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Tufvesson H, Hamrefors V, Fedorowski A, Hansson M, Ohlsson B. Gastrointestinal symptoms in patients with postural orthostatic tachycardia syndrome in relation to hemodynamic findings and immunological factors. Front Physiol 2024; 15:1342351. [PMID: 38348221 PMCID: PMC10859499 DOI: 10.3389/fphys.2024.1342351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/15/2024] [Indexed: 02/15/2024] Open
Abstract
Gastrointestinal (GI) symptoms are common in postural orthostatic tachycardia syndrome (POTS). We aimed to explore the prevalence and severity of GI symptoms in POTS, and to investigate immunological factors, hemodynamic findings, and their possible association with GI symptoms in POTS. Forty-three patients (93% female, median age 30.6 (26.0-41.0) years), previously diagnosed with POTS and 74 healthy controls (78% female, median age 35.6 (28.8-41.7) years) were included. The participants completed a questionnaire including prevalence of GI symptoms, the irritable bowel syndrome severity scoring system (IBS-SSS), and visual analog scale for IBS (VAS-IBS). All POTS patients were previously examined by tilt test (2010-2021) and the vast majority with more recent active standing test (2017-2021), which included monitoring of heart rate (HR). ΔHR was calculated as difference between supine and upright position. Continuous variables from IBS-SSS and VAS-IBS were correlated to ΔHR. A microarray containing several autoantigens commonly targeted in systemic autoimmune disorders was used to assess prevalent autoantibodies in POTS and controls. Total IgE and S-tryptase were analyzed. GI symptoms were more prevalent and severe in POTS than in controls; nausea being the most prevalent (79.1% vs 4.9%, p < 0.001) and bloating and flatulence being the most severe (median 65 (25-88) vs 0 (0-14), p < 0.001). The median total IBS-SSS was 213 (135-319) in POTS vs 13 (0-54) in controls (p < 0.001). Total IBS-SSS was associated with low psychological wellbeing (r = 0.539, p < 0.001) in POTS. ΔHRmax correlated inversely with abdominal pain (r = -0.406, p = 0.007). After adjustments for psychological wellbeing, total IBS-SSS still associated inversely with ΔHR10min (β: 4.748; 95% CI: -9.172 to -0.324; p = 0.036). Similar results were seen with active standing test. The prevalence of autoantibodies did not differ between POTS and controls (29.4% vs 33.3%, p = 0.803). There was no association between GI symptoms and autoantibody status. Total IgE and tryptase were elevated in a few cases. This study confirms the high prevalence of GI symptoms in POTS. More pronounced tachycardia upon tilt table testing seems to be inversely correlated with severity of chronic GI symptoms in POTS. This study did not support the hypothesis that POTS is associated with immunological factors.
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Affiliation(s)
- Hanna Tufvesson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Gastroenterology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Medicine, Karolinska Institute, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Monika Hansson
- Department of Medicine, Division of Rheumatology, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden
| | - Bodil Ohlsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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Petracek LS, Broussard CA, Swope RL, Rowe PC. A Case Study of Successful Application of the Principles of ME/CFS Care to an Individual with Long COVID. Healthcare (Basel) 2023; 11:healthcare11060865. [PMID: 36981522 PMCID: PMC10048325 DOI: 10.3390/healthcare11060865] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Persistent fatigue is one of the most common symptoms of post-COVID conditions, also termed long COVID. At the extreme end of the severity spectrum, some individuals with long COVID also meet the criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), raising the possibility that symptom management approaches for ME/CFS may benefit some long COVID patients. We describe the long-term outcomes of a 19-year-old male who developed profound impairment consistent with ME/CFS after a SARS-CoV-2 infection early in the pandemic. We evaluated and treated him using our clinic’s approach to ME/CFS. This included a history and physical examination that ascertained joint hypermobility, pathological reflexes, physical therapy maneuvers to look for a range of motion restrictions in the limbs and spine, orthostatic testing, and screening laboratory studies. He was found to have profound postural tachycardia syndrome, several ranges of motion restrictions, and mast cell activation syndrome. He was treated according to our clinic’s guidelines for managing ME/CFS, which included manual physical therapy maneuvers and both non-pharmacologic measures and medications directed at postural tachycardia syndrome and mast cell activation. He experienced significant improvement in his symptoms over 30 months. His case emphasizes how the application of the principles of treating ME/CFS has the potential to provide a direction for treating long COVID.
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Affiliation(s)
| | | | | | - Peter C. Rowe
- Correspondence: ; Tel.: +1-410-955-9229; Fax: +1-410-614-1178
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3
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El-Chammas KI, Santucci NR, Mansi S, Kaul A. Pediatric gastrointestinal neuromodulation: A review. Saudi J Gastroenterol 2022; 28:403-412. [PMID: 35418002 PMCID: PMC9843514 DOI: 10.4103/sjg.sjg_109_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Neuromodulation, also known as bioelectric neuromodulation or neurostimulation, is the therapeutic use of electrical stimulation of nerves or brain centers. Neuromodulation has been trialed in an increasing range of human diseases as well as gastrointestinal disorders. The application of neuromodulation to treat pediatric motility and functional disorders is an exciting recent development. This review aims to briefly discuss the use of neuromodulation for the treatment of pediatric gastroparesis, constipation, and visceral hyperalgesia.
