increase, p = 0.002 in controls). Three patients with scleroderma had a reduced response to neostigmine. CONCLUSIONS & INFERENCES Global small bowel motility in CIPO patients is significantly lower than controls and response to the pro-kinetic agent neostigmine may differ according to disease phenotype. Software-quantified bowel motility using cine MRI has potential as a future tool to investigate enteric dysmotility.
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Affiliation(s)
- A Menys
- Centre for Medical Imaging, UCL, London, UK
| | - S Butt
- Gastroenterology, University College London Hospitals, London, UK
| | - A Emmanuel
- Gastroenterology, University College London Hospitals, London, UK
| | - A A Plumb
- Centre for Medical Imaging, UCL, London, UK
| | - A Fikree
- Wingate Institute of Neurogastroenterology, Centre for Digestive Diseases, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - C Knowles
- Wingate Institute of Neurogastroenterology, Centre for Digestive Diseases, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - D Atkinson
- Centre for Medical Imaging, UCL, London, UK
| | - N Zarate
- Gastroenterology, University College London Hospitals, London, UK
| | - S Halligan
- Centre for Medical Imaging, UCL, London, UK
| | - S A Taylor
- Centre for Medical Imaging, UCL, London, UK
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Savarino E, Furnari M, de Bortoli N, Martinucci I, Bodini G, Ghio M, Savarino V. Gastrointestinal involvement in systemic sclerosis. Presse Med 2014; 43:e279-91. [PMID: 25179275 DOI: 10.1016/j.lpm.2014.03.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/18/2014] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis is an autoimmune chronic disease characterised by microvascular, muscular and immunologic abnormalities that lead to progressive and systemic deposition of connective tissue in the skin and internal organs. The gastrointestinal tract is often overlooked by physicians but it is the most affected organ after the skin, from the mouth to the anus. Indeed, 80% of SSc patients may present with gastrointestinal involvement. Gastrointestinal manifestations range from bloating and heartburn to dysphagia and anorectal dysfunction to severe weight loss and malabsorption. However, the gastrointestinal involvement is rarely the direct cause of death, but has great impact on quality of life and leads to several comorbidities that subsequently affect patients' survival. Treatments, including nutritional support and prokinetics provide limited benefits and do not arrest the progressive course of the disease, but earlier detection of gastrointestinal involvement may reduce the risk of complications such as malnutrition.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Irene Martinucci
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Giorgia Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Massimo Ghio
- Division of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Paine P, McLaughlin J, Lal S. Review article: the assessment and management of chronic severe gastrointestinal dysmotility in adults. Aliment Pharmacol Ther 2013; 38:1209-29. [PMID: 24102305 DOI: 10.1111/apt.12496] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 02/27/2013] [Accepted: 08/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The characterisation and management of chronic severe gastrointestinal (GI) dysmotility are challenging. It may cause intestinal failure requiring home parenteral nutrition (HPN). AIMS To review the presentation, aetiology, characterisation, management and outcome of chronic severe GI dysmotility, and to suggest a pragmatic management algorithm. METHODS PubMed search was performed up to December 2012 using appropriate search terms, restricted to human articles and reviewed for relevance. Segmental dysmotility, acute ileus, functional syndromes and non-English articles were excluded. Evidence and recommendations were evaluated using the GRADE system. RESULTS In total, 721 relevant articles were reviewed. A coherent and definitive picture is hampered by overlapping classification systems using multi-modal characterisation methods, subject to pitfalls and some requiring further validation. The literature is confined to case series with no randomised trials. Fewer than 20% undergo full thickness jejunal biopsy, which are otherwise labelled idiopathic. However, in studies with up to 80% biopsy rates, neuromuscular abnormalities may be found in 90%. Between 14% and 50% will require HPN, comprising 8-14% of all HPN patients, of which 2/3 are primary/idiopathic and 1/3 secondary, with scleroderma being the leading secondary cause. Ten-year mortality ranges from 13% to 35% and is worst in elderly scleroderma patients. Management includes limited treatments for secondary causes, prokinetics, symptom palliation, psychological support, nutrition, hydration and judicious surgery. CONCLUSIONS Severe dysmotility often remains idiopathic. It is rarely possible to alter disease trajectory; consequently, prognosis may be poor. Multi-disciplinary teams in a specialist setting can improve outcomes. Graded recommendations are enumerated and a pragmatic algorithm is suggested.
