Gastrointestinal transit in patients with systemic sclerosis

Small Intestinal Bacterial Overgrowth (SIBO) and Twelve Groups of Related Diseases-Current State of Knowledge

The human gut microbiota creates a complex microbial ecosystem, characterized by its high population density, wide diversity, and complex interactions. Any imbalance of the intestinal microbiome, whether qualitative or quantitative, may have serious consequences for human health, including small intestinal bacterial overgrowth (SIBO). SIBO is defined as an increase in the number of bacteria (103-105 CFU/mL), an alteration in the bacterial composition, or both in the small intestine. The PubMed, Science Direct, Web of Science, EMBASE, and Medline databases were searched for studies on SIBO and related diseases. These diseases were divided into 12 groups: (1) gastrointestinal disorders; (2) autoimmune disease; (3) cardiovascular system disease; (4) metabolic disease; (5) endocrine disorders; (6) nephrological disorders; (7) dermatological diseases; (8) neurological diseases (9); developmental disorders; (10) mental disorders; (11) genetic diseases; and (12) gastrointestinal cancer. The purpose of this comprehensive review is to present the current state of knowledge on the relationships between SIBO and these 12 disease groups, taking into account risk factors and the causal context. This review fills the evidence gap on SIBO and presents a biological-medical approach to the problem, clearly showing the groups and diseases having a proven relationship with SIBO, as well as indicating groups within which research should continue to be expanded.

Gastrointestinal Tract Considerations Part I

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.

Show Me What You Have Inside-The Complex Interplay between SIBO and Multiple Medical Conditions-A Systematic Review

The microbiota, as a complex of microorganisms in a particular ecosystem, is part of the wider term-microbiome, which is defined as the set of all genetic content in the microbial community. Imbalanced gut microbiota has a great impact on the homeostasis of the organism. Dysbiosis, as a disturbance in bacterial balance, might trigger or exacerbate the course of different pathologies. Small intestinal bacterial overgrowth (SIBO) is a disorder characterized by differences in quantity, quality, and location of the small intestine microbiota. SIBO underlies symptoms associated with functional gastrointestinal disorders (FGD) as well as may alter the presentation of chronic diseases such as heart failure, diabetes, etc. In recent years there has been growing interest in the influence of SIBO and its impact on the whole human body as well as individual systems. Therefore, we aimed to investigate the co-existence of SIBO with different medical conditions. The PubMed database was searched up to July 2022 and we found 580 original studies; inclusion and exclusion criteria let us identify 112 eligible articles, which are quoted in this paper. The present SIBO diagnostic methods could be divided into two groups-invasive, the gold standard-small intestine aspirate culture, and non-invasive, breath tests (BT). Over the years scientists have explored SIBO and its associations with other diseases. Its role has been confirmed not only in gastroenterology but also in cardiology, endocrinology, neurology, rheumatology, and nephrology. Antibiotic therapy could reduce SIBO occurrence resulting not only in the relief of FGD symptoms but also manifestations of comorbid diseases. Although more research is needed, the link between SIBO and other diseases is an important pathway for scientists to follow.

Gastric Emptying Time and Volume of the Small Intestine as Objective Markers in Patients With Symptoms of Diabetic Enteropathy

Background/Aims

Patients with diabetes mellitus (DM) often suffer from gastrointestinal (GI) symptoms, but these correlate poorly to established objective GI motility measures. Our aim is to perform a detailed evaluation of potential measures of gastric and small intestinal motility in patients with DM type 1 and severe GI symptoms.

Methods

Twenty patients with DM and 20 healthy controls (HCs) were included. GI motility was examined with a 3-dimensional-Transit capsule, while organ volumes were determined by CT scans.

Results

Patients with DM and HCs did not differ with regard to median gastric contraction frequency (DM 3.0 contractions/minute [interquartile range {IQR}, 2.9-3.0]; HCs 2.9 [IQR, 2.8-3.1]; P = 0.725), amplitude of gastric contractions (DM 9 mm [IQR, 8-11]; HCs 11 mm (IQR, 9-12); P = 0.151) or fasting volume of the stomach wall (DM 149 cm3 [IQR, 112-187]; HCs 132 cm3 [IQR, 107-154]; P = 0.121). Median gastric emptying time was prolonged in patients (DM 3.3 hours [IQR, 2.6-4.6]; HCs 2.4 hours [IQR, 1.8-2.7]; P = 0.002). No difference was found in small intestinal transit time (DM 5 hours [IQR, 3.7-5.6]; HCs 4.8 hours [IQR, 3.9-6.0]; P = 0.883). However, patients with DM had significantly larger volume of the small intestinal wall (DM 623 cm3 [IQR, 487-766]; HCs 478 cm3 [IQR, 393-589]; P = 0.003). Among patients, 13 (68%) had small intestinal wall volume and 9 (50%) had gastric emptying time above the upper 95% percentile of HCs.

Conclusion

In our study, gastric emptying time and volume of the small intestinal wall appeared to be the best objective measures in patients with DM type 1 and symptoms and gastroenteropathy.