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Affiliation(s)
- Khalil I. El-Chammas
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA,Address for correspondence: Dr. Khalil I. El-Chammas, 3333 Burnet Ave, Cincinnati, Ohio - 45229, USA. E-mail:
| | - Neha R. Santucci
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Sherief Mansi
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Ajay Kaul
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
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4
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Zhou W, Zikos TA, Clarke JO, Nguyen LA, Triadafilopoulos G, Neshatian L. Regional Gastrointestinal Transit and Contractility Patterns Vary in Postural Orthostatic Tachycardia Syndrome (POTS). Dig Dis Sci 2021; 66:4406-4413. [PMID: 33428036 DOI: 10.1007/s10620-020-06808-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) is an autonomic disorder that affects multiple organs, including the gastrointestinal system. These patients often have multiple GI complaints with a severe impact on their quality of life. GI dysmotility patterns in POTS remains poorly understood and difficult to manage. AIMS The aim of this study was to investigate the diagnostic yield of wireless motility capsule in patients with gastrointestinal symptoms and POTS, with use of a symptomatic control group without POTS as a reference. METHODS We retrospectively reviewed the charts of patients who had both autonomic testing and wireless motility capsule between 2016 and 2020. The two groups were divided into those with POTS and those without POTS (controls) as diagnosed through autonomic testing. We compared the regional transit times and motility patterns between the two groups using the data collected from wireless motility capsule. RESULTS A total of 25% of POTS patients had delayed small bowel transit compared to 0% of non-POTS patients (p = 0.047). POTS patients exhibited hypo-contractility patterns within the small bowel, including decreased contractions/min (2.95 vs. 4.22, p = 0.011) and decreased motility index (101.36 vs. 182.11, p = 0.021). In multivariable linear regression analysis, migraine predicted faster small bowel transit (p = 0.007) and presence of POTS predicted slower small bowel transit (p = 0.044). CONCLUSIONS Motility abnormalities among POTS patients seem to affect mostly the small bowel and exhibit a general hypo-contractility pattern. Wireless motility capsule can be a helpful tool in patients with POTS and GI symptoms as it can potentially help guide treatment.
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Affiliation(s)
- Wendy Zhou
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, USA
| | - Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Linda A Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA.
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Miller J, Khlevner J, Rodriguez L. Upper Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1237-1253. [PMID: 34736587 DOI: 10.1016/j.pcl.2021.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Children with disorders affecting the sensory and motor functions of the esophagus will present primarily with swallowing dysfunction, dysphagia, and chest pain, and those with disorders affecting the normal function of the stomach will present with symptoms like abdominal pain, nausea, and vomiting. Recent advances in the mechanisms of disease and technology have increased our understanding of gastrointestinal physiology and that knowledge has been applied to develop new diagnostic studies and therapeutic interventions. We present an overview of the clinical presentation, diagnosis, and treatment of common primary and secondary functional and motility disorders affecting the upper gastrointestinal tract in children.
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Affiliation(s)
- Jonathan Miller
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale New Haven Children's Hospital, Yale University School of Medicine, 333 Cedar Street, LMP 4093, New Haven, CT 06510, USA.
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Herrera A, Behm J. Using the PEOP Model to Understand Barriers to Functioning in Postural Orthostatic Tachycardia Syndrome. Occup Ther Health Care 2021; 36:283-305. [PMID: 34431731 DOI: 10.1080/07380577.2021.1967548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Individuals with postural orthostatic tachycardia syndrome (POTS) experience many barriers that lead to decreased functioning and quality of life. At this time, there are limited resources regarding the functional impact of POTS on occupational performance. Therefore, this narrative review demonstrates how occupational therapy practitioners can conceptualize, categorize, and systematically organize their thinking around barriers individuals with POTS experience using the Person-Environment-Occupation-Performance (PEOP) model of practice.
