[Involvement of the small intestine in systemic scleroderma]

Gastrointestinal Manifestations of Systemic Sclerosis

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibroproliferative alterations of the microvasculature leading to fibrosis and loss of function of the skin and internal organs. Gastrointestinal manifestations of SSc are the most commonly encountered complications of the disease affecting nearly 90% of the SSc population. Among these complications, the esophagus and the anorectum are the most commonly affected. However, this devastating disorder does not spare any part of the gastrointestinal tract (GIT), and includes the oral cavity, esophagus, stomach, small and large bowels as well as the liver and pancreas. In this review, we present the current understanding of the pathophysiologic mechanisms of SSc including vasculopathy, endothelial to mesenchymal transformation as well as the autoimmune pathogenetic pathways. We also discuss the clinical presentation and diagnosis of each part of the GIT affected by SSc. Finally, we highlight the latest developments in the management of this disease, addressing the severe malnutrition that affects this vulnerable patient population and ways to assess and improve the nutritional status of the patients.

Gastrointestinal manifestations of scleroderma: recent progress in evaluation, pathogenesis, and management

Gastrointestinal (GI) involvement is frequent in scleroderma (systemic sclerosis [SSc]) and is the most frequent internal complication of the disease. Patients with GI involvement have impaired quality of life, and their prognosis may be one of severe impairment. Unfortunately, GI involvement is often noticed when severe complications have already occurred, is irreversible, and is difficult to manage. The past 2 to 3 years have been rich in exciting studies that we hope will help identify, prevent, treat, and monitor disease progression. Recent studies on the pathophysiology of GI tract disease could lead to advances in the treatment of GI tract involvement. The importance of treating gastroesophageal reflux (GER) has been reinforced by studies showing GER damage in almost all SSc patients, and the fact that GER damage is reversible if early treatment with proton pump inhibitors is introduced. Moreover, recent data showing a link between GER and interstitial lung disease in SSc underscore the importance of aggressive GER treatment in SSc patients. A novel lung pattern possibly related to GER also has been described. New, exciting data on gastric vascular antral ectasia have been published. Finally, malnutrition in SSc patients has been highlighted, and anorectal involvement has been emphasized.

Gastrointestinal manifestations of scleroderma: recent progress in evaluation, pathogenesis, and management

Gastrointestinal (GI) involvement is frequent in scleroderma (systemic sclerosis [SSc]) and is the most frequent internal complication of the disease. Patients with GI involvement have impaired quality of life, and their prognosis may be one of severe impairment. Unfortunately, GI involvement is often noticed when severe complications have already occurred, is irreversible, and is difficult to manage. The past 2 to 3 years have been rich in exciting studies that we hope will help identify, prevent, treat, and monitor disease progression. Recent studies on the pathophysiology of GI tract disease could lead to advances in the treatment of GI tract involvement. The importance of treating gastroesophageal reflux (GER) has been reinforced by studies showing GER damage in almost all SSc patients, and the fact that GER damage is reversible if early treatment with proton pump inhibitors is introduced. Moreover, recent data showing a link between GER and interstitial lung disease in SSc underscore the importance of aggressive GER treatment in SSc patients. A novel lung pattern possibly related to GER also has been described. New, exciting data on gastric vascular antral ectasia have been published. Finally, malnutrition in SSc patients has been highlighted, and anorectal involvement has been emphasized.

Gastrointestinal symptoms and motility disorders in patients with systemic scleroderma

BACKGROUND

Studies on gastrointestinal symptoms, dysfunctions, and neurological disorders in systemic scleroderma are lacking so far.

METHODS

Thirty-eight scleroderma patients (34 limited, 4 diffuse), 60 healthy controls and 68 dyspeptic controls were scored for upper and lower gastrointestinal symptoms (dyspepsia, bowel habits), gastric and gallbladder emptying to liquid meal (functional ultrasonography) and small bowel transit (H2-breath test). Autonomic nerve function was assessed by cardiovascular tests.