Digestive Dysbiosis in Systemic Scleroderma: a Review

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by widespread microvasculopathy, inflammation, and fibrosis of the skin and internal organs. The involvement of the gastrointestinal tract is associated with a wide variety of symptoms and affects circa 90% of patients during the course of the disease. The gastrointestinal microbiota contains trillions of microbial cells and has been found to contribute to both local and systemic homeostasis. In both health and disease, a dynamic interrelationship between gut microbiome activity and the host immune system has been identified. Gastrointestinal dysbiosis has been described as having an important role in obesity, diabetes mellitus, liver disease, cardiovascular and neuropsychiatric disorders, neoplasia, as well as autoimmunity. Recent scientific data indicates a notable role of dysbiosis in the pathogenesis of SSc-related digestive involvement together with various other clinical manifestations. The present review aims to summarize the recent findings regarding digestive dysbiosis as well as the relationship between gastrointestinal microbiota and certain features of SSc.

Systemic manifestations - do not forget the small bowel

PURPOSE OF REVIEW

Systemic diseases can afflict the small bowel (SB) but be challenging to diagnose. In this review, we aim to provide a broad overview of these conditions and to summarise their management.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is an important modality to investigate pathology in the SB. SB imaging can be complementary to SBCE for mural and extramural involvement and detection of multiorgan involvement or lymphadenopathy. Device assisted enteroscopy provides a therapeutic arm, to SBCE enabling histology and therapeutics to be carried out.

SUMMARY

SB endoscopy is essential in the diagnosis, management and monitoring of these multi-system conditions. Collaboration across SB centres to combine experience will help to improve the management of some of these rarer SB conditions.

Prevalence and predictors of small intestinal bacterial overgrowth in systemic sclerosis: a systematic review and meta-analysis

The reported prevalence of small intestinal bacterial overgrowth (SIBO) among patients with systemic sclerosis (SSc) is highly variable. We conducted this systematic review and meta-analysis to estimate the prevalence and identify predictors of SIBO in SSc by summarizing all of the available data. A comprehensive literature search of the PubMed, Cochrane Library, and EMBASE databases from inception to July 2020 was conducted for studies correlating SIBO with SSc. Studies were screened, and relevant data were extracted and analyzed. The pooled prevalence of SIBO among SSc patients and the odds ratio (OR) of SIBO among SSc patients compared with healthy controls were calculated. Furthermore, predictors of SIBO in SSc were evaluated. Fourteen studies containing 700 SSc patients and 217 healthy controls met the inclusion criteria. The pooled prevalence of SIBO in SSc was 34% (95% CI 27-42%). The OR of SIBO in SSc patients was 12.51 (95% CI 6.51-24.03) compared with the healthy controls. Subgroup analyses showed that the prevalence of SIBO in SSc was higher in studies using the lactulose hydrogen breath test (LHBT) for diagnosis (56%, 95% CI 46-67%) compared with those that used the glucose hydrogen breath test (GHBT) (27%, 95%CI 20-35%) and a jejunal aspirated culture (JAC) (35%, 95%CI 25-51%). The prevalence of SIBO in SSc was higher in studies conducted in Western countries (38%, 95% CI 31-47%) than those conducted in Asian countries (15%, 95%CI 10-23%), and the prevalence of SIBO in the SSc population defined by ACR-EULAR 2013 (50%, 95% CI 0.21-0.79) was higher than the prevalence defined by ACR 1980 (30%, 95% CI 0.17-0.42) or other criteria (32%, 95% CI 0.16-0.48) Moreover, the risk of diarrhea was higher in SSc patients with SIBO than those without SIBO (OR 8.82, 95% CI 4.09-19, P < 0.00001); gender, SSc subset, digital ulcer, and pulmonary fibrosis do not seem to be associated with SIBO in SSc. Antibiotic therapy seems to be effective with SIBO in SSc patients. Approximately one-third of SSc patients tested positive for SIBO with a significantly increased risk over the controls. The prevalence of SIBO in SSc varied according to the SIBO diagnostic test performed, geographic area, and SSc diagnostic criteria. The presence of diarrhea may be a predictor of SIBO in SSc. Antibiotic treatment can lead to eradication of SIBO and gastrointestinal symptomatic improvement in SSc patients. Key Points • The pooled prevalence of SIBO in SSc patients was 34%, which varied according to the SIBO diagnostic test performed, geographic area and SSc diagnostic criteria. • The risk of SIBO in SSc was increased by nearly thirteenfold compared to the healthy controls. • Diarrhoea, but not gender, SSc subset, digital ulcer and pulmonary fibrosis, was associated with SIBO in SSc patients. • For SSc patients with SIBO, antibiotic treatment can lead to eradication of SIBO and gastrointestinal symptomatic improvement.

