Coexistent chronic idiopathic intestinal pseudo obstruction and inflammatory bowel disease

Review article: the assessment and management of chronic severe gastrointestinal dysmotility in adults

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.

Beyond hematoxylin and eosin: the importance of immunohistochemical techniques for evaluating surgically resected constipated patients

Chronic constipation requiring surgical ablation for intractability is often a frustrating condition from the pathologist's point of view. In fact, limiting the histological examination to only hematoxylin-eosin staining usually yields only the information that there are no abnormalities. By employing some simple and widely available immunohistochemical methods, discussed in this review, it is possible to gather data that may help in explaining the pathophysiological basis of constipation in these patients.

Impaired gastric emptying in primary Sjogren's syndrome

OBJECTIVE

To investigate the prevalence of impaired gastric emptying (IGE) and its relation to autonomic nervous dysfunction (AD), functional bowel syndrome, and inflammatory and serological variables in patients with primary Sjögren's syndrome (pSS).

METHODS

Twenty-eight patients with pSS according to the American-European Consensus Criteria were included in the study. Gastric emptying was evaluated by the octanoate breath test from which half-time (t(half)) and lag-time (t(lag)) were determined and compared with the results from 50 healthy controls. Autonomic nervous function was evaluated by 5 objective autonomic reflex tests (ART) and by the Autonomic Symptom Profile (ASP) questionnaire evaluating AD symptoms. These results were compared with previously investigated healthy ART controls and population-based ASP controls. Patients were also assessed regarding symptoms of functional bowel syndrome.

RESULTS

The t(half) and the t(lag) were significantly prolonged in patients compared to controls. Forty-three percent of patients with pSS presented signs of IGE and 29% fulfilled the criteria for gastroparesis. Significant correlations were found between t(lag) and increased levels of IgG (p = 0.02) and erythrocyte sedimentation rate (ESR; p = 0.01). In addition, rheumatoid factor (RF) seropositives showed objective signs of IGE to a greater extent than RF seronegatives. No associations between IGE, ART variables, ASP variables, or gastrointestinal symptoms were found.

CONCLUSION

IGE was common in pSS. Associations with inflammatory and serological features of pSS could imply immunological mechanisms behind the IGE. Objective signs of IGE were not associated with objective signs or subjective symptoms of AD or functional bowel syndrome.

Gastrointestinal neuromuscular pathology: guidelines for histological techniques and reporting on behalf of the Gastro 2009 International Working Group

The term gastrointestinal neuromuscular disease describes a clinically heterogeneous group of disorders of children and adults in which symptoms are presumed or proven to arise as a result of neuromuscular, including interstitial cell of Cajal, dysfunction. Such disorders commonly have impaired motor activity, i.e. slowed or obstructed transit with radiological evidence of transient or persistent visceral dilatation. Whilst sensorimotor abnormalities have been demonstrated by a variety of methods in these conditions, standards for histopathological reporting remain relatively neglected. Significant differences in methodologies and expertise continue to confound the reliable delineation of normality and specificity of particular pathological changes for disease. Such issues require urgent clarification to standardize acquisition and handling of tissue specimens, interpretation of findings and make informed decisions on risk-benefit of full-thickness tissue biopsy of bowel or other diagnostic procedures. Such information will also allow increased certainty of diagnosis, facilitating factual discussion between patients and caregivers, as well as giving prognostic and therapeutic information. The following report, produced by an international working group, using established consensus methodology, presents proposed guidelines on histological techniques and reporting for adult and paediatric gastrointestinal neuromuscular pathology. The report addresses the main areas of histopathological practice as confronted by the pathologist, including suction rectal biopsy and full-thickness tissue obtained with diagnostic or therapeutic intent. For each, indications, safe acquisition of tissue, histological techniques, reporting and referral recommendations are presented.

A prospective evaluation of the diagnostic value of video capsule endoscopy in patients initially classified as irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is characterized by chronic gastrointestinal dysfunction in the absence of detectable organic disease. The recently developed technique, video capsule endoscopy (CE), has been shown to be much more sensitive than traditional enterography in detecting mucosal changes in the small intestine. This study was performed to see if any earlier, not detectable by other standard methods, mucosal changes could be found in the small intestine in patients diagnosed as having IBS.