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Affiliation(s)
| | - Joanna Behm
- Master of Occupational Therapy Program, Messiah University, Mechanicsburg, PA, USA
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Wolfson S, Wilhelm Z, Opekun AR, Orth R, Shulman RJ, Chumpitazi BP. Clinical Characterization of Pediatric Gastroparesis Using a Four-hour Gastric Emptying Scintigraphy Standard. J Pediatr Gastroenterol Nutr 2021; 72:848-853. [PMID: 33605658 PMCID: PMC8486321 DOI: 10.1097/mpg.0000000000003089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Four-hour gastric emptying scintigraphy (GES) is the recommended method to identify both adult and childhood gastroparesis (GP). Previous pediatric studies have, however, not used this standard. We sought to determine the characteristics and outcomes of children versus adolescents with GP using the 4-hour GES evaluation. METHODS We performed a retrospective chart review of pediatric patients diagnosed with GP by 4-hour GES (>10% retention at 4 hours). Demographics, body mass index, GP-related symptoms, comorbidities, etiologies, therapies (eg, medications), healthcare utilization, and response to therapy were captured systematically. Symptoms were compared from the initial versus last gastroenterology visit. Outcomes were categorized as no improvement; improvement (resolution of at least 1 symptom while remaining on therapy); and complete resolution of symptoms. RESULTS A total of 239 subjects (12.1 ± 4.1 years [mean ± standard deviation], 70% girls) were included. The identified characteristics of childhood GP were broad with idiopathic GP being the most common etiology. Outcomes over a median of 22 months (25%-75%: 9.0-45.5 months) were 34.8% no improvement, 34.8% some improvement, and 30.3% with complete symptom resolution. Compared to younger children, adolescents had a higher female predominance (P < 0.01) and were more likely to have nausea (P = 0.006). Girls were more likely to have abdominal pain (P = 0.001), nausea (P = 0.03), and a documented diagnosis of dysautonomia (P = 0.03). Boys were more likely to have regurgitation (P = 0.006), gastroesophageal reflux disease (P = 0.02), and rumination (P = 0.02). CONCLUSIONS Using the 4-hour GES standard, childhood GP has broad clinical characteristics and outcomes. There are several significant age- and sex-based differences in childhood GP.
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Affiliation(s)
- Sharon Wolfson
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Zoe Wilhelm
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Antone R. Opekun
- Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Robert Orth
- Department of Radiology, Children’s Hospital of Wisconsin
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Children’s Nutrition Research Center, United States Department of Agriculture, Houston, TX USA
| | - Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Children’s Nutrition Research Center, United States Department of Agriculture, Houston, TX USA
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8
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Gensemer C, Burks R, Kautz S, Judge DP, Lavallee M, Norris RA. Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes. Dev Dyn 2021; 250:318-344. [PMID: 32629534 PMCID: PMC7785693 DOI: 10.1002/dvdy.220] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 12/14/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.
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Affiliation(s)
- Cortney Gensemer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
| | - Randall Burks
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Kautz
- Department of Health Sciences and Research, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel P. Judge
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Mark Lavallee
- Department of Family Medicine, Wellspan Health, York, Pennsylvania
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
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9
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Abstract
The extrinsic and autonomic nervous system intricately controls the major functions of the gastrointestinal tract through the enteric nervous system; these include motor, secretory, sensory, storage, and excretory functions. Disorders of the nervous system affecting gastrointestinal tract function manifest primarily as abnormalities in motor (rather than secretory) functions. Common gastrointestinal symptoms in neurologic disorders include sialorrhea, dysphagia, gastroparesis, intestinal pseudo-obstruction, constipation, diarrhea, and fecal incontinence. Diseases of the entire neural axis ranging from the cerebral hemispheres to the peripheral autonomic nerves can result in gastrointestinal motility disorders. The most common neurologic diseases affecting gastrointestinal function are stroke, parkinsonism, multiple sclerosis, and diabetic neuropathy. Diagnosis involves identification of the neurologic disease and its distribution, and documentation of segmental gut dysfunction, typically using noninvasive imaging, transit measurements, or intraluminal measurements of pressure activity and coordination of motility. Apart from treatment of the underlying neurologic disease, management focuses on restoration of normal hydration and nutrition and pharmacologic treatment of the gut neuromuscular disorder.
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10
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Manini ML, Barazi A, Khemani D, Abd-Rabu R, Absah I, Fischer PR, Mara K, Stephens M, Camilleri M. Gastrointestinal motility evaluation in children with orthostatic intolerance: Mayo Clinic experience. Neurogastroenterol Motil 2020; 32:e13863. [PMID: 32483845 DOI: 10.1111/nmo.13863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 03/02/2020] [Accepted: 04/02/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Orthostatic intolerance (OI) and autonomic dysfunction (AD) are common in adolescents and young adults. Patients experience multisystem symptoms including gastrointestinal (GI), postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension (OH), or only symptoms of OI (SOI) without significant findings on 70-degree head-up tilt testing (HUT). We hypothesize that patients with POTS, OH, and SOI show differences in GI symptoms and motility test and that heart rate (HR) changes on HUT predict severity of GI dysmotility. STUDY DESIGN From medical records of patients (<18 years) with OI, we collected demographics, presenting symptoms, GI manifestations, and GI motility testing. Data were compared between the 3 groups (POTS, OH, and SOI). We assessed changes in HR on HUT with changes on GI motility evaluation. RESULTS Two hundred twenty-nine patients were included (73% females). Abdominal pain (65%), nausea (49%), vomiting (18%), and constipation (24%) were the most common GI symptoms. In patients who had motility evaluation, there were 27% (53/193) with delayed gastric emptying (GE) at 4 hours, 35% (32/92) with delayed colonic transit (CT), 55% (17/31) with reduced gastric accommodation (GA), and 75% (21/28) with dyssynergic defecation (DD). Among 100 POTS, 34 OH, and 95 SOI patients, no significant differences in GI symptoms or motility tests were identified and HR changes on HUT were not associated with changes on motility tests. CONCLUSION GI symptoms are frequent in adolescents with OI and are associated with delayed GE, reduced GA, delayed CT, and presence of DD.
