Lactose malabsorption in systemic sclerosis

Gastrointestinal Tract Considerations: Part II: How Should a Rheumatologist Best Manage Common Lower Gastrointestinal Tract Complaints in Systemic Sclerosis?

Lower gastrointestinal (GI) symptoms are a frequently encountered problem for clinicians managing patients with systemic sclerosis. The current management practices are focused on the treatment of symptoms with little information available on how to use GI investigations in daily practice. This review demonstrates how to integrate the objective assessment of common lower GI symptoms into clinical care with the aim of guiding clinical decision making. Understanding the type of abnormal GI function that is affecting a patient and determining which parts of the gut are impacted can help clinicians to target therapy more precisely.

The Clinical Significance of Serum Biomarkers of the Intestinal Barrier in Systemic Sclerosis: A Cross-Sectional Study

Systemic sclerosis (SSc) is an immune-mediated connective tissue disease. Recent studies reported differences in the composition of intestinal microbiota (dysbiosis) in patients with SSc compared to nonsclerodermic subjects. Dysbiosis may disrupt the intestinal barrier, which leads to immunological activation via microbial antigen and metabolite translocation. The study aimed to assess the differences in intestinal permeability between SSc patients and controls and to examine the correlation between intestinal permeability and complications of SSc. The study comprised 50 patients with SSc and 30 matched subjects. Serum intestinal permeability markers: intestinal fatty acid binding protein, claudin-3, and lipopolysaccharides (LPS) were determined using an enzyme-linked immunosorbent assay. SSc patients had a significantly increased concentration of LPS compared to control subjects (232.30 [149.00-347.70] versus 161.00 [83.92-252.20] pg/mL, p < 0.05). The patients with shorter SSc duration (≤6 years) had an increased concentration of LPS and claudin-3 compared to the subgroup with longer disease length: LPS (280.75 [167.30-403.40] versus 186.00 [98.12-275.90] pg/mL, p < 0.05), and claudin-3 (16.99 [12.41-39.59] versus 13.54 [10.29-15.47] ng/mL, p < 0.05). The patients with esophageal dysmotility had a decreased LPS level compared to those without this complication (188.05 [102.31-264.40] versus 283.95 [203.20-356.30] pg/mL, p < 0.05). Increased intestinal permeability in SSc may exacerbate the course of the disease and increase the risk of developing complications. Lower LPS levels in SSc might be a hallmark of esophageal dysmotility.

Cow’s milk-induced gastrointestinal disorders: From infancy to adulthood

Milk is related to many gastrointestinal disorders from the cradle to the grave due to the many milk ingredients that can trigger gastrointestinal discomfort and disorders. Cow’s milk protein allergy (CMPA) is the most common food allergy, especially in infancy and childhood, which may persist into adulthood. There are three main types of CMPA; immunoglobulin E (IgE)-mediated CMPA, non-IgE-mediated CMPA, and mixed type. CMPA appears before the first birthday in almost all cases. Symptoms may start even during the neonatal period and can be severe enough to simulate neonatal sepsis. CMPA (often non-IgE mediated) can present with symptoms of gastroesophageal reflux, eosinophilic esophagitis, hemorrhagic gastritis, food protein-induced protein-losing enteropathy, and food protein-induced enterocolitis syndrome. Most CMPAs are benign and outgrown during childhood. CMPA is not as common in adults as in children, but when present, it is usually severe with a protracted course. Lactose intolerance is a prevalent condition characterized by the development of many symptoms related to the consumption of foods containing lactose. Lactose intolerance has four typical types: Developmental, congenital, primary, and secondary. Lactose intolerance and CMPA may be the underlying pathophysiologic mechanisms for many functional gastrointestinal disorders in children and adults. They are also common in inflammatory bowel diseases. Milk consumption may have preventive or promoter effects on cancer development. Milk may also become a source of microbial infection in humans, causing a wide array of diseases, and may help increase the prevalence of antimicrobial resistance. This editorial summarizes the common milk-related disorders and their symptoms from childhood to adulthood.

Nutrition and connective tissue disease

Despite an incomplete overall understanding, nutrition plays an important role in connective tissue disease. Assessment of patients with connective tissue disease for nutritional status and metabolic disturbances may significantly contribute to patient outcomes. Several studies have indicated the multifactorial role of macronutrients, micronutrients, and supplements in the setting of connective tissue disease. There is additional evidence regarding the roles of weight, obesity, and malnutrition. This contribution reviews a growing body of data regarding nutrition in the development and treatment of various connective tissue diseases, including systemic lupus erythematosus, dermatomyositis, and systemic sclerosis.

Anti-vinculin autoantibodies in systemic sclerosis: a step toward a novel biomarker?