METHODS

All consecutive women who, over the past five years, had received a well-founded diagnosis of IBS at the Department of Medicine were identified. Twenty-eight women, mean age 36+/-12 years were willing to participate in the study. They underwent a CE after a pre-test with a dummy capsule. The actual IBS activity was estimated by the validated Gastrointestinal Symptom Rating Scale (GSRS) and Psychological General Well-Being (PGWB) Index questionnaires.

RESULTS

The duration of the IBS symptoms was a mean of 10 years (range 3-25). Symptoms were present, according to the scores of the GSRS and the PGWB index, at the time the patients underwent the CE. In the majority, 24 of 27 IBS patients examined, no specific small intestinal lesions were seen on CE. In two patients, CE revealed multiple small intestinal lesions such as ulcerations and/or erosions, and in one patient a duodenal ulceration.

CONCLUSION

In the vast majority of patients who fulfil the symptom criteria of IBS, no pathological mucosal lesions can be found by CE explaining the symptomatology. However, a subgroup of these patients may benefit from investigation by CE to reconsider the diagnosis.

Sympathetic nerve dysfunction is common in patients with chronic intestinal pseudo-obstruction

GOAL

To clarify whether disturbances in the autonomic nervous system, reflected in abnormal cardiovascular reflexes, could explain symptoms of impaired heat regulation in patients with intestinal pseudo-obstruction.

BACKGROUND

Chronic intestinal pseudo-obstruction is a clinical syndrome characterized by diffuse, unspecific gastrointestinal symptoms due to damage to the enteric nervous system or the smooth muscle cells. These patients often complain of excessive sweating or feeling cold, suggesting disturbances in the autonomic nervous system. Earlier studies have pointed to a coexistence of autonomic disturbances in the enteric and cardiovascular nervous system.

STUDY

Thirteen consecutive patients (age range 23 to 79, mean 44 y) fulfilling the criteria for chronic intestinal pseudo-obstruction were investigated. Six of them complained of sweating or a feeling of cold. Examination of autonomic reflexes included heart rate variation to deep-breathing (expiration/inspiration index), heart rate reaction to tilt (acceleration index, brake index), and vasoconstriction (VAC) due to indirect cooling by laser doppler (VAC-index; high index indicates impaired VAC). Test results in patients were compared with healthy individuals.

RESULTS

Patients had significantly higher (more abnormal) median VAC-index compared with healthy controls [1.79 (interquartile ranges 1.89) vs. 0.08 (interquartile ranges 1.29); P=0.0007]. However, symptoms of impaired heat regulation were not related to the VAC-index. There were no differences in expiration/inspiration, acceleration index, or brake index between patients and controls.

CONCLUSIONS

The patients with severe gastrointestinal dysmotility showed impaired sympathetic nerve function which, however, did not seem to be associated with symptoms of impaired heat regulation.

Subclinical sympathetic neuropathy appears early in the course of Crohn's disease

BACKGROUND

We have previously demonstrated that patients with Crohn's disease (CD) of long duration have signs of autonomic neuropathy. The aim of this study was to examine whether autonomic neuropathy is an early manifestation of CD, or a sign appearing late in the course.

METHODS

Twenty patients, median age 40 years, with a short duration of CD were included. Examination of autonomic reflexes included heart rate reaction to tilt (acceleration index - AI, brake index - BI) and heart rate variation to deep-breathing (expiration/inspiration index-E/I). Seven years later the same examinations were repeated, and in addition we examined the vasoconstriction response to indirect cooling by laser Doppler (vasoconstriction-index - VAC-index). The results were compared with healthy individuals.

RESULTS

There was no difference in the blood pressure between controls and the patients with CD at rest, but eight minutes after tilt, the systolic blood pressure was lowered in patients compared to controls, both at the first assessment (p = 0.016) and after seven years (p = 0.042). The change in systolic blood pressure between rest and eight minutes after tilt was not significant at the first assessment, while a significant change compared to controls was observed seven years later (p = 0.028). This indicates a progressive dysfunction. There were no differences in E/I, AI, BI or VAC indexes between patients and controls.