Colonic motility in patients with type 1 diabetes and gastrointestinal symptoms

BACKGROUND

Gastrointestinal (GI) symptoms are common in patients with diabetes mellitus (DM). The electromagnetic 3D-Transit system allows assessment of regional transit times and motility patterns throughout the GI tract. We aimed to compare GI transit times and detailed motility patterns of the colon in patients with DM and GI symptoms to those of healthy controls (HC). We further aimed to determine whether any abnormalities in motility were reversible by cholinergic stimulation.

METHODS

We compared 18 patients with DM with 20 HC by means of the 3D-Transit system. Patients were studied before and during oral administration of 60 mg pyridostigmine.

KEY RESULTS

Compared to HC, patients had prolonged gastric emptying (DM: 3.3 hours (interquartile range (IQR) 2.6-4.6); HC: 2.3 hours (IQR 1.7-2.7) (P < .01)), colonic transit time (DM: 52.6 hours (IQR 23.3-83.0); HC: 22.4 hours (IQR 18.9-43.6) (P = .02)), and whole gut transit time (DM: 69.4 hours (IQR 32.9-103.6); HC: 30.3 hours (IQR 25.2-49.9) (P < .01)). In addition, compared to HC, patients had prolonged transit time in the ascending colon (DM: 20.5 hours (IQR 11.0-44.0); HC: 8.0 hours (IQR 3.8-21.0) (P < .05)) and more slow retrograde movements in the colon (DM: 2 movements (IQR 1-4); HC: 1 movement (IQR 0-1) (P = .01)). In patients, pyridostigmine increased the number of bowel movements (P < .01) and reduced small intestine transit times (P < .05).

CONCLUSIONS

Patients with DM and GI symptoms have longer than normal GI transit times. This is only partly reversible by pyridostigmine. The increased number of retrograde colonic movements in patients could potentially explain the abnormally long transit time in proximal colon.

Comparing Clinical, Imaging, and Physiological Correlates of Intestinal Pseudo-Obstruction: Systemic Sclerosis vs Amyloidosis and Paraneoplastic Syndrome

INTRODUCTION

Intestinal pseudo-obstruction is characterized by impaired transit and luminal dilation in the absence of mechanical obstruction. Our study aims to describe the clinical, radiographic, and physiological findings in pseudo-obstruction associated with systemic sclerosis (SSc), amyloidosis, and paraneoplastic syndrome.

METHODS

A retrospective cohort of patients evaluated at our institution between January 1, 2008, and August 1, 2018, was assembled. Clinical, imaging, and physiological characteristics were abstracted from electronic medical records.

RESULTS

We identified 100 cases of pseudo-obstruction (55 SSc, 27 amyloidosis, and 18 paraneoplastic). Female population predominance was seen in SSc (71%) vs male population in amyloidosis (74%). Most common symptom was abdominal bloating in all 3 groups. Vomiting was more common in SSc than amyloidosis (73% vs 46%, P = 0.02). Diarrhea was more common in amyloidosis and SSc compared with paraneoplastic (81% and 67% vs 28%, P < 0.01). Weight loss (>5%) was more common in SSc compared with amyloidosis and paraneoplastic (78% vs 31% and 17%, P < 0.0001). Only small bowel dilation was seen in 79%, 40%, and 44% and only large bowel dilation in 2%, 44%, and 44% of patients in SSc, amyloidosis, and paraneoplastic, respectively. Five of 8 SSc patients had myopathic and 3 of 5 paraneoplastic had neuropathic involvement on gastroduodenal manometry.

DISCUSSION

SSc-associated pseudo-obstruction demonstrates female population predominance and presents with vomiting, diarrhea, and weight loss. Amyloidosis-associated pseudo-obstruction shows male population predominance. Small bowel is more commonly involved than large bowel on both imaging and transit studies in SSc. Myopathic involvement was more common in SSc, contrary to neuropathic in paraneoplastic syndrome.

Small intestinal bacterial overgrowth in systemic sclerosis: a review of the literature

Systemic sclerosis (SSc) is a chronic, connective tissue disease with an autoimmune pattern characterized by inflammation, fibrosis and microcirculation changes leading to internal organs malfunctions. Recently, the presence of uncharacteristic gastrointestinal symptoms in the course of SSc has been underlined. The possible cause of such clinical presentation is the small intestinal bacterial overgrowth (SIBO). Nevertheless, these manifestations resulting from gastrointestinal tract hypomotility may occur in numerous disease entities. The systematic review of the literature was performed on MEDLINE database using the relevant MeSH terms including all sub-headings. After further investigation, the initial number of 56 records was limited to 7 results. The study analysis showed an increased presence of SIBO in 39% of patients suffering from SSc. The average SSc duration was longer in SSc patients with coexisting SIBO. SIBO remains a diagnostic and therapeutic challenge and therefore is a significant clinical problem among patients suffering from SSc.

