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Seelmann D, Poblete MP, Saavedra S, Madrid AM, von Muhlenbrock C, Estay C, Goecke A. Gastric dysrhythmias in patients with early systemic sclerosis: a cross-sectional study. Rheumatol Adv Pract 2024; 8:rkae041. [PMID: 38566833 PMCID: PMC10985681 DOI: 10.1093/rap/rkae041] [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: 11/28/2023] [Accepted: 03/03/2024] [Indexed: 04/04/2024] Open
Abstract
Objectives Gastric involvement in patients with early systemic sclerosis (SSc) has not been previously investigated. We aim to evaluate the association of gastric dysrhythmias with gastrointestinal (GI) symptoms and nailfold video capillaroscopy (NVC). Methods Cross-sectional study. Patients with early SSc, completed the UCLA GIT 2.0 questionnaire, performed an NVC, and a surface Electrogastrography (EGG). Descriptive statistics was used for demographic and clinical characteristics and Fisher and Kendall Tau tests were used for association analysis. Results 75 patients were screened, 30 patients were consecutively enrolled, 29 performed the EGG and 1 patient had a non-interpretable NVC. 29/30 were female with a mean age of 48.7 years (25-72). The mean disease duration from the first non-RP symptom was 22.6 +/-10.8 months and most of the patients had limited disease (76.6%). Total GIT 2.0 score symptoms were moderate-severe in 63% of the participants and 28/29 had an abnormal EGG. Bradygastria was the most common pattern present in 70% of the participants. NVC patterns: 17% early, 34% active, 28% scleroderma-like, 14% non-specific, and 2 patients had a normal NVC. There was no association between severe GI symptoms or NVC patterns and severely abnormal EGG, but the presence of bradygastria was associated with severe impairment in the social functioning area (p 0.018). Conclusions Gastric dysmotility is common in early SSc and there is a lack of correlation between GI symptoms and NVC scleroderma patterns. EGG is a sensitive, cheap, and non-invasive exam, that may be an alternative to early diagnosis of GI involvement.
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Affiliation(s)
- Daniela Seelmann
- Rheumatology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - María Paz Poblete
- Rheumatology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Silvana Saavedra
- Rheumatology Section, Medicine Department, Hospital Clínico de la Fuerza Aérea de Chile, Santiago, Chile
| | - Ana María Madrid
- Gastroenterology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Christian von Muhlenbrock
- Gastroenterology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
- Digestive Disease Center, Internal Medicine Department, Universidad de los Andes, Santiago, Chile
| | - Camila Estay
- Gastroenterology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Annelise Goecke
- Rheumatology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
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2
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Renaud A, Jirka A, Durant C, Connault J, Espitia O, Takoudju C, Agard C. [Gastrointestinal tract involvement in systemic sclerosis]. Rev Med Interne 2023; 44:410-422. [PMID: 37270380 DOI: 10.1016/j.revmed.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
Gastrointestinal tract involvement in systemic sclerosis concerns more than 90% of patients but is of heterogeneous clinical expression. It can involve the entire intestinal tract and be responsible for multifactorial malnutrition, which is frequent in this disease. It is a major source of deterioration in the quality of life and can even be life-threatening. Management is complex and multidisciplinary, ranging from simple hygienic and dietary measures, to specialized endoscopic or surgical interventional procedures, also including medical treatments, particularly proton pump inhibitors and prokinetics, with potential side effects. Ongoing research for new diagnostic and therapeutic tools promises to improve the management and prognosis of these patients.
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Affiliation(s)
- A Renaud
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France.
| | - A Jirka
- Service d'hépato-gastro-entérologie, Nantes université, CHU de Nantes, 44000 Nantes, France
| | - C Durant
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - J Connault
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - O Espitia
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - C Takoudju
- Service d'hépato-gastro-entérologie, Nantes université, CHU de Nantes, 44000 Nantes, France
| | - C Agard
- Service de médecine interne, Nantes université, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
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3
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McMahan ZH, Kulkarni S, Chen J, Chen JZ, Xavier RJ, Pasricha PJ, Khanna D. Systemic sclerosis gastrointestinal dysmotility: risk factors, pathophysiology, diagnosis and management. Nat Rev Rheumatol 2023; 19:166-181. [PMID: 36747090 DOI: 10.1038/s41584-022-00900-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
| | - Subhash Kulkarni
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joan Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Jiande Z Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Ramnik J Xavier
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - P Jay Pasricha
- Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Scleroderma Program, Ann Arbor, MI, USA.
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4
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Abstract
The upper gastrointestinal (GI) tract is frequently involved in systemic sclerosis (SSc) and may impact quality of life, physical function and survival. Although we are currently very proactive in terms of screening for heart and lung involvement, patients with SSc are not routinely screened for GI involvement. This review details the available investigations for common upper GI symptoms in SSc, including dysphagia, reflux and bloating and provides advice as to how to integrate these investigations into current clinical care.
