Anorectal motility and sensation abnormalities and its correlation with anorectal symptoms in patients with systemic sclerosis: a preliminary study

Systemic sclerosis and anorectal dysfunction: The Leeds experience

Systemic sclerosis is an autoimmune disorder which frequently affects the gastrointestinal tract. Anorectal dysfunction is common in systemic sclerosis and is manifested mainly by atrophy of internal anal sphincter. Faecal incontinence is the result of internal anal sphincter atrophy secondary to systemic sclerosis. In this study, we aimed to assess the internal anal sphincter in 17 patients with faecal incontinence and systemic sclerosis using anorectal manometry and endoanal ultrasound and compare them with an age and gender-matched control group without systemic sclerosis. Most patients have limited cutaneous systemic sclerosis. Majority of the patients with systemic sclerosis and faecal incontinence presented with symptoms of faecal leakage and urgency. Systemic sclerosis patients had low basal sphincter pressures. The mean thickness of internal anal sphincter in systemic sclerosis group was significantly lower than the control group (p < 0.001). Rectal sensation is preserved in systemic sclerosis. There was no difference in the mean thickness of the external anal sphincter between the two groups. To conclude internal anal sphincter is atrophic in systemic sclerosis resulting in decreased resting sphincter pressures and passive faecal leakage. Further investigations and studies are needed to determine the natural course of faecal incontinence in systemic sclerosis, associated risk factors and efficacy of therapeutic interventions.

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.

Systemic sclerosis gastrointestinal dysmotility: risk factors, pathophysiology, diagnosis and management

Nearly all patients with systemic sclerosis (SSc) are negatively affected by dysfunction in the gastrointestinal tract, and the severity of gastrointestinal disease in SSc correlates with high mortality. The clinical complications of this dysfunction are heterogeneous and include gastro-oesophageal reflux disease, gastroparesis, small intestinal bacterial overgrowth, intestinal pseudo-obstruction, malabsorption and the requirement for total parenteral nutrition. The abnormal gastrointestinal physiology that promotes the clinical manifestations of SSc gastrointestinal disease throughout the gastrointestinal tract are diverse and present a range of therapeutic targets. Furthermore, the armamentarium of medications and non-pharmacological interventions that can benefit affected patients has substantially expanded in the past 10 years, and research is increasingly focused in this area. Here, we review the details of the gastrointestinal complications in SSc, tie physiological abnormalities to clinical manifestations, detail the roles of standard and novel therapies and lay a foundation for future investigative work.

High Failure Rate Following Restorative Surgery for Rectal Prolapse in Systemic Sclerosis Patients

INTRODUCTION

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disorder. Colonic disorders are reported in 70% of patients. Only a few cases of rectal prolapse surgical repair in SSc patients were published, demonstrating high recurrence rate following any restorative surgery. The aim of this study is to present our surgical experience combined with the reported cases of SSc patients who underwent surgical interventions for rectal prolapse.

METHODS

We reviewed our data and the published reports in the English literature of patients with SSc who underwent surgery for rectal prolapse. We located 6 case reports, in addition to 3 patients who were operated in our center.

RESULTS

A total of 19 procedures (9 patients) were included, among them 17 restorative surgeries and 2 low anterior resections (LAR) with end-colostomy. All patients were female (mean age 70.3). Index surgery was perineal rectosigmoidectomy in 5, abdominal resection rectopexy in 3, and LAR with colostomy in 1 patient. All patients following restorative surgery suffered from fecal incontinence. 5 patients (62.5%) who underwent restorative surgery required at least 1 re-operation. The 2 patients who underwent LAR and colostomy reported a complete resolution of anorectal symptoms with a major improvement in their quality of life.

CONCLUSION

High recurrence rate is expected in SSc patients with rectal prolapse who undergo a restorative procedure. Low anterior resection and permanent colostomy provide an alternative surgical option to patients with SSc and prolapse in contrast to restorative surgery. We believe that this surgical approach should be offered for these patients.