Gastrointestinal and Hepatic Disease in Systemic Sclerosis

Although classification criteria for systemic sclerosis (SSc) do not incorporate gastrointestinal tract (GIT) manifestations often present in this disease, the GIT is the most common internal organ involved. Pathophysiology of GIT involvement is thought to be similar to other organs in SSc with fibroproliferative vascular lesions of small arteries and arterioles, increased production of profibrotic growth factors, and alterations of innate, humoral, and cellular immunity. These processes result in neuropathy progressing to myopathy with eventual fibrosis. Proper diagnostics and therapeutics for SSc-GIT involvement require the treating physician to have an understanding of an integrated approach and potential medication adverse effects.

Colorectal Transit and Volume During Treatment With Prolonged-release Oxycodone/Naloxone Versus Oxycodone Plus Macrogol 3350

BACKGROUND/AIMS

Opioid-induced constipation (OIC) is the most common gastrointestinal (GI) side effect to opioid treatment. Opioid receptor antagonists against OIC have been introduced, but their efficacy has not been directly compared to conventional laxatives. Our aim was to compare symptoms and objective parameters of gut function in an experimental model of OIC during treatment with the opioid antagonist naloxone and oxycodone in prolonged-release (PR) formulation versus oxycodone plus macrogol 3350.

METHODS

In this randomized, double-blind, crossover trial 20 healthy men received a 5-day treatment of combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350. Regional GI transit times and segmental colorectal transit were assessed with the Motilis 3D-Transit electromagnetic capsule system. Colorectal volumes were determined by MRI. OIC symptoms were assessed with validated questionnaires, along with stool frequency and consistency.

RESULTS

Total colorectal volume did not change after 5 days' treatment with PR oxycodone/naloxone (941 vs 1036 mL; P = 0.091), but increased significantly after PR oxycodone plus macrogol treatment (912 vs 1123 mL; P < 0.001). Neither regional GI transit times nor segmental colorectal transit differed between the treatments (all P > 0.05). The Patient Assessment of Constipation Symptom Questionnaire abdominal symptoms score was lower during PR oxycodone/naloxone compared to PR oxycodone plus macrogol (0.2 vs 3.2; P = 0.002). Stool frequency was lower during PR oxycodone/naloxone compared to PR oxycodone plus macrogol (4.2 vs 5.4; P = 0.035).

CONCLUSIONS

PR oxycodone plus macrogol increases colorectal volume, but does not improve GI transit compared to PR oxycodone/naloxone. However, PR oxycodone/naloxone results in a lower abdominal symptom burden, despite higher stool frequency during macrogol treatment.

Points to consider for clinical trials of the gastrointestinal tract in systemic sclerosis

The pathogenesis of gastrointestinal tract involvement in SSc is not fully understood. However, gastrointestinal signs and symptoms are very common. Trials to test therapies, with rare exceptions, should be double-blind, randomized trials with either active therapy or placebo as comparators. Trial duration will vary dependent on the anticipated therapy and should usually be 6-24 weeks long, although some motility trials may need to be 52 weeks. As in any well-controlled trial, inclusion and exclusion criteria should encourage relatively uniform patients with sufficiently active disease to discern response, importantly considering disease duration. Previous therapy, co-morbid conditions, potentially confounding and/or concomitant therapy should be considered. Outcome measures should include both objective/semi-objective and subjective measures, although validated measures are not frequent and design needs to consider using only validated measures. Unvalidated measures can be included to validate them for future use. A full analysis plan should be completed before study commencement, including the method to account for missing data.

From clinical uncertainties to precision medicine: the emerging role of the gut barrier and microbiome in small bowel functional diseases

Over the last decade, remarkable progress has been made in the understanding of disease pathophysiology. Many new theories expound on the importance of emerging factors such as microbiome influences, genomics/omics, stem cells, innate intestinal immunity or mucosal barrier complexities. This has introduced a further dimension of uncertainty into clinical decision-making, but equally, may shed some light on less well-understood and difficult to manage conditions. Areas covered: Comprehensive review of the literature on gut barrier and microbiome relevant to small bowel pathology. A PubMed/Medline search from 1990 to April 2017 was undertaken and papers from this range were included. Expert commentary: The scenario of clinical uncertainty is well-illustrated by functional gastrointestinal disorders (FGIDs). The movement towards achieving a better understanding of FGIDs is expressed in the Rome IV guidelines. Novel diagnostic and therapeutic protocols focused on the GB and SB microbiome can facilitate diagnosis, management and improve our understanding of the underlying pathological mechanisms in FGIDs.

Systemic sclerosis and the gastrointestinal tract

Systemic sclerosis (SSc) is an autoimmunological disease of unknown origin with complex pathogenesis and multiple organ involvement. It is characterised by vascular and immunological abnormalities leading to fibrosis of the skin and internal organs. It is a rather rare disease with a prevalence of around 20 per 100,000. The disease results in heterogeneous clinical findings and different courses. Systemic sclerosis usually begins with the onset of Raynaud’s phenomenon (RP), followed by skin sclerosis and internal organ involvement, although it may appear synchronously with RP. Gastrointestinal involvement is a serious and prevalent complication of SSc, and the oesophagus is the most frequently affected organ. Both limited and diffuse cutaneous SSc involve internal organs, with the involvement of the gastrointestinal tract as a leading cause of morbidity. At present, treatment is mainly symptomatic with no disease-modifying drugs.