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Affiliation(s)
- Mhd Louai Manini
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Adnan Barazi
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Disha Khemani
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rami Abd-Rabu
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Imad Absah
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Philip R Fischer
- Division of General Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kristin Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Michael Stephens
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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11
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Abstract
Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.
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Affiliation(s)
- A Sullivan
- Homerton University Hospital, London, UK
| | | | - A Ruban
- Department of Surgery and Cancer, Imperial College, London, UK.
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12
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Kovacic K, Elfar W, Rosen JM, Yacob D, Raynor J, Mostamand S, Punati J, Fortunato JE, Saps M. Update on pediatric gastroparesis: A review of the published literature and recommendations for future research. Neurogastroenterol Motil 2020; 32:e13780. [PMID: 31854057 DOI: 10.1111/nmo.13780] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/11/2019] [Accepted: 11/29/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Due to scarcity of scientific literature on pediatric gastroparesis, there is a need to summarize current evidence and identify areas requiring further research. The aim of this study was to provide an evidence-based review of the available literature on the prevalence, pathogenesis, clinical presentation, diagnosis, treatment, and outcomes of pediatric gastroparesis. METHODS A search of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines with the following databases: PubMed, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Web of Science. Two independent reviewers screened abstracts for eligibility. KEY RESULTS Our search yielded 1085 original publications, 135 of which met inclusion criteria. Most articles were of retrospective study design. Only 12 randomized controlled trials were identified, all of which were in infants. The prevalence of pediatric gastroparesis is unknown. Gastroparesis may be suspected based on clinical symptoms although these are often non-specific. The 4-hour nuclear scintigraphy scan remains gold standard for diagnosis despite lack of pediatric normative comparison data. Therapeutic approaches include dietary modifications, prokinetic drugs, and postpyloric enteral tube feeds. For refractory cases, intrapyloric botulinum toxin and surgical interventions such as gastric electrical stimulation may be warranted. Most interventions still lack rigorous supportive data. CONCLUSIONS Diagnosis and treatment of pediatric gastroparesis are challenging due to paucity of published evidence. Larger and more rigorous clinical trials are necessary to improve outcomes.
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Affiliation(s)
- Katja Kovacic
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Walaa Elfar
- Division of Gastroenterology and Nutrition, Department of Pediatrics, The Pennsylvania State Melton S. Hershey Medical Center, Hershey, PA, USA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Mercy Hospital, Kansas City, MO, USA
| | - Desale Yacob
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Jennifer Raynor
- Edward G. Miner Library, University of Rochester Medical Center, Rochester, NY, USA
| | - Shikib Mostamand
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jaya Punati
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John E Fortunato
- Neurointestinal and Motility Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Holtz Children's Hospital, Miller School of Medicine, University of Miami, Miami, FL, USA
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13
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Gomez Cifuentes J, Radetic M, Lopez R, Gabbard S. Clinical Predictors of Rapid Gastric Emptying in Patients Presenting with Dyspeptic Symptoms. Dig Dis Sci 2019; 64:2899-2909. [PMID: 30982211 DOI: 10.1007/s10620-019-05620-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rapid gastric emptying (RGE) is defined as less than 30% retention at 1 h of solid meal ingestion. It is unclear whether RGE represents a separated clinical entity or part of the functional dyspepsia spectrum. AIMS To determine clinical predictors of RGE in patients presenting with dyspeptic symptoms. METHODS Retrospective study of patients who underwent solid Gastric Emptying Scintigraphy to evaluate dyspeptic symptoms from January 2011 to September 2012. Patients with delayed gastric emptying (> 10% gastric retention at 4 h) or prior gastric surgery were excluded. Patients with RGE were compared to those with normal gastric emptying (NGE) in a patient ratio of 1:3. Demographic data, symptoms, comorbidities, surgeries, endoscopy findings, medications, HbA1c, and TSH were analyzed. Univariate and multivariate logistic regression analyses were performed. RESULTS A total of 808 patients were included, 202 patients with RGE and 606 patients with NGE. Mean gastric retention at 1 h was 18% [12.0, 24.0] and 65% [52.0, 76.0], respectively. Patient with RGE were more likely to present with nausea/vomiting (OR 2.4, p < 0.001), weight loss (OR 1.7, p = 0.008), and autonomic symptoms (OR 2.8, p = 0.022). Identified clinical predictors of RGE were older age (OR 1.08 [1.01, 1.1], p = 0.018), male gender (OR 2.0 [1.4, 2.9], p ≤ <0.001), higher BMI (OR 1.03 [1.00, 1.05], p = 0.018), diabetes (OR 1.8 [1.2, 2.7], p = 0.05), and fundoplication (OR 4.3 [2.4, 7.7], p ≤ 0.001). CONCLUSION RGE represents a distinct population among patients presenting with dyspepsia in whom fundoplication, diabetes, and male gender were the strongest clinical predictors. RGE was significantly associated with nausea/vomiting, weight loss, and autonomic symptoms.