Gastrointestinal (GI) disease is common in systemic sclerosis, and novel biomarkers are needed to identify and monitor these patients. Dr. Suliman and colleagues identify anti-vinculin autoantibodies in a subset of systemic sclerosis patients which associate with GI symptom severity, although more work is needed to determine their clinical utility.

Abdominal symptoms during Sjogren's syndrome: a pilot study

BACKGROUND

Abdominal symptoms in patients with primary Sjögren syndrome (pSS) are poorly documented. The objective of the study was to describe the abdominal symptoms of patients with pSS and to assess their association with characteristics of the disease.

METHODS

One hundred and fifty patients with pSS were evaluated using a composite global symptom score for abdominal symptoms and their severity. Data concerning the clinical and biological characteristics of pSS and abdominal disorders were also collected.

RESULTS

Of the patients with pSS, 95% suffered from abdominal symptoms (median global symptom score 7.5 ± 5.5 points out of 30). More than half of the patients experienced abdominal tension (68%), upper abdominal pain (54%), abdominal discomfort (58%) and/or constipation (54%). Regarding the pSS activity, in relation to European League Against Rheumatism (EULAR) Sjögren syndrome disease activity index score items, general and central nervous system involvement wereassociated with a high global symptom score. The EULAR Sjogren Syndrome Patient Reported Index (ESSPRI) symptom score was positively correlated with the global symptom score (p < 0.01). Multivariate analysis showed a significant association between a high global symptom score and SSA seronegativity, gastroparesis, and ESSPRI score (p < 0.01 for each).

CONCLUSIONS

The majority of patients with pSS suffered abdominal symptoms. There is currently no therapeutic recommendation because of the lack of information on the underlying pathophysiological mechanisms.

TRIAL REGISTRATION

NCT03157011 . Date of registration: July 17, 2017.

Haematological abnormalities in systemic sclerosis

Systemic sclerosis (SSc) is a connective tissue disease characterised by extremely high heterogeneity. This heterogeneity concerns the organ involvement, course of disease and prognosis. Unlike in some other systemic connective tissue diseases, especially systemic lupus erythematosus, in SSc haematological disorders occur rarely. When they develop, they affect erythrocytes, leucocytes and platelets. The most common cause of this pathology of erythrocyte abnormalities is microcytic anaemia resulting from micro-haemorrhages with telangiectasias within the digestive mucosa in patients with SSc. In SSc patients with severe haematological disturbances, the differential diagnosis should include overlapping with another systemic connective tissue disease or a haemato-oncological disease (lympho/myeloproliferative syndrome). In SSc patients with monoclonal proteins or cryoglobulins, it is essential to consider a haemato-oncological disease. In such cases, the differential diagnosis should be focused on a paraneoplastic syndrome, especially when the haematological symptoms develop shortly after the diagnosis of SSc and in the elderly.

Update on lactose malabsorption and intolerance: pathogenesis, diagnosis and clinical management

Lactose is the main source of calories in milk, an essential nutriedigestion, patients with visceral hypersensitivity nt in infancy and a key part of the diet in populations that maintain the ability to digest this disaccharide in adulthood. Lactase deficiency (LD) is the failure to express the enzyme that hydrolyses lactose into galactose and glucose in the small intestine. The genetic mechanism of lactase persistence in adult Caucasians is mediated by a single C→T nucleotide polymorphism at the LCTbo -13'910 locus on chromosome-2. Lactose malabsorption (LM) refers to any cause of failure to digest and/or absorb lactose in the small intestine. This includes primary genetic and also secondary LD due to infection or other conditions that affect the mucosal integrity of the small bowel. Lactose intolerance (LI) is defined as the onset of abdominal symptoms such as abdominal pain, bloating and diarrhoea after lactose ingestion by an individual with LM. The likelihood of LI depends on the lactose dose, lactase expression and the intestinal microbiome. Independent of lactose digestion, patients with visceral hypersensitivity associated with anxiety or the Irritable Bowel Syndrome (IBS) are at increased risk of the condition. Diagnostic investigations available to diagnose LM and LI include genetic, endoscopic and physiological tests. The association between self-reported LI, objective findings and clinical outcome of dietary intervention is variable. Treatment of LI can include low-lactose diet, lactase supplementation and, potentially, colonic adaptation by prebiotics. The clinical outcome of these treatments is modest, because lactose is just one of a number of poorly absorbed carbohydrates which can cause symptoms by similar mechanisms.

Gastrointestinal involvement in systemic sclerosis: diagnosis and management

PURPOSE OF REVIEW

This review provides important updates in systemic sclerosis (SSc)-related gastrointestinal disease, with a particular focus on the diagnosis and management of dysmotility.

RECENT FINDINGS

In the past 2 years, several studies were published that present interesting diagnostic insights into SSc and gastrointestinal dysmotility. Studies focusing on new therapies and the novel application of existing therapies, both in SSc and non-SSc-associated gastrointestinal dysmotility syndromes, demonstrate progress in the management of these challenging complications.