Stubborn rectal prolapse in systemic sclerosis

Systemic sclerosis (SSc) is an autoimmune connective tissue disorder. Anorectal involvement might typically cause fecal incontinence and rarely rectal prolapse. Here we report three female patients, who were admitted with a mean history of 10 years suffering from SSc. All patients presented with the initial symptom of anal incontinence, in all cases this was associated with rectal intussusception or rectal prolapse. The three women faced prolapse recurrence, independent of the initial procedure. After surgical removal of the prolapse, the incontinence remained.

In SSc rectal prolapse syndrome might occur at an earlier age, and a primary prolapse of the ventral aspect of the rectal wall seems to be typical for this disease. If patients with prior diagnosis of SSc appear with third degree of fecal incontinence, it is suspected to be associated with rectal prolapse. The prolapse recurrence rate after surgery in SSc patients is high.

Gastrointestinal Manifestations of Systemic Sclerosis

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.

The Impact of Pelvic Floor and Lower Gastrointestinal Symptoms on Quality of Life in Women With Systemic Sclerosis

BACKGROUND

Systemic sclerosis (SSc) patients with gastrointestinal (GI) involvement have a lower quality of life (QoL) and while the impact of upper GI symptoms on QoL in SSc patients has been described few data exist on the presence and impact of lower gastrointestinal (LGI) and pelvic floor symptoms in SSc. Our goal was to assess the prevalence of these symptoms in women with SSc and evaluate their impact on QoL. A secondary hypothesis was that the impact of LGI symptoms on QoL is mediated by depression.

STUDY

Women with SSc (n=175) attending an outpatient scleroderma clinic completed multiple validated questionnaires. Pelvic floor and LGI symptoms included fecal incontinence (FI), urinary incontinence (UI), dual incontinence (DI), chronic constipation, diarrhea, and pelvic pain. The Student t tests adjusted for multiple comparisons were used to evaluate group differences at the 0.05 level.

RESULTS

Complete data were available for 160 women. FI was reported by 65, UI by 64, DI by 40, chronic constipation by 94, diarrhea by 82, and pelvic pain by 35 of SSc patients. Overall QoL was reduced in SSc patients with FI (0.96 vs. 0.63; P=0.007), UI (0.96 vs. 0.65; P=0.01), DI (1.11 vs. 0.67; P=0.002), and pelvic pain (1.01 vs. 0.70; P=0.04). Antidepressant use was reported by 26%. The negative impact on QoL in patients with pelvic floor symptoms was partially mediated by depression.

CONCLUSIONS

Women with SSc suffer from an increased prevalence of LGI and pelvic floor symptoms including FI, UI, diarrhea, constipation, and pelvic pain and this effect seems to be partially mediated by depression.

High resolution gastrointestinal monitoring in a systemic sclerosis patient with gastrointestinal dysfunction

Gastrointestinal dysfunction is common in systemic sclerosis patients, but the characteristic findings of high resolution gastrointestinal monitoring and 24-h pH-Z monitoring in these patients are rarely reported. We performed high resolution esophageal pressure monitoring, 24-hour esophageal pH-Z monitoring, and high resolution anorectal pressure monitoring (3D) in a systemic sclerosis patient with gastrointestinal dysfunction. Esophageal pressure monitoring showed that the distal peristaltic pressure wave was absent, the lower esophageal sphincter (LES) relaxed, and the bolus could not be cleared from the esophagus. 24-h esophageal pH-Z monitoring showed severe gastroesophageal reflux, obvious weak acid reflux, and symptoms associated with acid reflux. Anorectal pressure monitoring showed that the pressure band of resting anal sphincter was narrow, and the initial feeling of defecation and maximum tolerance amount were significantly weaken. Thus, high resolution gastrointestinal monitoring allows to monitor gastrointestinal dysfunction in systemic sclerosis patients.

Quality of life in systemic sclerosis

Systemic sclerosis (SSc) is a chronic multi-system autoimmune disease associated with disability and reduced quality of life. There is no effective treatment or cure to SSc, so it is important improve global health of these patients and reduce morbidity and mortality associated with SSc. It was made a literature review about quality of life in patients with SSc, regarding the several factors that should be considered and evaluated when attending to SSc patients. It was also considered the validated scales and questionnaires used to measure outcomes in patients with SSc. We concluded that it is important to have an interdisciplinary approach to SSc patients considering the patient's cognitive representations of the disease and what they value most like mobility and hand function, pain, fatigue, sleep, depression and body image.

