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Diesing TS. Neurologic Manifestations of Gastrointestinal and Nutritional Disorders. Continuum (Minneap Minn) 2023; 29:708-733. [PMID: 37341328 DOI: 10.1212/con.0000000000001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE A tie between nutritional or gastrointestinal and neurologic disease has been recognized for centuries. Many gastrointestinal disorders are associated with neurologic disease through nutritional, immune-mediated, or degenerative pathophysiologies. This article reviews neurologic disorders in patients with gastrointestinal disease and gastrointestinal manifestations in their own neurologic patients. LATEST DEVELOPMENTS Development of new gastric and bariatric surgical procedures and the widespread use of over-the-counter gastric acid-reducing medications continue to create vitamin and nutritional deficiencies despite modern diet and supplementation. Some supplements, such as vitamin A, vitamin B6, and selenium, themselves are now found to cause disease. Recent work has shown extraintestinal and neurologic manifestations of inflammatory bowel disease. Chronic brain damage in liver disease has been recognized, and the opportunity to intervene may exist in the covert beginning stages. The characterization of gluten-related neurologic symptoms and differentiation from those of celiac disease is an evolving body of work. ESSENTIAL POINTS Gastrointestinal and neurologic diseases related to common immune-mediated, degenerative, or infectious mechanisms are common and can coexist in the same patient. Furthermore, gastrointestinal disease may cause neurologic complications because of nutritional inadequacies, malabsorption, and hepatic dysfunction. In many cases, the complications are treatable but have subtle or protean presentations. Therefore, the consulting neurologist must be current in knowledge of the growing ties between gastrointestinal and neurologic disease.
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Porlas RV, de Castillo LLC, Dioquino CPC. Neurologic Wilson disease: case series on a diagnostic and therapeutic emergency. DIALOGUES IN CLINICAL NEUROSCIENCE 2019. [PMID: 30936772 PMCID: PMC6436958 DOI: 10.31887/dcns.2018.20.4/rporlas] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Wilson disease is a rare genetic disease causing pathologic deposition of copper in the liver, brain, cornea, kidney, and cardiac muscles. Presented are two cases of neurologic Wilson disease with progressive movement disorder and Kayser-Fleischer rings with low serum copper, low ceruloplasmin, and increased 24-hour urine copper against a background of normal transaminases. Cranial imaging revealed symmetric basal ganglia hyperintensities in T2/FLAIR. More often than not, these cases go unnoticed and misdiagnosed because of its rarity and varied presentation. Extensive workup is necessary to confirm the diagnosis. As for management, the earlier the intervention is initiated, the better prognosis would be for recovery. There are several treatment options which should be tailored to every patient with neurologic Wilson disease. Neurologic Wilson disease is considered as a copper toxicity; immediate diagnostic evaluation and early treatment initiation is a must.
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Affiliation(s)
- Romeo V Porlas
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila
| | - Lennie Lynn C de Castillo
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila
| | - Carissa Paz C Dioquino
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila; National Poison Management and Control Center, Philippine General Hospital, University of the Philippines, Manila, Philippines
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Nagral A, Sarma MS, Matthai J, Kukkle PL, Devarbhavi H, Sinha S, Alam S, Bavdekar A, Dhiman RK, Eapen CE, Goyal V, Mohan N, Kandadai RM, Sathiyasekaran M, Poddar U, Sibal A, Sankaranarayanan S, Srivastava A, Thapa BR, Wadia PM, Yachha SK, Dhawan A. Wilson's Disease: Clinical Practice Guidelines of the Indian National Association for Study of the Liver, the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition, and the Movement Disorders Society of India. J Clin Exp Hepatol 2019; 9:74-98. [PMID: 30765941 PMCID: PMC6363961 DOI: 10.1016/j.jceh.2018.08.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/25/2018] [Indexed: 12/12/2022] Open
Abstract
Clinical practice guidelines for Wilson's disease (WD) have been published by the American Association for the Study of Liver Diseases and European Association for the Study of the Liver in 2008 and 2012, respectively. Their focus was on the hepatic aspects of the disease. Recently, a position paper on pediatric WD was published by the European Society of Pediatric Gastroenterology Hepatology and Nutrition. A need was felt to harmonize guidelines for the hepatic, pediatric, and neurological aspects of the disease and contextualize them to the resource-constrained settings. Therefore, experts from national societies from India representing 3 disciplines, hepatology (Indian National Association for Study of the Liver), pediatric hepatology (Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition), and neurology (Movement Disorders Society of India) got together to evolve fresh guidelines. A literature search on retrospective and prospective studies of WD using MEDLINE (PubMed) was performed. Members voted on each recommendation, using the nominal voting technique. The Grades of Recommendation, Assessment, Development and Evaluation system was used to determine the quality of evidence. Questions related to diagnostic tests, scoring system, and its modification to a version suitable for resource-constrained settings were posed. While ceruloplasmin and 24-h urine copper continue to be important, there is little role of serum copper and penicillamine challenge test in the diagnostic algorithm. A new scoring system - Modified Leipzig score has been suggested with extra points being added for family history and serum ceruloplasmin lower than 5 mg/dl. Liver dry copper estimation and penicillamine challenge test have been removed from the scoring system. Differences in pharmacological approach to neurological and hepatic disease and global monitoring scales have been included. Rising bilirubin and worsening encephalopathy are suggested as indicators predicting need for liver transplant but need to be validated. The clinical practice guidelines provide recommendations for a comprehensive management of WD which will be of value to all specialties.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ACLF, Acute on Chronic Liver Failure
- ALF, Acute Liver Failure
- ALT, Alanine Transaminase
- AST, Aspartate Transaminase
- Cu, Copper
- DP, D-Penicillamine
- EASL, European Association for the Study of the Liver
- GAS for WD, Global Assessment Scale for Wilson's Disease
- HCC, Hepatocellular Carcinoma
- INR, International Normalized Ratio
- KF, Kayser-Fleischer
- LT, Liver Transplantation
- MARS, Molecular Absorption Recirculating System
- MELD, Model for End-Stage Liver Disease
- MRI, Magnetic Resonance Imaging
- NGS, Next-Generation Sequencing
- NWI, New Wilson's Index
- PELD, Pediatric end stage liver disease
- TPE, Total Plasma Exchange
- TTM, Tetrathiomolybdate
- WD, Wilson's Disease
- Wilson's disease scoring
- genetic disorder
- modified Leipzig scoring
- rare disease
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Affiliation(s)
- Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India,Department of Gastroenterology, Apollo Hospitals, Navi Mumbai, India,Address for correspondence: Aabha Nagral, 7, Snehasagar, Prabhanagar, Prabhadevi, Mumbai 400025, India.
| | - Moinak S. Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - John Matthai
- Department of Paediatric Gastroenterology, Masonic Medical Centre for Children, Coimbatore, India
| | | | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Vinay Goyal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Neelam Mohan
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – The Medicity Hospital, Gurgaon, India
| | - Rukmini M. Kandadai
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Malathi Sathiyasekaran
- Department of Pediatric Gastroenterology, Kanchi Kamakoti Childs Trust Hospital Chennai, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anupam Sibal
- Department of Pediatric Gastroenterology and Hepatology, Indraprastha Apollo Hospitals, New Delhi, India
| | | | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Baburam R. Thapa
- Department of Gastroenterology & Pediatric Gastroenterology, MM Medical Institute of Medical Sciences and Research, Mullana, Ambala, India
| | - Pettarusp M. Wadia
- Department of Neurology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Surendra K. Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anil Dhawan
- Department of Pediatrics and Pediatric Liver GI and Nutrition Center and Mowat Labs, King's College Hospital, London, UK
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King RR, Reiss JP. The epidemiology and pathophysiology of pseudobulbar affect and its association with neurodegeneration. Degener Neurol Neuromuscul Dis 2013; 3:23-31. [PMID: 30890891 PMCID: PMC6065587 DOI: 10.2147/dnnd.s34160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pseudobulbar affect is a disorder resulting from neurologic damage manifesting as sudden, stereotyped affective outbursts that are not reflective of internal emotion. A literature review was completed to examine the current understanding of the epidemiology, characterization, diagnosis, pathophysiology, and treatment of pseudobulbar affect. This review revealed that it is common in neurodegenerative disorders but is poorly recognized, placing significant impacts on patients and their families. The disorder appears to result from a disruption of the cortico-limbic-subcortical-thalamic-pontocerebellar network involved in emotional expression and regulation with resulting disruptions of neurotransmitter systems. Effective treatment is available with agents such as selective serotonin reuptake inhibitors and dextromethorphan combined with quinidine, but further well-designed comparative studies are needed. Advances in technology such as neuroimaging may enhance knowledge about the pathophysiology of this disorder, and help guide future interventions.
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Affiliation(s)
- Rebecca R King
- Department of Psychiatry, University of Western Ontario, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada,
| | - Jeffrey P Reiss
- Department of Psychiatry, University of Western Ontario, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada,
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