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Affiliation(s)
- P Paine
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK; Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Acupuncture-based modalities: novel alternative approaches in the treatment of gastrointestinal dysmotility in patients with systemic sclerosis. Explore (NY) 2013; 10:44-52. [PMID: 24439095 DOI: 10.1016/j.explore.2013.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The gastrointestinal (GI) dysmotility of systemic sclerosis (SSc, scleroderma) patients requires careful evaluation and intervention. The lack of effective prokinetic drugs motivate researchers to search for alternative treatments. OBJECTIVES We present an overview of the pathophysiology of SSc GI dysmotility and the advances in its management, with particular focus on acupuncture-related modalities and innovative therapies. DATA SOURCES Original research articles were identified based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline methodology. We have searched the MEDLINE database using Medical Subject Heading (MeSH) for all English and non-English articles with an English abstract from 2005 to October 2012. RESULTS Only four original articles of various study designs were found studying Complementary and Alternative Medicine (CAM) therapies for SSc patients. Despite the small patient study numbers, CAM treatments, acupressure, and transcutaneous electroacupuncture, showed self-reported and physiologic evidence of improvement of GI functioning and/or symptoms in SSc patients. CONCLUSIONS CAM therapies include experimental modalities with the potential to offer relief of symptoms from GI dysmotility. Larger studies are needed to investigate their optimal use in patient subsets to tailor therapies to patient needs.
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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: 3.2] [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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Savarino E, Mei F, Parodi A, Ghio M, Furnari M, Gentile A, Berdini M, Di Sario A, Bendia E, Bonazzi P, Scarpellini E, Laterza L, Savarino V, Gasbarrini A. Gastrointestinal motility disorder assessment in systemic sclerosis. Rheumatology (Oxford) 2013; 52:1095-100. [PMID: 23382360 DOI: 10.1093/rheumatology/kes429] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES SSc is a clinically heterogeneous and generalized disease, characterized by thickness of the connective tissue of the skin and internal organs, such as the digestive tract, impairing gastrointestinal (GI) motility. Our aim is to evaluate retrospectively abnormalities of oesophageal motility, gastric emptying, oro-cecal transit time (OCTT) and small intestine bacterial overgrowth (SIBO) in a large cohort of SSc patients. METHODS Ninety-nine SSc patients were included in the study. Forty-two patients underwent oesophageal conventional manometry, 45 performed a [(13)C]octanoic acid breath test to measure gastric emptying time and all 99 patients performed a lactulose breath test in order to evaluate OCTT and SIBO. Data were compared with healthy controls. RESULTS In SSc patients, median lower oesophageal sphincter (LOS) pressure [14 mmHg (25th-75th; 8-19) vs 24 mmHg (19-28); P < 0.01] and median wave amplitude [30 mmHg (16-70) vs 72 mmHg (48-96); P < 0.01] were lower than in controls. Oesophageal involvement, defined as reduced LOS pressure and ineffective oesophageal motility pattern, was encountered in 70% of SSc patients. A delayed gastric emptying time was present in 38% of SSc patients: mean t½ was 141 ± 79 min vs 90 ± 40 min of controls (P < 0.01). Also, OCTT was significantly delayed in SSc: median OCTT was 160 min (25th-75th; 135-180) vs 105 min (25th-75th; 90-135) of controls (P < 0.01). SIBO was observed in 46% of SSc compared with 5% of controls (P < 0.01). CONCLUSION GI involvement is very frequent in SSc patients. Oesophagus and small bowel are more frequently impaired, whereas delayed gastric emptying is less common.