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5
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Adler B, Hummers LK, Pasricha PJ, McMahan ZH. Gastroparesis in systemic sclerosis: a detailed analysis using whole-gut scintigraphy. Rheumatology (Oxford) 2022; 61:4503-4508. [PMID: 35136977 PMCID: PMC9629369 DOI: 10.1093/rheumatology/keac074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Gastroparesis is a common complication of SSc. We sought to determine the degree of overlap between gastroparesis and dysmotility in other areas of the gut, correlate our findings with gastrointestinal (GI) symptoms, and examine associations between gastroparesis and SSc features. METHODS Whole-gut scintigraphy was performed on SSc patients who were enrolled in the Johns Hopkins Scleroderma Cohort, for whom detailed longitudinal clinical and serologic data are collected. A subset of patients completed the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument 2.0 (UCLA GIT 2.0) to quantify their GI symptoms. We examined associations between the presence and severity of gastroparesis, GI symptoms, and SSc clinical features. RESULTS Ninety-seven SSc patients with and without GI symptoms underwent whole-gut scintigraphy and completed the gastric emptying study. Of the 97, 34 (35%) met criteria for gastroparesis. Of the measures assessed, delayed liquid emptying captured more patients with delayed gastric transit than delayed solid emptying (74% vs 55%), and percentage liquid emptying correlated best with GIT Reflux (ρ = -0.33, P = 0.01) and Distension (ρ = -0.30, P = 0.03) scores. Of 33 patients with gastroparesis, 30 (91%) had abnormal transit in other areas of the GI tract. Higher anti-centromere protein B (CENP-B) titres correlated with slower gastric emptying (ρ = -0.26, P = 0.03), but no specific clinical features of SSc were associated with gastroparesis. CONCLUSIONS Gastric emptying of liquids when given alongside solids may be more sensitive and provide a more clinically relevant measure of gastroparesis in SSc than solid gastric emptying or liquid gastric emptying alone. SSc patients with gastroparesis frequently have dysmotility in other areas of the GI tract, underscoring the need for whole-gut scintigraphy to evaluate the entire gut.
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Affiliation(s)
| | | | - P Jay Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
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6
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Gastrointestinal dysfunction in neuroinflammatory diseases: Multiple sclerosis, neuromyelitis optica, acute autonomic ganglionopathy and related conditions. Auton Neurosci 2021; 232:102795. [PMID: 33740560 DOI: 10.1016/j.autneu.2021.102795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/09/2021] [Accepted: 03/02/2021] [Indexed: 01/25/2023]
Abstract
Disorders of the nervous system can produce a variety of gastrointestinal (GI) dysfunctions. Among these, lesions in various brain structures can cause appetite loss (hypothalamus), decreased peristalsis (presumably the basal ganglia, pontine defecation center/Barrington's nucleus), decreased abdominal strain (presumably parabrachial nucleus/Kolliker-Fuse nucleus) and hiccupping and vomiting (area postrema/dorsal vagal complex). In addition, decreased peristalsis with/without loss of bowel sensation can be caused by lesions of the spinal long tracts and the intermediolateral nucleus or of the peripheral nerves and myenteric plexus. Recently, neural diseases of inflammatory etiology, particularly those affecting the PNS, are being recognized to contribute to GI dysfunction. Here, we review neuroinflammatory diseases that potentially cause GI dysfunction. Among such CNS diseases are multiple sclerosis, neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein associated disorder, and autoimmune encephalitis. Peripheral nervous system diseases impacting the gut include Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, acute sensory-autonomic neuropathy/acute motor-sensory-autonomic neuropathy, acute autonomic ganglionopathy, myasthenia gravis and acute autonomic neuropathy with paraneoplastic syndrome. Finally, collagen diseases, such as Sjogren syndrome and systemic sclerosis, and celiac disease affect both CNS and PNS. These neuro-associated GI dysfunctions may predate or present concurrently with brain, spinal cord or peripheral nerve dysfunction. Such patients may visit gastroenterologists or physicians first, before the neurological diagnosis is made. Therefore, awareness of these phenomena among general practitioners and collaboration between gastroenterologists and neurologists are highly recommended in order for their early diagnosis and optimal management, as well as for systematic documentation of their presentations and treatment.
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7
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Emmanuel A. Current management of the gastrointestinal complications of systemic sclerosis. Nat Rev Gastroenterol Hepatol 2016; 13:461-72. [PMID: 27381075 DOI: 10.1038/nrgastro.2016.99] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic sclerosis is a multisystem autoimmune disorder that involves the gastrointestinal tract in more than 90% of patients. This involvement can extend from the mouth to the anus, with the oesophagus and anorectum most frequently affected. Gut complications result in a plethora of presentations that impair oral intake and faecal continence and, consequently, have an adverse effect on patient quality of life, resulting in referral to gastroenterologists. The cornerstones of gastrointestinal symptom management are to optimize symptom relief and monitor for complications, in particular anaemia and malabsorption. Early intervention in patients who develop these complications is critical to minimize disease progression and improve prognosis. In the future, enhanced therapeutic strategies should be developed, based on an ever-improving understanding of the intestinal pathophysiology of systemic sclerosis. This Review describes the most commonly occurring clinical scenarios of gastrointestinal involvement in patients with systemic sclerosis as they present to the gastroenterologist, with recommendations for the suggested assessment protocol and therapy in each situation.