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Affiliation(s)
| | - Mark Radetic
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Gabbard
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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14
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Zhang LN, Moak JP, Desbiens J, Hanumanthaiah S, Fabian RR, Clarke L, Sahay RD, Darbari A. Utility of Diagnostic Studies for Upper Gastrointestinal Symptoms in Children with Orthostatic Intolerance. J Pediatr 2019; 205:138-144. [PMID: 30529135 DOI: 10.1016/j.jpeds.2018.09.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/22/2018] [Accepted: 09/14/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the utility of gastrointestinal (GI) diagnostic studies in the evaluation of patients with orthostatic intolerance. STUDY DESIGN Medical records of 103 consecutive children/young adults with orthostatic intolerance and gastrointestinal symptoms were reviewed. All patients had undergone antroduodenal manometry in conjunction with the tilt table test, autonomic testing, and upper gastrointestinal endoscopy (EGD). A gastric emptying study (GES) was performed in 81 patients. RESULTS The median age of the cohort was 17 years (IQR, 15-19) with a female predominance (females:males, 3:1). As expected, the tilt table test was abnormal in all patients. Antroduodenal manometry was abnormal in 83 of 103 patients (81%), showing neurogenic intestinal dysmotility in 50%, rumination in 20%, and visceral hyperalgesia in 10%. The GES results were abnormal in 23 of 81 patients (28.4%), mostly (21 of 23) with delayed GES. None of the tilt table test or autonomic results were predictive of abnormal antroduodenal manometry or GES. Analysis of EGD biopsy samples revealed nonspecific esophagitis and/or gastritis in 16 of 103 patients (15%). CONCLUSIONS Antroduodenal manometry with the tilt table test were the most insightful investigations in adolescents and young adults with orthostatic intolerance and gastrointestinal symptoms. GES and EGD provided limited information. Gastrointestinal symptoms were related more to functional rather than mucosal or organic etiologies, suggesting a limited role of endoscopy alone in evaluating patients with orthostatic intolerance presenting with gastrointestinal symptoms.
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Affiliation(s)
- Lana N Zhang
- Division of Cardiology, Children's National Health System, Washington, DC
| | - Jeffrey P Moak
- Division of Cardiology, Children's National Health System, Washington, DC
| | - John Desbiens
- Division of Gastroenterology, Children's National Health System, Washington, DC
| | | | - Robin R Fabian
- Division of Cardiology, Children's National Health System, Washington, DC
| | - Lindsay Clarke
- Division of Gastroenterology, Children's National Health System, Washington, DC
| | - Rashmi D Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Anil Darbari
- Division of Gastroenterology, Children's National Health System, Washington, DC.
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Factors Associated With Use of Nonoral Nutrition and Hydration Support in Adult Patients With Postural Tachycardia Syndrome. JPEN J Parenter Enteral Nutr 2018; 43:734-741. [DOI: 10.1002/jpen.1493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/25/2018] [Indexed: 12/12/2022]
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16
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DiBaise JK, Harris LA, Goodman B. Postural Tachycardia Syndrome (POTS) and the GI Tract: A Primer for the Gastroenterologist. Am J Gastroenterol 2018; 113:1458-1467. [PMID: 30072778 DOI: 10.1038/s41395-018-0215-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/16/2018] [Indexed: 12/11/2022]
Abstract
Postural tachycardia syndrome (POTS) is one of the most common causes of orthostatic intolerance and is being increasingly recognized in clinical practice. Gastrointestinal (GI) symptoms are reported commonly in patients with POTS and pose a considerable management challenge, making it imperative that gastroenterologists be aware of this condition and its GI comorbidities. Although the evidence presented herein does not prove causation, it does support an association between GI symptoms, GI dysmotility, and POTS. At present, the evaluation and treatment of GI symptoms in patients with POTS remains largely empirical. General measures to treat POTS may lead to improvement in both GI and non-GI symptoms. GI symptoms refractory to these measures should prompt further diagnostic evaluation of gastrointestinal dysmotility and appropriate dietary and pharmacologic management. This review focuses its attention on the involvement of the GI tract in POTS including a discussion of GI symptoms and conditions associated with POTS, followed by an analysis of abnormalities in gut physiology described in POTS, and concluding with an overview of management and suggestions for research directions.
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Affiliation(s)
- John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, 85259, USA. Department of Neurology, Mayo Clinic, Scottsdale, AZ, 85259, USA
| | - Lucinda A Harris
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, 85259, USA. Department of Neurology, Mayo Clinic, Scottsdale, AZ, 85259, USA
| | - Brent Goodman
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, 85259, USA. Department of Neurology, Mayo Clinic, Scottsdale, AZ, 85259, USA
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17
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Chelimsky G, Chelimsky T. The gastrointestinal symptoms present in patients with postural tachycardia syndrome: A review of the literature and overview of treatment. Auton Neurosci 2018; 215:70-77. [PMID: 30245098 DOI: 10.1016/j.autneu.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 09/06/2018] [Accepted: 09/06/2018] [Indexed: 12/18/2022]
Abstract
Orthostatic intolerance, including postural tachycardia syndrome, is often associated with gastrointestinal symptoms. In the vast majority of the cases, the gastrointestinal symptoms are not secondary to the orthostatic disorder, but rather just a comorbid condition. This concept is critical, since treatment aimed at the orthostatic condition will not improve the gastrointestinal symptoms. Only when the gastrointestinal symptoms develop in the upright position and improve or resolve in the supine position, they may be related to the orthostatic stress. The most common symptoms associated with orthostatic intolerance include nausea, dyspepsia, bloating and constipation. The majority of subjects do not have gastroparesis. The chapter discusses available treatments of these conditions.