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Fynne L, Worsøe J, Gregersen T, Schlageter V, Laurberg S, Krogh K. Gastrointestinal transit in patients with systemic sclerosis. Scand J Gastroenterol 2011; 46:1187-93. [PMID: 21815862 DOI: 10.3109/00365521.2011.603158] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis and collagen deposits. Gastrointestinal symptoms of SSc, including abdominal pain, bloating and discomfort, are common but diffuse and their pathophysiology remains obscure. AIM To investigate the pathophysiology of abdominal pain and discomfort in individuals with SSc. METHODS A total of 15 individuals with SSc (13 women, median age 58 years), all suffering from diffuse abdominal symptoms, and 17 healthy volunteers (12 women, median age 52 years) were evaluated with the Motility Tracking System, MTS-1, measuring gastric emptying (GE) and velocity through the small intestine. SSc patients were also examined for bacterial overgrowth using the hydrogen breath test and with radiopaque markers to determine the total gastrointestinal transit time (GITT). RESULTS Assessed with the MTS-1, the velocity through the proximal small intestine was significantly reduced in SSc patients (median 0.525 m/h, range 0.11-1.15) when compared to healthy subjects (median 0.91 m/h, range 0.51-1.74) (p = 0.02). Prolonged GE was found in 4 SSc patients (27%) but in none of the healthy volunteers (p = 0.04). Only 3 SSc patients (21%) had positive breath tests for small intestinal bacterial overgrowth. GITT was >3 days in 8 patients (53%). Slow small intestinal transit was associated with a prolonged GITT (p < 0.05). CONCLUSION Velocity through the small intestine is significantly reduced in SSc patients with diffuse abdominal symptoms.
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Affiliation(s)
- Lotte Fynne
- Department of Hepatology and Gastroenterology V, Neurogastroenterology Unit, Aarhus University Hospital, Denmark.
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Gustafsson RJ, Littorin B, Berntorp K, Frid A, Thorsson O, Olsson R, Ekberg O, Ohlsson B. Esophageal dysmotility is more common than gastroparesis in diabetes mellitus and is associated with retinopathy. Rev Diabet Stud 2011; 8:268-75. [PMID: 22189550 DOI: 10.1900/rds.2011.8.268] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Gastroparesis is a well-known complication of diabetes mellitus, both in symptomatic and asymptomatic patients. Esophageal dysmotility has also been described, but is not as well-characterized. The etiology and effect of these complications need to be clarified. The aim of the present study was to evaluate esophageal and gastric motility, complications, gastrointestinal symptoms, and plasma biomarkers in a cross-sectional study comprising patients with diabetes mellitus. METHODS Patients with diabetes were consecutively asked to participate, and eventually 84 volunteers were included in the study. Esophageal manometry and the gastric emptying test were performed in all patients. Type of diabetes, symptoms, diabetic complications, body mass index (BMI), and biomarkers were recorded. Patients were interviewed about gastrointestinal symptoms. RESULTS Esophageal dysmotility was present in 63% of patients and gastroparesis in 13% of patients. There was no difference in dysmotility between patients with type 1 and type 2 diabetes or between genders. Gastrointestinal symptoms did not correlate to objective findings. Age correlated negatively with gastric emptying rate (p = 0.004). Patients with esophageal dysmotility had longer duration of diabetes compared to those without dysmotility (p = 0.043). In logistic regression analysis, retinopathy was strongly associated with esophageal dysmotility, independent of duration (p = 0.003). CONCLUSIONS Esophageal dysmotility is more common than gastroparesis in diabetes mellitus independent of gender, symptoms, and type of diabetes. There is a strong association between retinopathy and esophageal dysmotility.