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Affiliation(s)
- Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, 235 Euston Road, London NW1 2BU, UK
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8
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Savarino E, Furnari M, de Bortoli N, Martinucci I, Bodini G, Ghio M, Savarino V. Gastrointestinal involvement in systemic sclerosis. Presse Med 2014; 43:e279-91. [PMID: 25179275 DOI: 10.1016/j.lpm.2014.03.029] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/18/2014] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis is an autoimmune chronic disease characterised by microvascular, muscular and immunologic abnormalities that lead to progressive and systemic deposition of connective tissue in the skin and internal organs. The gastrointestinal tract is often overlooked by physicians but it is the most affected organ after the skin, from the mouth to the anus. Indeed, 80% of SSc patients may present with gastrointestinal involvement. Gastrointestinal manifestations range from bloating and heartburn to dysphagia and anorectal dysfunction to severe weight loss and malabsorption. However, the gastrointestinal involvement is rarely the direct cause of death, but has great impact on quality of life and leads to several comorbidities that subsequently affect patients' survival. Treatments, including nutritional support and prokinetics provide limited benefits and do not arrest the progressive course of the disease, but earlier detection of gastrointestinal involvement may reduce the risk of complications such as malnutrition.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Irene Martinucci
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Giorgia Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Massimo Ghio
- Division of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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9
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Murakami H, Matsumoto H, Ueno D, Kawai A, Ensako T, Kaida Y, Abe T, Kubota H, Higashida M, Nakashima H, Oka Y, Okumura H, Tsuruta A, Nakamura M, Hirai T. Current status of multichannel electrogastrography and examples of its use. J Smooth Muscle Res 2014; 49:78-88. [PMID: 24662473 PMCID: PMC5137273 DOI: 10.1540/jsmr.49.78] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Electrogastrography (EGG) is a non-invasive diagnostic motility for recording gastric
myoelectrical activity. Gastric myoelectrical activity was first recorded in 1922.
Advances in recording equipment enabled widespread use of cutaneous EGG after 1985. Later,
introduction of multichannel EGG (M-EGG) enabled measurement of electrical activity
transmission. At present, M-EGG findings are used as objective indicators of gastric
motility disorders caused by various diseases. EGG measures two categories of gastric
electrical activity: electrical response activity, or spike potentials; and electrical
control activity, or slow waves. The appearance of abnormal rhythmic electrical activity
is indicative of abnormalities in gastric motility. The normal frequency range of gastric
electrical activity (normogastria) is around 3 cycles per min. Multiple EGG parameters
assist in the assessment of gastric myoelectrical activity, and significant correlations
between EGG and other gastric motility tests have been demonstrated in many studies. In
Japan, however, EGG remains in the exploratory stage, and its clinical use is limited.
There are large variations in procedures and systems used in previous studies, thus there
is a need for standardization of EGG procedures and technical terminology. Here, we
outline the current status of EGG and report the M-EGG procedures used in our department
in addition to our M-EGG findings. The abstract of this manuscript was presented
during an educational seminar titled "Current status of gastrointestinal motility tests
and keys for immediate implementation" at the 54th Annual Meeting of the Japan Society of
Smooth Muscle Research
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10
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Ariyasu H, Iwakura H, Yukawa N, Murayama T, Yokode M, Tada H, Yoshimura K, Teramukai S, Ito T, Shimizu A, Yonezawa A, Kangawa K, Mimori T, Akamizu T. Clinical effects of ghrelin on gastrointestinal involvement in patients with systemic sclerosis. Endocr J 2014; 61:735-42. [PMID: 24739333 DOI: 10.1507/endocrj.ej14-0088] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The majority of patients with systemic sclerosis (SSc) have gastrointestinal (GI) tract involvement, but therapies using prokinetic agents are usually unsatisfactory. Ghrelin stimulates gastric motility in healthy human volunteers. In this study, we investigated whether ghrelin could improve gastric emptying in patients with gastrointestinal symptoms due to SSc. The study was performed in a randomized, double-blind, placebo-controlled crossover fashion on two occasions. Ten SSc patients with GI tract involvement received an infusion of either ghrelin (5.0 μg/kg) or saline, and gastric emptying rate was evaluated by ¹³C-acetic acid breath test. Gastric emptying was significantly accelerated by ghrelin infusion in patients with SSc (ghrelin vs. saline: 43.3 ± 11.4 min vs. 53.4 ± 5.4 min, P=0.03). No serious adverse effects were observed. Our results suggest that ghrelin might represent a new therapeutic approach for GI tract involvement in patients with SSc.
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Affiliation(s)
- Hiroyuki Ariyasu
- Ghrelin Research Project, Translational Research Center, Kyoto University Hospital, Kyoto 606-8507, Japan
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11
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Abstract
Gastrointestinal involvement (GI) is increasingly recognized as a major cause of both morbidity and mortality in systemic sclerosis (SSc). GI complications are common, second only to skin involvement, and affect up to 90% of patients. Although treatment modalities have changed little for upper gut symptoms such as GI reflux, there are emerging treatment modalities for the common lower gut symptoms (constipation and fecal incontinence), which will be reviewed. The important link between reflux and interstitial lung disease in SSc is also addressed. The aim of this review is to help the clinician understand and manage GI symptoms in SSc.