Gastrointestinal Manifestations of Systemic Sclerosis

In patients with systemic sclerosis (SSc), gastrointestinal (GI) tract involvement is almost universal. Any segment of the GI tract from mouth to anus can be involved, and GI symptoms are a frequent cause of morbidity. In severe cases, GI tract involvement can progress to the point of malnutrition requiring parenteral nutrition. GI tract involvement in SSc contributes to disease-related mortality although mostly as a co-morbidity rather than direct cause of death. The review is intended to help address challenges in the assessment and treatment of GI tract involvement in SSc.

Association between small intestinal bacterial overgrowth and deep vein thrombosis

Objective: Small intestinal bacterial overgrowth (SIBO) has been associated with several diseases. The association between SIBO and deep vein thrombosis (DVT) has not been investigated. This study was aimed to investigate the frequency and risk factors for the development of DVT in patients tested for SIBO.

Methods: All 321 eligible patients were included from the Cleveland Clinic Gastrointestinal Motility Lab databank from January 2008 to January 2014. Patients who were evaluated with glucose hydrogen/methane breath test as well as Doppler ultrasonography for suspected DVT were included. Patients with catheter-related DVT were excluded. The primary outcomes were the frequency and risk factors (including SIBO) for DVT in this patient population.

Results: Of the 321-case cohort, 144 patients (44.9%) tested positive for SIBO, and 53 (16.5%) had ultrasonographic findings of DVT. SIBO evaluation before the evaluation of DVT occurred in 201 patients (median time from the breath test to ultrasonography: 27 months; interquartile range [IQR]: 11.0–45.0 months), and SIBO evaluation after evaluation for DVT occurred in 120 patients (median time from ultrasonography to the breath test: 30 months; IQR: 11.8–54.3 months). In the univariate analysis, DVT was associated with family history of thromboembolic events (35.8% vs 16.0%, P=0.001), chronic kidney diseases (CKD; 26.4% vs 13.4%, P=0.019) and the presence of SIBO (69.8% vs 39.9%, P<0.001). In the multivariate analysis, family history of thromboembolic events (odds ratio [OR]: 3.39; 95% confidence interval [CI]: 1.67–6.87; P<0.001), CKD (OR: 2.23; 95%CI: 1.04–4.74; P = 0.037), and the presence of SIBO (OR: 3.27; 95% CI: 1.70–6.32; P < 0.001) remained independently associated with DVT.

Conclusion: SIBO was found to be associated with DVT. The nature of this association warrants further investigation.

An Unusual Case of Obstruction Due to Colonic Intussusception in a Scleroderma Patient

Scleroderma is an autoimmune disease that can affect multiple organ systems, including the gastrointestinal tract. Intussusception, the telescoping of the bowel that can lead to intestinal obstruction, is an uncommon phenomenon in adults. We report the first case of sigmoid intussusception in a patient with scleroderma.

Regional Gastrointestinal Transit Times in Patients With Carcinoid Diarrhea: Assessment With the Novel 3D-Transit System

Background/Aims

The paucity of knowledge regarding gastrointestinal motility in patients with neuroendocrine tumors and carcinoid diarrhea restricts targeted treatment. 3D-Transit is a novel, minimally invasive, ambulatory method for description of gastrointestinal motility. The system has not yet been evaluated in any group of patients. We aimed to test the performance of 3D-Transit in patients with carcinoid diarrhea and to compare the patients’ regional gastrointestinal transit times (GITT) and colonic motility patterns with those of healthy subjects.

Methods

Fifteen healthy volunteers and seven patients with neuroendocrine tumor and at least 3 bowel movements per day were investigated with 3D-Transit and standard radiopaque markers.

Results

Total GITT assessed with 3D-Transit and radiopaque markers were well correlated (Spearman’s rho = 0.64, P = 0.002). Median total GITT was 12.5 (range: 8.5–47.2) hours in patients versus 25.1 (range: 13.1–142.3) hours in healthy (P = 0.007). There was no difference in gastric emptying (P = 0.778). Median small intestinal transit time was 3.8 (range: 1.4–5.5) hours in patients versus 4.4 (range: 1.8–7.2) hours in healthy subjects (P = 0.044). Median colorectal transit time was 5.2 (range: 2.9–40.1) hours in patients versus 18.1 (range: 5.0–134.0) hours in healthy subjects (P = 0.012). Median frequency of pansegmental colonic movements was 0.45 (range: 0.03–1.02) per hour in patients and 0.07 (range: 0–0.61) per hour in healthy subjects (P = 0.045).

Conclusions

Three-dimensional Transit allows assessment of regional GITT in patients with diarrhea. Patients with carcinoid diarrhea have faster than normal gastrointestinal transit due to faster small intestinal and colorectal transit times. The latter is caused by an increased frequency of pansegmental colonic movements.