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Affiliation(s)
- Rita J Gustafsson
- Department of Clinical Sciences, Division of Gastroenterology, Skane University Hospital, Malmö, Lund University, Lund, Sweden
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Czirjak L, Matucci-Cerinic M. Beyond Raynaud's phenomenon hides very early systemic sclerosis: the assessment of organ involvement is always mandatory. Rheumatology (Oxford) 2011; 50:250-251. [DOI: 10.1093/rheumatology/keq374] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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MCNEARNEY TA, SALLAM HS, HUNNICUTT SE, DOSHI D, WOLLASTON DE, MAYES MD, CHEN JDZ. Gastric slow waves, gastrointestinal symptoms and peptides in systemic sclerosis patients. Neurogastroenterol Motil 2009; 21:1269-e120. [PMID: 19566588 PMCID: PMC3176740 DOI: 10.1111/j.1365-2982.2009.01350.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Impaired gastric slow waves, frequent gastrointestinal (GI) symptoms and altered GI peptides have been reported in Scleroderma (SSc) patients. The aim of this study was to investigate the associations among these three important components in GI dysmotility. Seventeen fasted SSc patients underwent four channel surface electrogastrography, measuring % of normal gastric slow waves or dysrhythmia. Patients completed a questionnaire designed by us to assess demographics, upper and lower GI symptoms (symptom presence, frequency and impact on quality of life, QOL), by YES/NO, Likert Scales and Visual Analogue Scales 1-100 mm (called GI Dysmotility Questionnaire, GIDQ) and health-related QOL by SF-36. Fasting plasma vasoactive intestinal peptide (VIP) and motilin levels were measured by peptide immunoassays. There were significant correlations between percentages of gastric dysrhythmias (bradygastria or arrhythmia) and a number of major GI symptoms such as nausea, abdominal bloating and pain. The plasma level of VIP was correlated positively with % dysrhythmia but negatively with % normal slow waves. Motilin was positively correlated with slow wave coupling (coordination). No major differences were noted in the measured peptides or gastric slow waves between limited SSc and diffuse SSc. Correlations were noted between SF-36 domain scores and our GIDQ scores. In SSc patients, gastric dysrhythmias are correlated with certain GI symptoms. Correlations are also noted between plasma VIP/Motilin levels and gastric slow waves. Thus in SSc, gastric dysrhythmias may be predictive of development of certain dyspeptic symptoms. Plasma VIP may be involved in the development of dysrhythmias.
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Affiliation(s)
- T. A. MCNEARNEY
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, USA, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA, Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - H. S. SALLAM
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - S. E. HUNNICUTT
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - D. DOSHI
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - D. E. WOLLASTON
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - M. D. MAYES
- Department of Internal Medicine, Division of Rheumatology and Immunogenetics, University of Texas Houston Health Science Center, Houston, TX, USA
| | - J. D. Z. CHEN
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Borg J, Melander O, Johansson L, Uvnäs-Moberg K, Rehfeld JF, Ohlsson B. Gastroparesis is associated with oxytocin deficiency, oesophageal dysmotility with hyperCCKemia, and autonomic neuropathy with hypergastrinemia. BMC Gastroenterol 2009; 9:17. [PMID: 19243587 PMCID: PMC2650701 DOI: 10.1186/1471-230x-9-17] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 02/25/2009] [Indexed: 11/23/2022] Open
Abstract
Background Gastrointestinal (GI) dysmotility and autonomic neuropathy are common problems among diabetics with largely unknown aetiology. Many peptides are involved in the autonomic nervous system regulating the GI tract. The aim of this study was to examine if concentrations of oxytocin, cholecystokinin (CCK), gastrin and vasopressin in plasma differ between diabetics with normal function and dysfunction in GI motility. Methods Nineteen patients with symptoms from the GI tract who had been examined with gastric emptying scintigraphy, oesophageal manometry, and deep-breathing test were included. They further received a fat-rich meal, after which blood samples were collected and plasma frozen until analysed for hormonal concentrations. Results There was an increase in postprandial oxytocin plasma concentration in the group with normal gastric emptying (p = 0.015) whereas subjects with delayed gastric emptying had no increased oxytocin secretion (p = 0.114). Both CCK and gastrin levels increased after the meal, with no differences between subjects with normal respective delayed gastric emptying. The concentration of vasopressin did not increase after the meal. In patients with oesophageal dysmotility the basal level of CCK tended to be higher (p = 0.051) and those with autonomic neuropathy had a higher area under the curve (AUC) of gastrin compared to normal subjects (p = 0.007). Conclusion Reduced postprandial secretion of oxytocin was found in patients with delayed gastric emptying, CCK secretion was increased in patients with oesophageal dysmotility, and gastrin secretion was increased in patients with autonomic neuropathy. The findings suggest that disturbed peptide secretion may be part of the pathophysiology of digestive complications in diabetics.