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Affiliation(s)
- Shamaila Butt
- Gastrointestinal Physiology unit, University College Hospital, London, UK.
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12
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Noaiseh G, Li S, Derk CT. Management of gastrointestinal manifestations in systemic sclerosis (scleroderma). ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Marie I, Gourcerol G, Leroi AM, Ménard JF, Levesque H, Ducrotté P. Delayed gastric emptying determined using the 13C-octanoic acid breath test in patients with systemic sclerosis. ACTA ACUST UNITED AC 2012; 64:2346-55. [DOI: 10.1002/art.34374] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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14
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Schmeiser T, Saar P, Jin D, Noethe M, Müller A, Soydan N, Hardt PD, Jaeger C, Distler O, Roeb E, Bretzel RG, Müller-Ladner U. Profile of gastrointestinal involvement in patients with systemic sclerosis. Rheumatol Int 2011; 32:2471-8. [PMID: 21769490 DOI: 10.1007/s00296-011-1988-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 07/03/2011] [Indexed: 02/07/2023]
Abstract
Systemic sclerosis (SSc) is a chronic autoimmune connective tissue disease. Of the numerous organ manifestations, involvement of the upper and lower gastrointestinal tract (GIT) appears to be the most frequent with regard to the clinical symptoms. However, as the frequency and clinical relevance of GI involvement in patients with SSc are not known in detail, the German network of the systemic sclerosis (DNSS) has developed a detailed questionnaire to evaluate the extent and profile of gastrointestinal involvement in SSc patients. The multi-symptom questionnaire was used at baseline and after 1 year in registered patients of the DNSS. In addition, the results were compared with gastrointestinal disorders in patients with SSc and other rheumatic diseases, as well as with the medical history of the patients. In total, 90 patients were included in the study. The results of the study show that in reality, a much higher (nearly all) percentage of (98,9%) patients than expected suffer from GI-symptoms, regardless of the stage of their disease. Of these, meteorism (87,8%) was the most common followed by coughing/sore voice (77,8%), heartburn (daytime 68,9%, nighttime 53,3%), diarrhea (67,8%), stomach ache (68,9%) and nausea (61,1%). Although SSc patients were treated according to the respective recommendations, only limited improvements with regard to GI-symptoms could be achieved after 1 year of follow-up. In addition, the study revealed that the multi-symptom questionnaire is a useful tool to contribute to identify the gastrointestinal sequelae in systemic sclerosis.
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Affiliation(s)
- T Schmeiser
- Department of Rheumatology and Immunology, Kerckhoff-Clinic Bad Nauheim, Benekestr. 2- 8, 61231 Bad Nauheim, Germany.
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15
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Sallam HS, McNearney TA, Chen JZ. Anorectal motility and sensation abnormalities and its correlation with anorectal symptoms in patients with systemic sclerosis: a preliminary study. ISRN GASTROENTEROLOGY 2011; 2011:402583. [PMID: 21991506 PMCID: PMC3168395 DOI: 10.5402/2011/402583] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 04/19/2011] [Indexed: 11/23/2022]
Abstract
Gastrointestinal (GI) hypomotility and symptoms are common in Scleroderma (SSc) patients yet so far uncorrelated. Eight SSc patients and matched controls were queried about their GI dysmotility symptoms and quality of life (QoL) and underwent anorectal motility and sensory tests. Specific scoring systems were developed for anorectal symptoms and anorectal dysmotility. We found that (1) the SSc patients showed low QoL and marked overall GI symptoms. The most common anorectal symptom was incomplete bowel movement (50%). (2) Compared to normal controls, SSc patients showed impaired anorectal pressures, sensations, and rectal compliance (P ≤ .01
for each). (3) The anorectal motility/sensation abnormality score was robustly correlated with the total anorectal symptom score (rs = .78,
P = .02). In conclusion, scleroderma patients have impaired anorectal motor and sensory functions, and the abnormality score of these anorectal functions is correlated with the total anorectal symptoms score. These scoring systems may assist clinicians in predicting dysmotility based on patient symptoms.
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Affiliation(s)
- Hanaa S Sallam
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0655, USA
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16
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Cozzi F, Parisi G, Ciprian L, Bullo A, Cardarelli S, Rizzo M, Sfriso P, Punzi L. Gastric dysmotility after liquid bolus ingestion in systemic sclerosis: an ultrasonographic study. Rheumatol Int 2011; 32:1219-23. [PMID: 21258796 DOI: 10.1007/s00296-010-1779-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 12/30/2010] [Indexed: 01/15/2023]
Abstract
Gastric involvement appears quite commonly in systemic sclerosis (SSc). The aim of this study was to evaluate gastric wall motility using ultrasonography, a noninvasive method able to track both filling and emptying of fundus and antrum. The study was performed in 20 SSc patients and 20 healthy control subjects. Gastric filling and emptying were evaluated by transabdominal ultrasonography, measuring changes in fundus and antral areas over a 1-h period after ingestion of a liquid bolus (500 ml of mineral water). Areas of both gastric fundus and antrum at basal evaluation were found to be smaller in SSc patients than in healthy controls. Gastric filling was significantly reduced after ingestion of liquid bolus. Gastric emptying was delayed both in fundus and antrum. No significant differences of gastric wall motility have been observed in different subsets of SSc patients. Our findings show that gastric dysmotility is frequent and severe in SSc patients, contributing to the gastrointestinal disturbances which are very common in this disease.