RESULTS

The score for dyspepsia (mainly gastric fullness) was greater in scleroderma patients than healthy controls, but lower than dyspeptic controls who had multiple symptoms, instead. Scleroderma patients with dyspepsia had a longer disease duration. Fasting antral area and postprandial antral dilatation were smaller in scleroderma patients than dyspeptic and healthy controls. Gastric emptying was delayed in both scleroderma patients (particularly in those with abnormal dyspeptic score) and dyspeptic controls, who also showed a larger residual area. Despite gallbladder fasting and postprandial volumes were comparable across the three groups, gallbladder refilling appeared delayed in dyspeptic controls and mainly dependent on delayed gastric emptying in scleroderma. Small intestinal transit was also delayed in 74% of scleroderma and 66% of dyspeptic controls. Bowel habits were similar among the three groups. Autonomic neuropathy was not associated with dyspepsia, gastric and gallbladder motility and small intestinal transit.

CONCLUSION

In scleroderma patients dyspepsia (mainly gastric fullness), restricted distension of the gastric antrum and diffuse gastrointestinal dysmotility are frequent features. These defects are independent from the occurrence of autonomic neuropathy.

Atteinte digestive au cours de la sclérodermie systémique

Gastrointestinal involvement is frequent in systemic sclerosis (SSc), occurring in 75 to 90% of patients with diffuse or limited cutaneous SSc. Although all regions of the gut may be affected, the esophagus is the most common gastrointestinal localization of this disease. If not diagnosed at an early stage, resulting complications may include esophagitis (leading to stenosis, strictures, and Barrett's esophagus) and increased risk of interstitial lung disease. Esophageal manometry is the most sensitive test for accurate diagnosis of motor dysfunction. Antisecretory agents (mainly proton-pump inhibitors) are effective for treating esophageal manifestations. Gastrointestinal involvement is reported in 50-88% of patients with SSc. It remains associated with a poor prognosis and leads to death in 6 to 12% of cases. Gastrointestinal impairment may lead to life-threatening complications, including severe dyspepsia, hemorrhage related to watermelon stomach (gastric antral vascular ectasia), malabsorption syndrome (related to bacterial overgrowth), and intestinal pseudo-obstruction. Treatment for the latter two remains difficult, although octreotide has proven to be effective in SSc patients. Small bowel manometry is useful for careful selection of SSc patients who will benefit from this treatment. Anorectal involvement is frequent in SSc patients (50-70%) and causes fecal incontinence and rectal prolapse. Other digestive manifestations, including liver impairment, are less common in SSc.

Gastrointestinal manifestations in Hungarian scleroderma patients

Systemic sclerosis (SSc) is a chronic connective tissue disease characterized by fibrosis and destruction of the microvasculature. Increased deposition of collagen and other extracellular matrix components affects not only the skin but most of the internal organs including lungs, heart, kidneys and the gastrointestinal (GI) tract. Within the GI tract, esophageal involvements are most frequently seen features. However, abnormalities in the small intestine, colon and anorectum may also occur. A retrospective study was performed to investigate the frequency and clinical relevances of GI involvement in patients with SSc. Charts of altogether 246 SSc patients were reviewed. This patient population included 40 males and 206 females, with a mean age of 54.2 years. In general, 176 of 246 patients (71.5%) had GI symptoms. Esophageal involvement including gastro-esophageal reflux disease (GERD), aperistalsis, pseudodiverticuli, etc. was the most common (62.6%). In addition, diseases of the stomach (31.7%), dysfunctions of the colon and anorectum (11.4%), as well as sclerosis of the biliary tract and other pancreato-biliary disorders (9.8%) also occurred. Diarrhea and malabsorption resulted in cachexia and other secondary complications leading to death in two cases. Our results support that GI manifestations are rather common in SSc. Apart from the esophagus, other GI complications in SSc are usually mild, however, early recognition is necessary to improve quality of life.

Assessment of intestinal permeability and orocecal transit time in patients with systemic sclerosis: analysis of relationships with epidemiologic and clinical parameters

OBJECTIVE

The aim of this study was to assess intestinal permeability (IP) in patients with systemic sclerosis (SSc) and to relate the results with general disease activity and gastrointestinal involvement.

METHODS

Twenty-eight females and four males were studied. Patients with severe gastrointestinal involvement were excluded. Thirty-three healthy volunteers served as controls. Intestinal permeability was assessed by means of the orally administered cellobiose/mannitol sugar (Ce/Ma) test. Intestinal transit time (ITT) was investigated with the H2-lactulose breath test.