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Affiliation(s)
- Julia Borg
- Department of Clinical Sciences, Gastroenterology Division, Malmö University Hospital, Lund University, Lund, Sweden.
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20
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Parodi A, Sessarego M, Greco A, Bazzica M, Filaci G, Setti M, Savarino E, Indiveri F, Savarino V, Ghio M. Small intestinal bacterial overgrowth in patients suffering from scleroderma: clinical effectiveness of its eradication. Am J Gastroenterol 2008; 103:1257-62. [PMID: 18422815 DOI: 10.1111/j.1572-0241.2007.01758.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES After the skin, the gastrointestinal tract is the second most common target of systemic sclerosis (SSc). AIM Our aims were to investigate orocecal transit time (OCTT) and the presence of small intestinal bacterial overgrowth (SIBO) in SSc as a cause of intestinal symptoms. METHODS Fifty-five SSc patients and 60 healthy controls, sex and age matched, entered the study. Enrolled subjects completed a questionnaire for intestinal symptoms and a global symptomatic score (GSS) was calculated. OCTT and the presence of SIBO were assessed by a lactulose breath test (LBT). Patients with SIBO were treated with rifaximin 1,200 mg/day for 10 days. Finally, a second questionnaire and LBT were performed 1 month after the end of therapy. RESULTS The prevalence of SIBO was higher in SSc patients compared with controls (30/54 vs 4/60, respectively, P < 0.001). OCTT was significantly slower in SSc patients compared with controls (150 min, 25-75th percentile 142.5-165 vs 105 min, 25-75th percentile 90-135, respectively, P < 0.001). In patients with SIBO, the median GSS score was 8 (25-75th percentile 3.25-10.75). Eradication of SIBO was achieved in 73.3% of patients, with a significant reduction of symptoms in 72.7% of them (GSS score 2, 25-75th percentile 1-3, P < 0.05). CONCLUSIONS These data suggest that SIBO occurs more frequently in SSc patients than in controls. Intestinal symptoms in these patients may be related to this syndrome and its eradication seems useful to improve clinical features. OCTT is significantly delayed in SSc patients, suggesting an impairment of intestinal motility, a further risk factor for the development of SIBO.
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Affiliation(s)
- Andrea Parodi
- Di.M.I. Unit of Gastroenterology, University of Genoa, Genoa, Italy
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Abstract
PURPOSE OF REVIEW To review recently published studies presenting novel and relevant information on small intestinal motility. RECENT FINDINGS The reviewed studies covered a variety of topics with several themes emerging. Our understanding of the influence of systemic disorders, intestinal and extraintestinal infections and enteric bacteria on digestive motor function continues to involve. Elegant and important new studies have been published that better define the physiology of intestinal gas handling along with the genesis of symptoms commonly attributed to excessive intestinal gas. While interest in small intestinal bacterial overgrowth in irritable bowel syndrome continues, the utility and specificity of lactulose hydrogen breath testing is yet again questioned and further data are needed before the practice of routinely prescribing antibiotics to patients with irritable bowel syndrome can be endorsed. SUMMARY Small intestinal motility remains an understudied area. Recent publications provide additional new information related to physiology and pathophysiology of small bowel motility. These findings should be of interest to clinician and investigator alike.