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Affiliation(s)
- Gisela Chelimsky
- Department of Pediatrics, Division of Pediatric Gastroenterology, Medical College of Wisconsin, United States of America.
| | - Thomas Chelimsky
- Department of Neurology; Medical College of Wisconsin, United States of America
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18
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Mehr SE, Barbul A, Shibao CA. Gastrointestinal symptoms in postural tachycardia syndrome: a systematic review. Clin Auton Res 2018; 28:411-421. [PMID: 29549458 PMCID: PMC6314490 DOI: 10.1007/s10286-018-0519-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/05/2018] [Indexed: 01/06/2023]
Abstract
Gastrointestinal symptoms are among the most common complaints in patients with postural tachycardia syndrome (POTS). In some cases, they dominate the clinical presentation and cause substantial disabilities, including significant weight loss and malnutrition, that require the use of invasive treatment to support caloric intake. Multiple cross-sectional studies have reported a high prevalence of gastrointestinal symptoms in POTS patients with connective tissue diseases, such as Ehlers-Danlos, hypermobile type, and in patients with evidence of autonomic neuropathy. Previous studies that evaluated gastric motility in these patients reported a wide range of abnormalities, particularly delayed gastric emptying. The pathophysiology of gastrointestinal symptoms in POTS is likely multifactorial and probably depends on the co-morbid conditions. In patients with POTS and Ehlers-Danlos syndromes, structural and functional abnormalities in the gastrointestinal connective tissue may play a significant role, whereas in neuropathic POTS, the gastrointestinal tract motility and gut hormonal secretion may be directly impaired due to localized autonomic denervation. In patients with normal gastrointestinal motility but persistent gastrointestinal symptoms, gastrointestinal functional disorders should be considered. We performed a systematic review of the literature related to POTS and gastrointestinal symptoms have proposed possible mechanisms and discussed diagnosis and treatment approaches for delayed gastric emptying, the most common gastrointestinal abnormality reported in patients with POTS.
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Affiliation(s)
- Shahram E Mehr
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, 506 RRB, 2222 Pierce Ave, Nashville, TN, 37232, USA
| | - Adrian Barbul
- Department of Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, 506 RRB, 2222 Pierce Ave, Nashville, TN, 37232, USA.
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19
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Botrus G, Baker O, Borrego E, Ngamdu KS, Teleb M, Gonzales Martinez JL, Maldonado G, Hussein AM, McCallum R. Spectrum of Gastrointestinal Manifestations in Joint Hypermobility Syndromes. Am J Med Sci 2018; 355:573-580. [DOI: 10.1016/j.amjms.2018.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 02/20/2018] [Accepted: 03/01/2018] [Indexed: 10/17/2022]
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20
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Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT, Singer W, Tarbell S, Chelimsky TC. Pediatric Disorders of Orthostatic Intolerance. Pediatrics 2018; 141:peds.2017-1673. [PMID: 29222399 PMCID: PMC5744271 DOI: 10.1542/peds.2017-1673] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 01/18/2023] Open
Abstract
Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.
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Affiliation(s)
| | | | | | | | - John E. Fortunato
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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21
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Mohr LD. A Case Report and Review of Postural Orthostatic Syndrome in an Adolescent. J Pediatr Health Care 2017; 31:717-723. [PMID: 28600184 DOI: 10.1016/j.pedhc.2017.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 04/11/2017] [Indexed: 10/19/2022]
Abstract
Because there are many young women between the ages of 12 and 25 years who have been diagnosed with postural orthostatic syndrome (POTS), with the time to the diagnosis of about 5 years, it is important for health care providers to have an understanding of the clinical presentation of POTS to manage the diagnosis appropriately. The purpose of this article is to present a case study review of an adolescent woman who experienced POTS syndrome at age 16 years and to provide a clinical overview of POTS in the adolescent population.