Evaluation and management of gastrointestinal manifestations in scleroderma

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Pilot study trialling a new ambulatory method for the clinical assessment of regional gastrointestinal transit using multiple electromagnetic capsules

BACKGROUND

Gastrointestinal (GI) motor disorders often involve several regions of the GI tract. Therefore, easy and safe assessment of whole gut and regional motility is valuable for more precise diagnosis. 3D-Transit is a novel method for ambulatory evaluation of total and regional gastrointestinal transit times (GITT) based on the anatomical localization of ingestible electromagnetic capsules. The main purpose of this study was to test the performance of the 3D-Transit system.

METHODS

Twenty healthy volunteers each ingested three electromagnetic capsules over a period of two consecutive days. Standard radio-opaque markers (ROM) were also ingested to assess the agreement between total GITT obtained with both methods.

KEY RESULTS

Investigations were well-tolerated and three capsules could be tracked simultaneously with minimal data loss (Capsule 1: median: 0.2% of time (range 0-25.3%). Region specific contraction patterns were identified and used for computation of total and regional GITT in all subjects. Inter-observer agreement was 100% for total GITT (median variation 0%) but less for regional GITT. Day-to-day and diurnal variations were significant for total and regional GITT. Total GITT assessed by 3D-Transit capsules were moderately well-correlated to those assessed with standard ROM (Spearman's rho = 0.7).

CONCLUSIONS & INFERENCES

3D-transit is a well-tolerated and minimal invasive ambulatory method for assessment of GI motility. By providing both total and regional transit times, the 3D-Transit system holds great promise for future clinical studies of GI function in health and disease.

A randomised, controlled study of small intestinal motility in patients treated with sacral nerve stimulation for irritable bowel syndrome

Background

Irritable bowel syndrome (IBS) is among the most common gastrointestinal disorders worldwide. In selected patients with severe diarrhoea-predominant or mixed IBS subtypes sacral nerve stimulation (SNS) alleviates IBS-specific symptoms and improves quality of life. The mode of action, however, remains unknown. The present study aimed to evaluate the effect of SNS on small intestinal motility in IBS patients.

Methods

Twenty patients treated with SNS for severe diarrhoea-predominant or mixed IBS were included in a randomised, controlled, crossover study. The neurostimulator was turned ON or OFF for the first one month and then to the opposite setting for the next month. Gastrointestinal transit patterns were investigated with the Motility Tracking System-1 (MTS-1) at the end of each the ON and OFF period. Primary endpoint was change in the velocity of the magnetic pill within the small intestine. Statistical testing was performed with Wilcoxon’s rank sum test and Fisher’s exact test.

Results

The median velocity of the magnetic pill through the small intestine in the fasting state was not significantly different between periods with and without SNS (Group ON-OFF: median change 0 m/h (range -1.07, 0.63), Group OFF-ON: median change 0.27 m/h (range -0.59, 1.12)) (p = 0.25). Neither, was the median velocity of the magnetic pill through the small intestine in the postprandial state significantly different between periods with and without SNS (Group ON-OFF: median change -0.13 m/h (range -0.46, 0.23), Group OFF-ON: median change 0.015 m/h (range -0.48, 0.59)) (p = 0.14).

Conclusion

Even though SNS may reduce symptoms of diarrhoea-predominant and mixed IBS, it has no detectable effect on small intestinal transit patterns.

Trial registration

Clinical.trials.gov, (NCT00919672).

A descriptive study of colorectal function in adults with Prader-Willi Syndrome: high prevalence of constipation

BACKGROUND

Some patients with Prader-Willi Syndrome (PWS) have symptoms of constipation, but bowel function in PWS has never been systematically evaluated. The aim of the present study was to describe colorectal function in PWS by means of validated techniques.

METHODS

Twenty-one patients with PWS (14 women, age 17-47 (median = 32)) were evaluated with the Rome III constipation criteria, stool diary, digital rectal examination, rectal diameter assessed from transabdominal ultrasound, and total gastrointestinal transit time (GITT) determined with radio-opaque markers. Results were compared with those of healthy controls.

RESULTS

Among PWS patients able to provide information for Rome III criteria, 8/20 (40%) fulfilled the criteria for constipation. Most commonly reported symptoms were a feeling of obstructed defecation (8/19, 42%), <3 defecations per week (8/17, 47%), straining during defecation (7/19, 37%) and lumpy or hard stools (6/19, 32%). Rectal diameter did not differ between PWS (median 3.56 centimeters, range 2.24-5.36) and healthy controls (median 3.42 centimeters, range 2.67-4.72) (p = 0.96), but more PWS patients (13/20; 65%) than healthy controls (3/25; 12%) (p < 0.001) had fecal mass in the rectum. Median GITT was 2.0 days (range 0.5-4.4) in PWS versus 1.6 (range 0.7-2.5) in the control group (p = 0.26). However, GITT was >3 days in 5/21 (24%) of PWS and none of the controls (p = 0.047).