RESULTS

The mean value of IP in 32 SSc patients was significantly higher than in 33 controls ( P<0.05), although it fell within the normal range. Eleven patients showed abnormally high individual IP values (>0.028) that significantly correlated to disease duration ( r=0.73). Altered IP was associated with the higher but not statistically relevant presence of anti-Scl70 antibodies (9/11) and to more severe gastrointestinal involvement. More than half of the SSc patients showed slower orocecal transit times on the H2 breath test. In particular, delayed ITT was observed in 60% of patients with increased IP and in all patients with moderate gastrointestinal involvement according to the scleroderma severity scale.

CONCLUSION

Intestinal permeability was altered in 11/32 SSc patients. Correlations between increased IP and duration of disease and degree of gastrointestinal involvement appear to support the hypothesis of secondary involvement of the intestinal barrier, and the presence of anti-Scl70 antibodies in 82% of the patients with higher IP clearly reinforces the hypothesis of an altered immune response in these subjects.

[Influence of age on the clinical and biological characteristics of systemic scleroderma]

PURPOSE

The present study was aimed at assessing the influence of age on clinical and biological features of systemic sclerosis.

METHODS

This retrospective study included 151 consecutive patients with systemic sclerosis. The median age at diagnosis was 50.0 years (range: 10-84 years). Patients were divided into two groups according to their age (lower than 50.0 years of age: 73 patients, equal to or above 50 years of age: 78 patients). The following features were compared between the two groups: gender, disease duration, extent of skin sclerosis, Crest syndrome, lung fibrosis, secondary Sjögren's syndrome, antinuclear, anticentromere, and anti-Scl70 antibodies.

RESULTS

The disease duration was significantly higher in patients over 50 years of age (7.1 +/- 6.8 years vs 5.5 +/- 5.0 years, P < 0.05). Crest syndrome, secondary Sjögren's syndrome and anticentromere antibodies were significantly more common in patients over 50 years of age (17/73 vs 30/78, P < 10(-2); 9/73 vs 20/78, P < 10(-2), and 19/73 vs 31/78, P < 0.05; respectively). Anti-Scl70 antibodies were significantly more common in patients under 50 years of age (17/73 vs 10/78, P < 10(-2)). No significant difference was found in regard to the other features.

CONCLUSION

The clinical and biological patterns of systemic sclerosis are different according to the age at disease onset. Crest syndrome including anticentromere antibodies and Sjögren's syndrome is more common in elderly patients, while anti- Scl-70 antibodies are more common in younger patients. This suggests the involvement of various mechanisms in the pathogenesis of systemic sclerosis, and that these mechanisms may depend on the age.

[Pulmonary involvement in systemic scleroderma. Part I. Chronic fibrosing interstitial lung disease]

INTRODUCTION

Chronic pulmonary interstitial fibrosis is the most frequent respiratory manifestation in systemic sclerosis, occurring in 80% of cases. It remains a severe complication of the disease and is the primary cause of mortality related to respiratory insufficiency in 20 to 60% of cases.

CURRENT KNOWLEDGE AND KEY POINTS

The date of onset of interstitial lung disease remains undetermined, and only in rare cases does it reveal the presence of systemic sclerosis. The clinical signs are only observable at a later stage, when at least 50% of the lung parenchyma is affected. The methods of choice adopted for early diagnosis of this disease are high resolution computed tomography and pulmonary functional investigations; they should be carried out during the preliminary investigation and at follow-up once a year. Moreover, high resolution computed tomography also provides prognostic data, for there is a correlation between the type of lesion and its severity as determined by high resolution computed tomography and by histological findings. The value of other methods of investigation, in particular bronchoalveolar lavage, has not yet been clearly established. The association of cyclophosphamide and corticoids is currently being evaluated (indications, administration modalities, duration), and this combination may be the most effective treatment.

FUTURE PROSPECTS AND PROJECTS

Interstitial lung disease is one of the major causes of morbidity and mortality in systemic sclerosis. Early diagnosis and management of this disease is therefore of utmost importance.