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22
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Saar P, Schmeiser T, Tarner IH, Müller-Ladner U. [Gastrointestinal involvement in systemic sclerosis. An underestimated complication]. Hautarzt 2008; 58:844-50. [PMID: 17726594 DOI: 10.1007/s00105-007-1380-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Systemic sclerosis (SSc) belongs to the family of autoimmune connective tissue diseases and is still a challenge to every practicing physician. The disorder is characterized by progressing fibrosis of the skin and internal organs, abnormal activation of the immune system, and distinct changes in microcirculation. Although it is rare--with a prevalence of about 20:100000--patients need to be cared for in a daily setting. In general thickening of the skin is the first sign of the disease, so dermatologists are most frequently consulted first. Two subtypes exist, limited and diffuse forms. Both entities usually involve internal organs, and therefore interdisciplinary cooperation is mandatory. The increased morbidity and mortality depend predominantly on the grade of involvement of the affected organs. Therefore it is essential to diagnose systemic sclerosis early and to identify and monitor all complications closely. In this respect gastrointestinal involvement is frequently neglected, owing to its primarily non-life-threatening character, resulting in substantially delayed therapy.
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Affiliation(s)
- P Saar
- Abt. für Rheumatologie und klinische Immunologie, Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie der Justus-Liebig-Universität Giessen, Kerckhoff-KlinikBad Nauheim, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.
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Abstract
Progressive systemic sclerosis (PSS) is a chronic multisystem disease characterized by excess deposition of connective tissue in skin and internal organs, associated with microvasculature changes and immunologic abnormalities. Involvement of the gastrointestinal tract may occur in 2 stages, a neuropathic disorder followed by a myopathy. Gastric emptying is delayed in 10% to 75% of patients and correlates with symptoms of early satiety, bloating, and emesis. Compliance of the fundus is increased although perception of fullness is normal. Myoelectric abnormalities have been found in some studies. Treatments include metoclopramide, cisapride, and erythromycin. Bleeding from telangiectasias and watermelon stomach is treated endoscopically. Small bowel involvement in PSS occurs in 17% to 57% of patients. The migrating motor complexes are reduced or absent, predisposing to bacterial overgrowth. Malabsorption may also be due to pancreatic insufficiency. Barium enemas demonstrate pancolonic involvement in 10% to 50% of patients with PSS. Wide-mouthed diverticuli, involving all layers of the intestinal wall, are characteristic. Pseudoobstruction may respond to octreotide or prucalopride therapy. Complications include pneumatosis cystoides intestinalis, stercoral ulcerations, and perforation. Fecal incontinence may be due to dysfunction of the internal anal sphincter, a smooth muscle responsible for most of the resting anal sphincter pressure. Anal manometry may show a reduction or loss of the rectoanal inhibitory reflex. Treatments include biofeedback, sacral nerve stimulation, and surgery. PSS involves the gastrointestinal tract from the mouth to the anus. Studies are needed to define effective treatments in these diseases, which cause great morbidity.
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25
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Abstract
PURPOSE OF REVIEW The aim of this article is to review recently published studies presenting novel and relevant information on small intestinal motility. RECENT FINDINGS The reviewed studies covered a variety of topics with several themes emerging. The presentation and causes of chronic intestinal dysmotility continue to expand. Evidence continues to accrue that at least a subset of patients with severe colonic inertia may have a more diffuse motility disorder highlighting the need for careful assessment prior to embarking on surgery for refractory constipation. While interest in bacterial overgrowth in irritable bowel syndrome continues, the utility and specificity of lactulose hydrogen breath testing is yet again being called into question. Methane appears to slow intestinal transit and constipation appears more common among methane-positive patients. The association is presently only correlative and further study is needed. SUMMARY Small intestinal motility remains an understudied area. Recent publications provide additional new information related to physiology and pathophysiology of small bowel motility. These findings should be of interest to clinician and investigator alike.
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Affiliation(s)
- Jason R Bratten
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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