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Affiliation(s)
- Franco Cozzi
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy.
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17
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Early endoscopy in systemic sclerosis without gastrointestinal symptoms. Rheumatol Int 2010; 32:165-8. [PMID: 20711592 DOI: 10.1007/s00296-010-1595-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 07/28/2010] [Indexed: 12/18/2022]
Abstract
Investigation into the upper GI-tract of patients suffering from systemic sclerosis [SSc] and mixed connective tissue disease [MCTD] without symptoms of GI-tract involvement early in the course of the disease to diagnose inflammatory and motility disorders. We retrospectively analysed patients with SSc and MCTD who underwent oesophago-gastro-duodenoscopy [OGD] within a year of the first diagnosis. Patients with a Rodnan skin score above 5, proton pump inhibitors and treatment regimes potentially harmful to the mucosa of the upper GI-tract were excluded. Mucosal damage of the oesophagus was classified according to the Los Angeles Classification. Oesophageal dysmotility was assessed during OGD and confirmed by video cineradiography. A total of thirteen patients with SSc and six with MCTD fulfilled the inclusion criteria. OGD revealed reflux-oesophagitis in 77%, dysmotility of the distal oesophagus in 85%, gastritis in 92% [31% erosive gastritis] and Helicobacter pylori positivity in 38% of our patients suffering from SSc. Patients with MCTD showed features of reflux-oesophagitis, dysmotility of the distal oesophagus, gastritis and dysmotility of the stomach in 0.6%. In all thirteen patients with SSc, significant pathology of the upper GI-tract was found. The results of this study might indicate that OGD should be performed early in patients diagnosed with SSc, even if they do not report typical symptoms. An early diagnose of GI involvement might be followed by an effective therapy and therefore subsequently may improve the prognosis.
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MCNEARNEY TA, SALLAM HS, HUNNICUTT SE, DOSHI D, WOLLASTON DE, MAYES MD, CHEN JDZ. Gastric slow waves, gastrointestinal symptoms and peptides in systemic sclerosis patients. Neurogastroenterol Motil 2009; 21:1269-e120. [PMID: 19566588 PMCID: PMC3176740 DOI: 10.1111/j.1365-2982.2009.01350.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Impaired gastric slow waves, frequent gastrointestinal (GI) symptoms and altered GI peptides have been reported in Scleroderma (SSc) patients. The aim of this study was to investigate the associations among these three important components in GI dysmotility. Seventeen fasted SSc patients underwent four channel surface electrogastrography, measuring % of normal gastric slow waves or dysrhythmia. Patients completed a questionnaire designed by us to assess demographics, upper and lower GI symptoms (symptom presence, frequency and impact on quality of life, QOL), by YES/NO, Likert Scales and Visual Analogue Scales 1-100 mm (called GI Dysmotility Questionnaire, GIDQ) and health-related QOL by SF-36. Fasting plasma vasoactive intestinal peptide (VIP) and motilin levels were measured by peptide immunoassays. There were significant correlations between percentages of gastric dysrhythmias (bradygastria or arrhythmia) and a number of major GI symptoms such as nausea, abdominal bloating and pain. The plasma level of VIP was correlated positively with % dysrhythmia but negatively with % normal slow waves. Motilin was positively correlated with slow wave coupling (coordination). No major differences were noted in the measured peptides or gastric slow waves between limited SSc and diffuse SSc. Correlations were noted between SF-36 domain scores and our GIDQ scores. In SSc patients, gastric dysrhythmias are correlated with certain GI symptoms. Correlations are also noted between plasma VIP/Motilin levels and gastric slow waves. Thus in SSc, gastric dysrhythmias may be predictive of development of certain dyspeptic symptoms. Plasma VIP may be involved in the development of dysrhythmias.
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Affiliation(s)
- T. A. MCNEARNEY
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, USA, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA, Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - H. S. SALLAM
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - S. E. HUNNICUTT
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - D. DOSHI
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - D. E. WOLLASTON
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - M. D. MAYES
- Department of Internal Medicine, Division of Rheumatology and Immunogenetics, University of Texas Houston Health Science Center, Houston, TX, USA
| | - J. D. Z. CHEN
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Forbes A, Marie I. Gastrointestinal complications: the most frequent internal complications of systemic sclerosis. Rheumatology (Oxford) 2009; 48 Suppl 3:iii36-9. [PMID: 19487222 DOI: 10.1093/rheumatology/ken485] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Manifestations of SSc in the gastrointestinal (GI) tract are common, occurring in 50-90% of patients. They typically result from the fibrosis that characterizes this disease. Manifestations of SSc can affect many sites within the GI tract, and patients may experience substantial dysfunction in the processes of motility, digestion, absorption and excretion. Oesophageal dysfunction is the most common GI manifestation, but patients may also experience dysfunction of the stomach, small intestine, colon and rectum, each of which can be responsible for severe and distressing symptoms. At present, few specific therapeutic options are available for the treatment of these patients, but relief of symptoms is often possible with appropriate knowledge and support. It is therefore particularly important to identify, monitor and manage these patients carefully, with a view to minimizing further degeneration and maximizing quality of life.