Evaluation and management of gastrointestinal manifestations in scleroderma

PURPOSE OF REVIEW

The gastrointestinal tract is the most common extra-cutaneous organ system involved with systemic sclerosis (SSc) affecting approximately 90% of patients. This review summarizes the recent advances in the evaluation and management of gastrointestinal manifestations of SSc.

RECENT FINDINGS

There is a growing body of evidence that uncontrolled GERD can play a significant role in the pathogenesis of SSc-associated interstitial lung disease. Newer forms of management of Barrett esophagus are showing significant promise as potentially curative therapy. Gastric antral vascular ectasias have strongly been associated with the presence of RNA polymerase III antibody. Newer technologies have advanced the assessment of gastrointestinal dysmotility in SSc. Evidence of probiotic use for the treatment of gastrointestinal complications is emerging. The UCLA SCTC GIT 2.0 questionnaire is being increasingly accepted by the SSc experts as a validated instrument for evaluation of patient-reported outcomes involving the gastrointestinal tract.

SUMMARY

Our knowledge of the complex pathogenesis of gastrointestinal manifestations of SSc has expanded substantially in the last few decades. There has also been considerable technological progress in the evaluation of these manifestations. Patient care is being optimized by close collaboration of rheumatologists and gastroenterologists, leading to a more coordinated approach in the management of these complications.

Acupuncture-based modalities: novel alternative approaches in the treatment of gastrointestinal dysmotility in patients with systemic sclerosis

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.

Neurologic involvement in scleroderma: a systematic review

OBJECTIVES

To perform a systematic review of neurologic involvement in Systemic sclerosis (SSc) and Localized Scleroderma (LS), describing clinical features, neuroimaging, and treatment.

METHODS

We performed a literature search in PubMed using the following MeSH terms, scleroderma, systemic sclerosis, localized scleroderma, localized scleroderma "en coup de sabre", Parry-Romberg syndrome, cognitive impairment, memory, seizures, epilepsy, headache, depression, anxiety, mood disorders, Center for Epidemiologic Studies Depression (CES-D), SF-36, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Patient Health Questionnaire-9 (PHQ-9), neuropsychiatric, psychosis, neurologic involvement, neuropathy, peripheral nerves, cranial nerves, carpal tunnel syndrome, ulnar entrapment, tarsal tunnel syndrome, mononeuropathy, polyneuropathy, radiculopathy, myelopathy, autonomic nervous system, nervous system, electroencephalography (EEG), electromyography (EMG), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Patients with other connective tissue disease knowingly responsible for nervous system involvement were excluded from the analyses.

RESULTS

A total of 182 case reports/studies addressing SSc and 50 referring to LS were identified. SSc patients totalized 9506, while data on 224 LS patients were available. In LS, seizures (41.58%) and headache (18.81%) predominated. Nonetheless, descriptions of varied cranial nerve involvement and hemiparesis were made. Central nervous system involvement in SSc was characterized by headache (23.73%), seizures (13.56%) and cognitive impairment (8.47%). Depression and anxiety were frequently observed (73.15% and 23.95%, respectively). Myopathy (51.8%), trigeminal neuropathy (16.52%), peripheral sensorimotor polyneuropathy (14.25%), and carpal tunnel syndrome (6.56%) were the most frequent peripheral nervous system involvement in SSc. Autonomic neuropathy involving cardiovascular and gastrointestinal systems was regularly described. Treatment of nervous system involvement, on the other hand, varied in a case-to-case basis. However, corticosteroids and cyclophosphamide were usually prescribed in severe cases.

CONCLUSIONS

Previously considered a rare event, nervous system involvement in scleroderma has been increasingly recognized. Seizures and headache are the most reported features in LS en coup de sabre, while peripheral and autonomic nervous systems involvement predominate in SSc. Moreover, recently, reports have frequently documented white matter lesions in asymptomatic SSc patients, suggesting smaller branches and perforating arteries involvement.