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22
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Greco C, Di Gennaro F, D'Amato C, Morganti R, Corradini D, Sun A, Longo S, Lauro D, Pierangeli G, Cortelli P, Spallone V. Validation of the Composite Autonomic Symptom Score 31 (COMPASS 31) for the assessment of symptoms of autonomic neuropathy in people with diabetes. Diabet Med 2017; 34:834-838. [PMID: 27990686 DOI: 10.1111/dme.13310] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2016] [Indexed: 12/11/2022]
Abstract
AIM To validate the Composite Autonomic Symptom Score (COMPASS) 31, in its Italian version, for the diagnosis of diabetic cardiovascular autonomic neuropathy in a clinic-based, single-centre study. METHODS A total of 73 participants with diabetes (age 55 ± 14 years) completed the COMPASS 31 questionnaire before undergoing cardiovascular autonomic neuropathy and diabetic polyneuropathy assessment according to cardiovascular reflex tests, neuropathic symptoms and signs, and vibration and thermal thresholds. RESULTS The COMPASS 31 total weighted score differed between participants with and without cardiovascular autonomic neuropathy (29.9 ± 19.5 vs 16.1 ± 14.7; P = 0.003) and with and without diabetic polyneuropathy (28.9 ± 19.1 vs 12.7 ± 11.3; P < 0.0001). It was related to cardiovascular reflex tests score (rho = 0.38, P = 0.0013) as well as diabetic polyneuropathy symptoms (rho=0.61, P < 0.0001) and signs scores (rho = 0.49, P < 0.0001). Receiver-operating curve analysis showed a fair diagnostic accuracy of total score for cardiovascular autonomic neuropathy (area under the curve 0.748 ± 0.068, 95% CI 0.599-0.861) and diabetic polyneuropathy (area under the curve 0.742 ± 0.061, 95% CI 0.611-0.845). The best score thresholds were 16 for early cardiovascular autonomic neuropathy (sensitivity 75.0%, specificity 64.9%, positive predictive value 37.5% and negative predictive value 90.2%), and 17 for both confirmed cardiovascular autonomic neuropathy and diabetic polyneuropathy (sensitivity 70.0% and 65.5%, respectively; specificity 66.7% and 79.5%, respectively; positive predictive value 25.0% and 67.9%, respectively; and negative predictive value 93.0% and 77.8%, respectively). COMPASS 31 had a good internal consistency according to Cronbach's α coefficient of 0.73. CONCLUSIONS COMPASS 31 can represent a valid, easy-to-use, quantitative assessment tool for autonomic symptoms in diabetic neuropathy, with a fair diagnostic accuracy for both cardiovascular autonomic neuropathy and diabetic polyneuropathy.
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Affiliation(s)
- C Greco
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - F Di Gennaro
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - C D'Amato
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - R Morganti
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - D Corradini
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - A Sun
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - S Longo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - D Lauro
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - G Pierangeli
- IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
- Neurology, DIBINEM, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | - P Cortelli
- IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
- Neurology, DIBINEM, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | - V Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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23
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Antroduodenal Manometry Is Abnormal in Children Presenting With Orthostatic Intolerance and Gastrointestinal Symptoms. J Pediatr Gastroenterol Nutr 2016; 63:329-35. [PMID: 26859090 DOI: 10.1097/mpg.0000000000001150] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Gastrointestinal (GI) symptoms of nausea, vomiting, and abdominal pain are common in patients with orthostatic intolerance (OI), including neurally mediated hypotension (NMH) and postural orthostatic tachycardia syndrome (POTS). Autonomic dysregulation is considered the underlying pathophysiology behind the cardiovascular symptoms of POTS. Because the autonomic nervous system also regulates GI motility, we hypothesized that patients with POTS and GI symptoms will have evidence of autonomic dysmotility of the upper GI tract. METHODS Thirty-five subjects with OI and GI symptoms were studied. All the subjects had a 24-hour antroduodenal manometry (ADM) study, in conjunction with pharmacologic challenge and autonomic and tilt table testing (TTT). RESULTS The mean subject age was 16.2 ± 2.8 years (range 10-23.8 years), and male to female ratio was 10:25. TTT was abnormal in all the 35 subjects, whereas Valsalva testing was abnormal (+40 mmHG) in 21 of 34 (62%) subjects, and corrected QT interval was ≥0.44 seconds in 19 of 35 (54%) subjects. During TTT, GI symptoms were reproduced in 31 of 35 (89%) studies. ADM was found to be abnormal at baseline, before the TTT in 5 of 35 (14%) subjects, whereas it became abnormal in 23 of 34 (68%) subjects during TTT. In addition, the expected response to the pharmacologic challenge was limited. Overall, ADM was abnormal in 26 of 35 (74%) patients either at baseline or during TTT in these subjects with OI. CONCLUSIONS ADM is frequently abnormal in children with OI and GI symptoms. Upper GI motility studies should be a part of the comprehensive evaluation in this population.