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Affiliation(s)
- A Forbes
- Department of Gastroenterology and Nutrition, University College Hospital, London, UK.
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20
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Domsic R, Fasanella K, Bielefeldt K. Gastrointestinal manifestations of systemic sclerosis. Dig Dis Sci 2008; 53:1163-74. [PMID: 17934861 DOI: 10.1007/s10620-007-0018-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 09/07/2007] [Indexed: 12/12/2022]
Abstract
Systemic sclerosis is a chronic disorder of connective tissue that affects the gastrointestinal tract in more than 80% of patients. Changes in neuromuscular function with progressive fibrosis of smooth muscle within the muscularis propria impair normal motor function, which may secondarily alter transit and nutrient absorption. Esophageal manifestations with gastroesophageal reflux and dysphagia are the most common visceral manifestation of the disease, often requiring more intense acid-suppressive medication. Gastric involvement may lead to gastroparesis, which can be found in up to 50% of patients. Severe small bowel disease can present as chronic intestinal pseudo-obstruction with distended loops of small intestine, bacterial overgrowth, impaired absorption and progressive development of nutritional deficiencies. While not studied as extensively, systemic sclerosis often also affects colorectal function resulting in constipation, diarrhea or fecal incontinence. Nutritional support and prokinetics have been used with some success to manage gastric and small or large bowel involvement in patients with systemic sclerosis. Despite advances in management, significant gastrointestinal manifestations of systemic sclerosis still carry a poor prognosis with a five-year mortality exceeding 50%.
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Affiliation(s)
- Robyn Domsic
- Division of Rheumatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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21
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Di Ciaula A, Covelli M, Berardino M, Wang DQH, Lapadula G, Palasciano G, Portincasa P. Gastrointestinal symptoms and motility disorders in patients with systemic scleroderma. BMC Gastroenterol 2008; 8:7. [PMID: 18304354 PMCID: PMC2276219 DOI: 10.1186/1471-230x-8-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Accepted: 02/27/2008] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
| | - Michele Covelli
- Department of Internal and Public Medicine (DIMIMP) University Medical School of Bari, Section of Rheumatology, Bari, Italy
| | - Massimo Berardino
- Department of Internal and Public Medicine (DIMIMP) University Medical School of Bari, Section of Internal Medicine, Bari, Italy
| | - David QH Wang
- Department of Medicine, Liver Center and Gastroenterology Division, Beth Israel Deaconess Medical Center, Harvard Medical School and Harvard Digestive Diseases Center, Boston, Massachusetts, USA
| | - Giovanni Lapadula
- Department of Internal and Public Medicine (DIMIMP) University Medical School of Bari, Section of Rheumatology, Bari, Italy
| | - Giuseppe Palasciano
- Department of Internal and Public Medicine (DIMIMP) University Medical School of Bari, Section of Internal Medicine, Bari, Italy
| | - Piero Portincasa
- Department of Internal and Public Medicine (DIMIMP) University Medical School of Bari, Section of Internal Medicine, Bari, Italy
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22
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Saar P, Schmeiser T, Tarner IH, Müller-Ladner U. [Gastrointestinal involvement in systemic sclerosis. An underestimated complication]. Hautarzt 2008; 58:844-50. [PMID: 17726594 DOI: 10.1007/s00105-007-1380-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Systemic sclerosis (SSc) belongs to the family of autoimmune connective tissue diseases and is still a challenge to every practicing physician. The disorder is characterized by progressing fibrosis of the skin and internal organs, abnormal activation of the immune system, and distinct changes in microcirculation. Although it is rare--with a prevalence of about 20:100000--patients need to be cared for in a daily setting. In general thickening of the skin is the first sign of the disease, so dermatologists are most frequently consulted first. Two subtypes exist, limited and diffuse forms. Both entities usually involve internal organs, and therefore interdisciplinary cooperation is mandatory. The increased morbidity and mortality depend predominantly on the grade of involvement of the affected organs. Therefore it is essential to diagnose systemic sclerosis early and to identify and monitor all complications closely. In this respect gastrointestinal involvement is frequently neglected, owing to its primarily non-life-threatening character, resulting in substantially delayed therapy.
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Affiliation(s)
- P Saar
- Abt. für Rheumatologie und klinische Immunologie, Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie der Justus-Liebig-Universität Giessen, Kerckhoff-KlinikBad Nauheim, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.