CONCLUSION

Patients with CD suffer from autonomic neuropathy early in their disease, suggesting involvement of many different organ systems in this entity.

Findings in patients with chronic intestinal dysmotility investigated by capsule endoscopy

Background

Capsule endoscopy (CE) is a unique tool to visualize the mucosa of the small intestine. Chronic intestinal dysmotility (CID) is a group of rare disorders of gastrointestinal motility that often are complicated by bacterial overgrowth. The aim of this study was to determine the prevalence of small bowel mucosal abnormalities in patients with CID. We also studied the usefulness of CE in the diagnosis of intestinal dysmotility.

Methods

We conducted a prospective study using CE in 18 patients; six with myopathic, 11 with neuropathic and one with indeterminate CID. A control group was used for comparison of small bowel transit.

Results

Mucosal breaks (erosions and ulcerations) were found in 16/18 (89%) patients. The capsule reached the caecum in 11/18 (61%) patients with a median transit time of 346 minutes. In the control group the capsule reached the caecum in 29/36 (81%) cases with a median transit time of 241 minutes. The difference in transit time was not significant (p = 0.061) in this material. The capsule was retained in the stomach in 3/18 patients. None of the patients developed symptoms or signs of mechanical obstruction.

Conclusion

A high frequency of mucosal breaks and signs of motility disturbances were seen in CID patients. CE is feasible for the examination of small bowel mucosa in patients with CID. The relevance of observed mucosal abnormalities in CID remains uncertain.

Enteric ganglioneuritis and abnormal interstitial cells of Cajal: features of inflammatory bowel disease

BACKGROUND

An increased prevalence of irritable bowel syndrome (IBS) and disturbances in cardiac and blood pressure reflexes have been described in patients with Crohn's disease (CD) and ulcerative colitis (UC). These features could be due to abnormalities in the gastrointestinal neurotransmission. The aims of this study were to examine whether histopathologic changes in the enteric nervous system correlate with disturbances in cardiac and blood pressure reflexes and the occurrence of IBS- and dyspepsia-like symptoms in these patients.

METHODS

Thirty patients with CD and UC with bowel resection were examined by deep-breathing and orthostatic tests. The resection specimens were evaluated histologically regarding visceral neuro- or myopathy. All medical records were studied for treatment and clinical course.

RESULTS

Ganglioneuritis was observed in 11 of 19 patients with CD and in 5 of 11 with UC. Only patients with CD had ganglioneuritis in the small intestine. Moreover, in CD the interstitial cells of Cajal (ICCs) in the small bowel showed atrophy and vacuolar degeneration, along with a reduced number of cells (P = 0.005). In UC the colonic ICCs were hyperplastic (P = 0.05) without signs of degeneration. The indices of deep-breathing and orthostatic tests were impaired, except in CD with ganglioneuritis, who showed normal test values. There were no correlations between histopathologic alterations versus IBS and dyspepsia.

CONCLUSIONS

Visceral ganglioneuritis and pathologic ICCs were observed in patients with CD and UC. However, these histopathologic abnormalities could not be related to the clinical or autonomic features of the disease.

The role of the sympathetic nervous system in intestinal inflammation

The nervous system in the intestine controls motility, secretion, sensory perception, and immune function. Peptidergic neurones with neurotransmitters such as substance P and nerve growth factors have been the main focus of neuroimmunomodulation research in the gut. This review summarises the present knowledge concerning the role of the sympathetic nervous system (SNS) in modulating intestinal inflammation. The role of the SNS for gut inflammation is compared with its role in rheumatoid arthritis which demonstrates notable similarities. Nerve fibres of the SNS not only enter the enteric plexuses but also innervate the mucosa and gut associated lymphoid tissue (GALT). The SNS has pro- and anti-inflammatory functions. Neurotransmitters such as norepinephrine, adenosine, and others can evoke remarkably different opposing effects depending on concentration (presence of sympathetic nerve fibres and extent of neurotransmitter release), receptor affinity at different receptor subtypes, expression of adrenoceptors, availability of cotransmitters, and timing of SNS activity in relation to the inflammatory course. This review attempts to integrate the different perspectives of the pro- and anti-inflammatory effects of the SNS on inflammatory disease of the gut.