SUMMARY

SSc gastrointestinal disease is heterogeneous in its clinical presentation, which presents a challenge in diagnosis and management. Objective studies may help to identify patterns of gastrointestinal dysmotility and more specifically target therapy. A variety of drugs are now available or are under study in the management of gastrointestinal dysmotility, such as prucalopride, intravenous immunoglobulin, pyridostigmine, linaclotide, relamorelin, and others. These drugs may improve symptoms and quality of life in SSc gastrointestinal patients. Combination therapies are also under study. Electroacupuncture, dietary intervention (e.g. medical nutrition therapy, low FODmap diet), and medical cannibus may also play a role in alleviating patient symptoms; however, more data are needed to define the role of these interventions in SSc.

Colonic and Anorectal Manifestations of Systemic Sclerosis

PURPOSE OF REVIEW

Systemic sclerosis is a chronic autoimmune disorder commonly involving the gastrointestinal tract, including the colon and anorectum. In this review, we summarize major clinical manifestations and highlight recent developments in physiology, diagnostics, and treatment.

RECENT FINDINGS

The exact pathophysiology of systemic sclerosis is unclear and likely multifactorial. The role of the microbiome on gastrointestinal manifestations has led to a better understanding of potential pathogenic gut flora. Carbohydrate malabsorption is common. Evaluation using fecal calprotectin and high-resolution anorectal manometry may broaden our understanding of the etiologies of diarrhea and fecal incontinence and help with early recognition of pathology. Prucalopride, a high-affinity 5HT₄ agonist, and pyridostigmine, an acetylcholinesterase inhibitor, may help improve colonic transit in patients with constipation. Intravenous immunoglobulins have been used to target muscarinic receptor antibodies that are believed to contribute to gastrointestinal dysmotility. Colonic and anorectal manifestations of systemic sclerosis include constipation, diarrhea, and fecal incontinence, and can diminish quality of life for these patients. Recent studies regarding pathophysiology as well as diagnostic and treatment options are promising. Further targeted studies to facilitate early intervention and better management of refractory symptoms are still needed.

Nutrition Management in Patients With Chronic Gastrointestinal Motility Disorders: A Systematic Literature Review

BACKGROUND

The aim of this study was to systematically review effects of nutrition interventions on outcomes in patients with chronic gastrointestinal (GI) motility disorders. There is currently a lack of evidence-based guidelines for nutrition management in this group, likely a result of the rarity of the conditions.

METHODS

A systematic review of all study types to evaluate current evidence-based nutrition interventions was performed using Medline, Embase, and CINAHL databases. Two independent reviewers participated in the process of this systematic review. A total of 15 studies and a total of 524 subjects were included.

RESULTS

Best treatment of this population group was found to include a stepwise process, progressing from oral nutrition to jejunal nutrition and lastly to parenteral nutrition. Small particle, low-fat diets were significantly better tolerated than the converse, with jejunal nutrition prior to consuming oral food significantly improving oral intake and motility. In more progressive cases, percutaneous endoscopic gastrostomy with jejunal extension nutrition had lower reported symptoms than other enteral routes. Exclusive long-term parenteral nutrition is a feasible option for advanced cases, with a 68% survival rate at 15 years duration, though oral intake with parenteral nutrition is associated with higher survival rates.

CONCLUSION

Treatment of patients with GI motility disorders should first trial oral nutrition. For patients who progress to jejunal or parenteral feeds, the primary aim should be to maintain or reinstate oral intake to reduce morbidity and mortality risk. Higher-quality studies are still required in this area, particularly in the areas of chronic intestinal pseudo-obstruction and systemic sclerosis.

The Microbiome in Connective Tissue Diseases and Vasculitides: An Updated Narrative Review

Objective

To provide a narrative review of the most recent data concerning the involvement of the microbiome in the pathogenesis of connective tissue diseases (CTDs) and vasculitides.

Methods

The PubMed database was searched for articles using combinations of words or terms that included systemic lupus erythematosus, systemic sclerosis, autoimmune myositis, Sjögren's syndrome, undifferentiated and mixed CTD, vasculitis, microbiota, microbiome, and dysbiosis. Papers from the reference lists of the articles and book chapters were reviewed, and relevant publications were identified. Abstracts and articles written in languages other than English were excluded.

Results

We found some evidence that dysbiosis participates in the pathogenesis of systemic lupus erythematosus, systemic sclerosis, Sjögren's syndrome, and Behçet's disease, but there are still few data concerning the role of dysbiosis in other CTDs or vasculitides.

Conclusions

Numerous studies suggest that alterations in human microbiota may be involved in the pathogenesis of inflammatory arthritides as a result of the aberrant activation of the innate and adaptive immune responses. Only a few studies have explored the involvement of dysbiosis in other CTDs or vasculitides, and further research is needed.