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23
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Abstract
Progressive systemic sclerosis (PSS) is a chronic multisystem disease characterized by excess deposition of connective tissue in skin and internal organs, associated with microvasculature changes and immunologic abnormalities. Involvement of the gastrointestinal tract may occur in 2 stages, a neuropathic disorder followed by a myopathy. Gastric emptying is delayed in 10% to 75% of patients and correlates with symptoms of early satiety, bloating, and emesis. Compliance of the fundus is increased although perception of fullness is normal. Myoelectric abnormalities have been found in some studies. Treatments include metoclopramide, cisapride, and erythromycin. Bleeding from telangiectasias and watermelon stomach is treated endoscopically. Small bowel involvement in PSS occurs in 17% to 57% of patients. The migrating motor complexes are reduced or absent, predisposing to bacterial overgrowth. Malabsorption may also be due to pancreatic insufficiency. Barium enemas demonstrate pancolonic involvement in 10% to 50% of patients with PSS. Wide-mouthed diverticuli, involving all layers of the intestinal wall, are characteristic. Pseudoobstruction may respond to octreotide or prucalopride therapy. Complications include pneumatosis cystoides intestinalis, stercoral ulcerations, and perforation. Fecal incontinence may be due to dysfunction of the internal anal sphincter, a smooth muscle responsible for most of the resting anal sphincter pressure. Anal manometry may show a reduction or loss of the rectoanal inhibitory reflex. Treatments include biofeedback, sacral nerve stimulation, and surgery. PSS involves the gastrointestinal tract from the mouth to the anus. Studies are needed to define effective treatments in these diseases, which cause great morbidity.
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24
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Abid S, Lindberg G. Electrogastrography: Poor correlation with antro-duodenal manometry and doubtful clinical usefulness in adults. World J Gastroenterol 2007; 13:5101-7. [PMID: 17876876 PMCID: PMC4434640 DOI: 10.3748/wjg.v13.i38.5101] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To investigate if there is a correlation between electrical activity measured by electrogastrography (EGG) and contractile activity of the stomach as measured by antroduodenal manometry (ADM). We also studied whether the underlying motility disorder could be predicted from EGG parameters.
METHODS: We compared 21 parameters measured from EGG with 8 parameters measured from ADM. The ability of EGG to identify the underlying diagnosis was tested by comparing EGG parameters for each diagnosis group against other patients. The study comprised recordings from 148 patients and 125 females. Their median age was 45 (range 17-76) years.
RESULTS: We found few and weak correlations between EGG and ADM. Specifically the correlation between parameters reflecting the response to meal was poor (r = -0.07, P = 0.39). The discriminatory power of EGG for underlying motility disorder was also low. Patients with slow transit constipation (STC) showed a lower postprandial power in normogastric (3.7 ± 0.5 vs 4.0 ± 0.5) and tachygastric (3.5 ± 0.4 vs 3.7 ± 0.4) regions, a lower percentage of time with normogastria [87.2 (56.5-100)% vs 95.7 (0-100)%], and a higher percentage of time with tachygastria [9.3 (0-33)% vs 3.5 (0-100)%] and bradygastria [1.8 (0-20)% vs 0 (0-17.1)%]. Patients with irritable bowel syndrome had a higher percentage of time with normogastria [96.5 (62.5-100)% vs 93.3 (0-100)%] and a less unstable dominant frequency as measured by the instability coefficient [15 (3-77) vs 24 (2-72)].
CONCLUSION: EGG and ADM seem to measure different aspects of gastric motor activity but cannot show a spatial correlation. The diagnostic value of EGG is poor, but EGG may have some value for the identification of patients with STC.
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Affiliation(s)
- Shahab Abid
- Karolinska Institutet, Department of Medicine, Division of Gastroenterology and Hepatology, Karolinska University Hospital, Huddinge, Stockholm 14186, Sweden
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25
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Sallam H, McNearney TA, Doshi D, Chen JDZ. Transcutaneous electrical nerve stimulation (TENS) improves upper GI symptoms and balances the sympathovagal activity in scleroderma patients. Dig Dis Sci 2007; 52:1329-37. [PMID: 17372833 DOI: 10.1007/s10620-006-9257-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Accepted: 02/13/2006] [Indexed: 12/09/2022]
Abstract
To assess the impact of transcutaneous electrical nerve stimulation (TENS) at gastrointestinal (GI) acupoints on GI symptoms and quality of life in scleroderma patients, 17 patients filled out SF-36 and GI symptom questionnaires before the electrocardiogram was recorded for two intervals: baseline and TENS. At home, patients applied TENS for 14 days, then were reassessed. Acutely, TENS application significantly increased sympathetic and vagal activities vs. baseline (P=0.02 and P=0.004), respectively. Prolonged TENS application normalized the sympathovagal balance (P=0.04), decreased GI symptom scores (P=0.02) and increased the physical functioning score (SF36), which strongly correlated with the change in the sympathovagal balance (r=0.6, P=0.02). In conclusion, TENS at GI acupoints offers a potential option in the treatment of upper GI symptoms, but further study is necessary.