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24
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Gastrointestinal dysfunction in postural tachycardia syndrome. J Neurol Sci 2015; 359:193-6. [DOI: 10.1016/j.jns.2015.10.052] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 09/18/2015] [Accepted: 10/14/2015] [Indexed: 11/18/2022]
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25
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Chow D, Young R, Valcour N, Kronmal RA, Lum CJ, Parikh NI, Tracy RP, Budoff M, Shikuma CM. HIV and coronary artery calcium score: comparison of the Hawaii Aging with HIV Cardiovascular Study and Multi-Ethnic Study of Atherosclerosis (MESA) cohorts. HIV CLINICAL TRIALS 2015; 16:130-8. [PMID: 26038953 DOI: 10.1179/1528433614z.0000000016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To determine the association of HIV, immunologic, and inflammatory factors on coronary artery calcium (CAC), a marker of subclinical atherosclerosis. METHODS Cross-sectional study comparing baseline data of males from Hawaii Aging with HIV - Cardiovascular Study (HAHCS) with the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. The cohorts were pooled to determine effects of HIV on CAC and explore immunologic and inflammatory factors that may explain development of CAC in HIV. Multivariable regression models compared CAC prevalence in HAHCS with MESA adjusting for coronary heart disease (CHD) risk profiles. RESULTS We studied 100 men from HAHCS and 2733 men from MESA. Positive CAC was seen in 58% HAHCS participants and 57% MESA participants. Mean CAC was 260.8 in HAHCS and 306.5 in MESA. Using relative risk (RR) regression, HAHCS participants had a greater risk (RR = 1.20, P < 0.05) of having positive CAC than MESA when adjusting for age, smoking status, diabetes, antihypertensive therapy, BMI, systolic blood pressure, total cholesterol, and HDL cholesterol. Among participants with positive CAC, HIV infection was not associated with larger amounts of CAC. Among HAHCS participants, current HIV viral load, CD4, length of HIV, interleukin 6 (IL-6), fibrinogen, C-reactive protein (CRP), and D-dimer were not associated with the presence or amount of CAC. DISCUSSION HIV was independently associated with a positive CAC in men with increased likelihood occurring between 45 and 50 years of age. Current HIV viral load, CD4 count, length of HIV, and inflammatory markers were unrelated to either presence or amount of CAC.
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Deb A, Morgenshtern K, Culbertson CJ, Wang LB, Hohler AD. A survey-based analysis of symptoms in patients with postural orthostatic tachycardia syndrome. Proc (Bayl Univ Med Cent) 2015; 28:157-9. [PMID: 25829642 DOI: 10.1080/08998280.2015.11929217] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a type of dysautonomia seen most commonly in young women and children. It is defined as an increase in heart rate of 30 beats per minute (bpm) or more within 10 minutes of standing in adults, or by 40 bpm or more in children in the absence of orthostatic hypotension. In addition to typical autonomic symptoms, POTS patients report a wide range of subjective complaints in multiple organ systems, though the exact frequencies are unclear. To address the symptom frequency, we had 39 patients with POTS at our institution complete an intake form consisting of a list of 37 symptoms. The most frequently reported symptoms included palpitations, lightheadedness, and headache, although sleep disturbances, gastrointestinal complaints, sensitivity to temperature, and rash were also common.
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Affiliation(s)
- Anindita Deb
- Department of Neurology, Boston University Medical Center, Boston, Massachusetts
| | - Karen Morgenshtern
- Department of Neurology, Boston University Medical Center, Boston, Massachusetts
| | - Collin J Culbertson
- Department of Neurology, Boston University Medical Center, Boston, Massachusetts
| | - Liz B Wang
- Department of Neurology, Boston University Medical Center, Boston, Massachusetts
| | - Anna DePold Hohler
- Department of Neurology, Boston University Medical Center, Boston, Massachusetts
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27
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Loavenbruck A, Iturrino J, Singer W, Sletten DM, Low PA, Zinsmeister AR, Bharucha AE. Disturbances of gastrointestinal transit and autonomic functions in postural orthostatic tachycardia syndrome. Neurogastroenterol Motil 2015; 27:92-8. [PMID: 25483980 PMCID: PMC4286289 DOI: 10.1111/nmo.12480] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 11/06/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal symptoms are common in the postural orthostatic tachycardia syndrome (POTS). However, few studies have evaluated gastrointestinal transit in POTS. Our primary objectives were to evaluate gastrointestinal emptying and the relationship with autonomic dysfunctions in POTS. METHODS We reviewed the complete medical records of all patients aged 18 years and older with POTS diagnosed by a standardized autonomic reflex screen who also had a scintigraphic assessment of gastrointestinal transit at Mayo Clinic Rochester between 1998 and 2012. Associations between specific gastric emptying and autonomic (i.e., cardiovagal, adrenergic, and sudomotor) disturbances were evaluated. KEY RESULTS Among 163 patients (140 women, mean [± SEM] age 30 [± 1] years), 55 (34%) had normal, 30 (18%) had delayed, and 78 (48%) had rapid gastric emptying. Fifty-eight patients (36%) had clinical features of physical deconditioning, which was associated (p = 0.02) with rapid gastric emptying. Associations with delayed gastric emptying included vomiting, which was more common (p < 0.003), and anxiety or depression, which was less common (p = 0.02). The tilt-associated increase in heart rate and reduction in systolic BP at 1 min was associated (p < 0.05), being greater in patients with delayed gastric emptying. CONCLUSIONS & INFERENCES Two-thirds of patients with POTS and GI symptoms had abnormal, most frequently rapid gastric emptying. Except for more severe adrenergic impairment in patients with delayed gastric emptying, the pattern of autonomic dysfunction did not discriminate among gastric emptying groups. Further studies are necessary to ascertain whether extravascular volume depletion and/or deconditioning contribute to POTS in patients with gastrointestinal symptoms.
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Affiliation(s)
| | - Johanna Iturrino
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Program. Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Phillip A. Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Program. Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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