CONCLUSION

Constipation is very common in PWS. Patients with PWS have an increased prevalence of prolonged GITT and palpable stools in the rectum at digital rectal examination.

Magnet tracking allows assessment of regional gastrointestinal transit times in children

Background

Data on small intestinal transit time in healthy children are lacking, and normal values for gastric emptying and colonic transit time are sparse. Conventional methods, including radiopaque markers, scintigraphy, and PillCam™ involve radiation or require the child to swallow a large pill. The minimally invasive, radiation-free Motility Tracking System-1 (MTS-1) has been introduced for description of gastrointestinal motility in adults. The aim of the study was to evaluate the MTS-1 for assessment of gastrointestinal transit times and motility patterns in healthy children.

Methods

Twenty-one healthy children (nine girls), median age 10 (range 7–12) years were included. For evaluation with MTS-1, a small magnetic pill was ingested and tracked through the gastrointestinal tract by a matrix of 16 magnetic sensors placed behind a nonmagnetic bed. The children were investigated for 8 hours after swallowing the magnetic pill and again for 4 hours the following morning. After leaving the unit, each child came back after every bowel movement to determine if the pill had been expelled.

Results

Nineteen children could swallow the pill. Characteristic contraction patterns were identified for the stomach (three per minute), small intestine (9–11 per minute), and colon (4–5 per minute). Median total gastrointestinal transit time was 37.7 (range 9.5–95.8) hours, median gastric emptying time was 37 (range 2–142) minutes, median small intestinal transit time was 302 (range 164 to >454) minutes, and median colorectal transit time was 38.1 (range 5.6–90.0) hours.

Conclusion

MTS-1 allows minimally invasive evaluation of gastrointestinal motility in children. Use of the method is, however, restricted by the nonambulatory setup.

Stratification and compartmentalisation of immunoglobulin responses to commensal intestinal microbes

The gastrointestinal tract is heavily colonized with commensal microbes with the concentration of bacteria increasing longitudinally down the length of the intestine. Bacteria are also spatially distributed transversely from the epithelial surface to the intestinal lumen with the inner mucus layer normally void of bacteria. Maintenance of this equilibrium is extremely important for human health and, as the dominant immunoglobulin at mucosal sites, IgA influences mutualism between the host and its normal microbiota. In this review we focus on the links between immune and microbial geography of the mammalian intestinal tract.

Gastrointestinal complications of systemic sclerosis

Systemic sclerosis is an autoimmune disease characterized by progressive skin thickening and tightness. Pulmonary interstitial fibrosis and kidney damage are the most important indicators for mortality; however, the gastrointestinal tract is the most commonly damaged system. Virtually all parts of the gastrointestinal (GI) tract can be involved, although the esophagus is the most frequently reported. The mechanisms that cause such extensive damage are generally unclear, but vascular changes, immunological abnormalities, excessive accumulation of collagen in the submucosa, smooth muscle atrophy and neuropathy may participate because these are the most common histological findings in biopsies and autopsies. Most patients with GI tract involvement complain about dyspepsia, nausea, vomiting, abdominal bloating/distension, and fecal incontinence. These symptoms are generally mild during the early stage of the disease and are likely ignored by physicians. As the disease becomes more advanced, however, patient quality of life is markedly influenced, whereby malnutrition and shortened survival are the usual consequences. The diagnosis for systemic sclerosis is based on manometry measurements and an endoscopy examination. Supportive and symptomatic treatment is the main therapeutic strategy; however, an early diagnosis is critical for successful management.

Lactulose breath test to assess oro-cecal transit delay and estimate esophageal dysmotility in scleroderma patients

OBJECTIVES

To assess the correlation between delayed oro-cecal transit time (OCTT) and esophageal motility abnormalities in a cohort of systemic sclerosis (SSc) patients.

METHODS

We prospectively enrolled 50 consecutive SSc patients and 60 healthy volunteers (HVs) as controls. Both groups underwent glucose breath test (GBT) to exclude small intestine bacterial overgrowth, lactulose hydrogen, and octanoic acid breath tests (LHBT and OBT) to measure OCTT and gastric emptying (GE), respectively, and manometry to assess esophageal motility.

RESULTS

Thirty-one (63%) SSc patients presented ineffective esophageal motility (IEM) compared with 3 HVs (5%; P<0.01), 37 (74%) had an abnormal OCTT compared with 4 HVs (7%; P <0.01), and 16 (32%) had an altered GE compared with 4 HVs (7%; P <0.01). The median OCTT and gastric t½ were longer in SSc than in HVs (165 min vs. 101 min and 125 min vs. 78 min, respectively; P <0.01). A delayed GE was present in 12/37 (32%), whereas IEM in 27/37 (73%) SSc patients with prolonged OCTT. The prevalence of IEM increased in parallel with the prolongation of OCTT (31% when OCTT<150 min, 73% when OCTT≥150 min, and up to 85% when OCTT>180 min, P<0.01).