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Affiliation(s)
- Hanaa Sallam
- Division of Gastroenterology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas 77555, USA
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26
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Misra R, Singh G, Aggarwal P, Aggarwal A. Juvenile onset systemic sclerosis: a single center experience of 23 cases from Asia. Clin Rheumatol 2006; 26:1259-62. [PMID: 17180299 DOI: 10.1007/s10067-006-0483-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 11/03/2006] [Accepted: 11/06/2006] [Indexed: 11/29/2022]
Abstract
The aim of this paper was to study the spectrum of juvenile scleroderma (JSSc) seen at a tertiary care referral center in Asia. Retrospective analysis of case records of patients with systemic sclerosis, having age of onset less than 16 years and seen at our hospital from 1988 to 2004, was done. Patients with linear scleroderma and morphea were excluded. There were 23 patients (19 girls, 4 boys) with median age of onset of 12 years (range 5-16 years). The median age at presentation was 17 years (range 10-34 years). The median time from first symptoms to presentation was 4 years (range 0.2-26 years). Among these, 14 had diffuse systemic sclerosis (DSSc), while 9 had limited scleroderma (LSSc). The clinical features seen at presentation in patients were: Raynaud's phenomenon in 19, digital ulcers in 14, loss of finger tip pulp in 12, reflux in 8, dysphagia in 7, arthritis in 8, digital gangrene in 2, and pulmonary artery hypertension in 1. Antinuclear antibody was positive in 15 out of 18 patients tested. Interstitial lung disease was seen in 15 patients, 6 of whom had diffuse disease. The median skin score was 22 (range 7-48) . One patient died of primary pulmonary hypertension within 1 year of onset of symptoms. At a mean follow-up of 34 months, 14 patients were stable or had improvement in skin score or dyspnea on exertion. DSSc and LSSc in childhood have a clinical presentation similar to adult patients, with cardiopulmonary involvement being the major predictor of outcome. The short-term prognosis of JSSc is good.
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Affiliation(s)
- Ramnath Misra
- Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
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27
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Szamosi S, Szekanecz Z, Szucs G. Gastrointestinal manifestations in Hungarian scleroderma patients. Rheumatol Int 2006; 26:1120-4. [PMID: 16770615 DOI: 10.1007/s00296-006-0146-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2005] [Accepted: 05/06/2006] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Szilvia Szamosi
- Division of Rheumatology, Third Department of Medicine, Institute for Medicine, Medical and Health Science Center, University of Debrecen, 22 Móricz street, Debrecen 4004, Hungary.
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28
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Sallam H, McNearney TA, Chen JDZ. Systematic review: pathophysiology and management of gastrointestinal dysmotility in systemic sclerosis (scleroderma). Aliment Pharmacol Ther 2006; 23:691-712. [PMID: 16556171 DOI: 10.1111/j.1365-2036.2006.02804.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastrointestinal dysmotility in systemic sclerosis (scleroderma) is prevalent in 90% of patients, increasing morbidity and in some cases mortality. The resultant gastrointestinal complications are usually extensive, involving many regions of the gut from the oesophagus to the anus. Collagen replacement of vascular and enteric smooth muscle results in hypomotility, lumen dilatation, tensile rigidity and eventual loss of organ functions. The aim of this paper is to provide an overview of systemic sclerosis-related gastrointestinal dysmotility and available/potential therapeutic options. We evaluated published data on the pathophysiology and management of gastrointestinal dysmotility in systemic sclerosis patients using the MEDLINE database for English and non-English articles from 1966 to July 2005. Based on this systematic review, lifestyle and medical therapy approaches are preferred as they often improve and/or ameliorate symptoms. Surgery is only recommended with serious, rare complications such as bowel perforation or ischaemia. Alternative therapies such as acupuncture-based therapies are well tolerated, with clinical improvement and may be of potential therapeutic benefit for systemic sclerosis gastrointestinal dysmotility. Further elucidation of initiating and persistent mechanisms of systemic sclerosis-related gastrointestinal dysmotility will optimize the development of a multidisciplinary and more directed treatment regimen.
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Affiliation(s)
- H Sallam
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-0632, USA
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29
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Abstract
PURPOSE OF REVIEW Abnormalities of gastric sensory and motor function are considered key players in the pathogenesis of upper gastrointestinal symptoms in functional dyspepsia and in gastroparesis. This review summarizes recent progress in our understanding of normal and pathologic gastric sensory and motor function. RECENT FINDINGS Several novel tests have been developed to study gastric sensitivity and meal-induced accommodation, including scintigraphic analysis of meal distribution within the stomach, single photon emission computed tomography of gastric volumes, and nutrient or water challenge tests. Several studies have reported on the occurrence of delayed gastric emptying in functional dyspepsia and in gastroparesis, but the correlation with symptoms was generally poor. The pathways and neurotransmitter involved in gastric hypersensitivity are progressively being unraveled. Several studies have confirmed and focused on increased symptom occurrence after nutrient challenge in functional dyspepsia. The role of the proximal stomach in the control of food intake and the stomach as a target in the treatment of obesity are areas of intense research. Studies have reported on pharmacologic approaches as well as electric stimulation in the treatment of gastric sensorimotor dysfunction. SUMMARY Progress in our understanding of normal and abnormal gastric sensory and motor function may lead to new or improved treatment modalities. Areas of major advances are the study of meal-induced symptoms in functional dyspepsia, unraveling of the role of the stomach in the control of food intake, and the use of gastric electric stimulation in gastroparesis and in obesity.
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Affiliation(s)
- Jan Tack
- University Hospital Gasthuisberg, University of Leuven, Belgium.
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