Gastrointestinal involvement in L-tryptophan (L-Trp) associated eosinophilia-myalgia syndrome (EMS)

Psychosocial aspects of Crohn's disease

In clinical practice, significant discrepancies occur between disease activity and severity, and the patient's symptom experience and behavior. Discrepancies cannot be explained by biologic or morphologic findings, and usually are considered to be related to psychosocial factors. Recent advances in the scientific understanding of the relationship between environmental stress and the neural, endocrine, and immune systems, combined with new methodologies in clinical research, provide a challenging opportunity for clinicians and researchers to establish a more comprehensive understanding of Crohn's disease. This article reviews the important relationship of psychosocial factors, pathogenesis, clinical expression, response to treatment, and outcome of Crohn's disease, and presents a comprehensive model of illness, disease, and ways to integrate psychosocial factors with diagnosis and patient care.

Presidential address: Gastrointestinal illness and the biopsychosocial model

OBJECTIVE

To review the evidence supporting the biopsychosocial model in understanding patients with gastrointestinal disorders (GI).

METHOD

Essay of personal experience and review of related literature through a MEDLINE search.

RESULTS

Through clinical examples of three common gastrointestinal disorders, a case is made to refocus our understanding from a biomedical or disease-based model of illness to a biopsychosocial model. With the latter model, the psychosocial and biological predeterminants are seen to interact in the clinical expression of illness and disease. With gastroesophageal reflux disease, the evidence shows that stress can lead to amplification of heartburn symptoms that is independent of the degree of reflux. Functional gastrointestinal pain is "an illness without disease," where structural or physiological disturbance of the GI system does not exist. Rather, the symptoms are understood in terms of visceral hypersensitivity as modulated by central nervous system activity. With the Crohn's disease example, the clinical expression of the disorder is not explained by the degree of disease activity. Rather, the symptoms and impaired quality of life relate to preexisting psychosocial determinants. The observed association of stress with disease activation in Crohn's disease is explained by stress-related alterations in psychoimmunological function via the hypothalamic-pituitary-adrenal axis.

CONCLUSIONS

Gastrointestinal disorders, as a model for other medical conditions, exemplify the important role of an integrated, biopsychosocial model of illness.

The role of psychosocial factors in gastrointestinal illness

Psychosocial factors have a complex relationship with gastrointestinal illness. Early life factors can contribute to illness susceptibility and condition later illness experiences and behaviors. Existing psychosocial factors, gut physiology and pathology are not associated in a linear or causative fashion, but instead interact to determine symptoms and illness behavior. Investigation of the clinical outcome of these disorders, an area of recent interest, involves both 'hard' (i.e., disability, healthcare use, costs) and 'soft' (i.e., physical and psychologic status and function, health-related Quality of Life) endpoints. In this article I present a biopsychosocial framework for understanding these integrated relationships which are supported by recent data involving both functional and structural (i.e., 'organic') gastrointestinal disorders.

Head and neck manifestations of eosinophilia-myalgia syndrome

Eosinophilia-myalgia syndrome (EMS) is a multisystemic disease that occurs in patients who have consumed products containing L-tryptophan. Prominent features include incapacitating myalgias, arthralgias, neuropathies, and eosinophilia. Despite the frequent association of dysphagia, dyspnea, and the potential for aspiration, the otolaryngology literature is devoid of information on EMS. In order to determine the frequency of otolaryngic symptoms, questionnaires were distributed to patients with EMS in 33 different US states. Among the 28 various head and neck manifestations studied, 70% of EMS patients complained of generalized muscle spasms, 66% xerostomia, 62% dyspnea, and 56% dysphagia. In addition, the epidemiology, clinical presentation, diagnostic criteria, and treatment options are discussed. This paper assesses the frequency of otolaryngic manifestations of EMS, as well as introduces this syndrome to the otolaryngologist-head and neck surgeon. It is important for the otolaryngologist to be aware of EMS and its manifestations and treatments so that patients with this potentially lethal disease can receive appropriate evaluation and expeditious treatment.

Pericrypt eosinophilic enterocolitis and chronic diarrhea

An unusual pattern of eosinophilic infiltration around intestinal crypts was detected in mucosal biopsy specimens of 10 patients with chronic diarrhea, half of whom had evidence of systemic connective tissue disease. The median duration of symptoms was 11 months, and no other explanation for diarrhea could be determined in any case. The cellular infiltrate on biopsy specimens was present deep in the mucosa of small and large intestinal specimens, separating crypt bases from the muscularis mucosae and penetrating the latter. Consistent with the microscopic findings, surface mucosal appearance by endoscopy was uniformly normal. These histological features of colonic biopsy specimens were statistically differentiated from those of asymptomatic subjects (n = 8), subjects with diarrhea-predominant irritable bowel syndrome (n = 6), and subjects with collagenous colitis (n = 7) or lymphocytic colitis (n = 5). Diarrhea improved in five of seven subjects treated with oral prednisone or prednisone in conjunction with azathioprine (median follow-up period, 2.2 years). Histological changes on subsequent biopsy specimens correlated closely with symptomatic status. These findings strongly suggest that chronic diarrhea is related to this pericrypt eosinophilic enterocolitis, a pathological lesion often associated with features of systemic connective tissue disease. The disorder appears responsive to corticosteroid therapy in some cases.