CONCLUSIONS

Abnormalities of both esophageal and small intestine motility are frequent in SSc patients and esophageal motility is altered in most cases with small bowel involvement. Delayed GE plays a limited role in prolonging OCTT. LHBT is a non-invasive, cheap, well-tolerated diagnostic tool that may be useful to estimate intestinal involvement and also to estimate a higher risk of esophageal hypomotility in SSc patients.

Opioid-induced bowel dysfunction: pathophysiology and management

Opioids are the most commonly prescribed medications to treat severe pain in the Western world. It has been estimated that up to 90% of American patients presenting to specialized pain centres are treated with opioids. Along with their analgesic properties, opioids have the potential to produce substantial side effects, such as nausea, cognitive impairment, addiction and urinary retention. In the gut, opioids exert their action on the enteric nervous system, where they bind to the myenteric and submucosal plexuses, causing dysmotility, decreased fluid secretion and sphincter dysfunction, which all leads to opioid-induced bowel dysfunction (OIBD). In the clinic, this is reported as nausea, vomiting, gastro-oesophageal reflux-related symptoms, constipation, etc. One of the most severe symptoms is constipation, which can be assessed using different scales for subjective assessment. Objective methods such as radiography and colonic transit time can also be used, together with manometry and evaluation of anorectal function to explore the pathophysiology. Dose-limiting adverse symptoms of OIBD can lead to insufficient pain treatment. Even though several treatment strategies are available, the side effects are still a major challenge. Traditional laxatives are normally prescribed but they are often insufficient to alleviate symptoms, especially those from the upper gastrointestinal tract. Newer prokinetics, such as prucalopride and lubiprostone, may be more effective in alleviating OIBD. Another treatment approach is co-administration of opioid antagonists, which either cannot cross the blood-brain barrier or selectively target opioid receptors in the gastrointestinal tract. However, although these new agents have proved to be more efficacious than placebo, clinical trials still need to prove their superiority to standard co-prescribed laxative regimes.

Systemic sclerosis--challenges for clinical practice

The management of patients with systemic sclerosis (SSc) can be challenging because disease-associated damage is often difficult to reverse and curative therapies are not yet available. Early identification and appropriate monitoring of patients with SSc is, therefore, critical so that active disease can be controlled and tissue damage prevented or delayed. However, early diagnosis of SSc is often difficult because the early clinical stages of the disease can be very similar to that of other autoimmune conditions. Screening for major organ manifestations of SSc, particularly interstitial lung disease, pulmonary hypertension, renal involvement and cardiac disease is a priority because involvement of these organs is associated with shorter life expectancies and early intervention might prevent disease progression. The prevention and management of digital ischaemia is also important as appropriate therapy often prevents substantial morbidity and functional loss. Treating gastrointestinal dysmotility can usually be managed using proton pump inhibitors and promotility agents, although in severe cases total parenteral nutrition is required. Calcinosis in patients with SSc is another common challenge that requires appropriate disease management and pain control. Each of these topics, which are relevant to both physicians and patients with SSc, are reviewed in further detail herein.

Turning off sacral nerve stimulation does not affect gastric and small intestinal motility in patients treated for faecal incontinence

AIM

Sacral nerve stimulation (SNS) reduces symptoms in up to 80% of patients with faecal incontinence (FI). Its effects are not limited to the distal colon and the pelvic floor. Accordingly, spinal or supraspinal neuromodulation have been suggested as part of the mode of action. The effect of SNS on gastric and small-intestinal motility was studied.

METHOD

Using the magnet tracking system, MTS-1, a small magnetic pill was tracked twice through the upper gastrointestinal tract of eight patients with FI successfully treated with SNS. Following a randomized double-blind crossover design, the stimulator was either left active or was turned off for 1 week before investigations with MTS-1.

RESULTS

The median (range) frequency of gastric con-tractions was 3.05 (2.83-3.40) per min during SNS and 3.04 (2.79?-3.76) per min without (P=NS). The median (range) frequency of contractions in the small intestine during the first 2h after pyloric passage was 10.005 (9.68-10.70) per min during SNS and 10.09 (9.79-10.29) per min without SNS (P=NS). The median (range) velocity of the magnetic pill during the first 2h in the small intestine was 1.6 (1.2-2.8) cm/min during SNS and 1.7 (0.8-3.7) cm/min without SNS (P=NS). Small-intestinal propagation mainly occurred during very fast movements (>15cm/min), accounting for 51% (42-60%) of the distance 3% (2-4%) of the time during SNS and for 53% (18-73%) of the distance 3% (1-8%) of the time without SNS (P=NS).

CONCLUSION

Turning off SNS for 1week did not affect gastric or small-intestinal motility patterns.

Gastric transit and small intestinal transit time and motility assessed by a magnet tracking system

Background

Tracking an ingested magnet by the Magnet Tracking System MTS-1 (Motilis, Lausanne, Switzerland) is an easy and minimally-invasive method to assess gastrointestinal transit. The aim was to test the validity of MTS-1 for assessment of gastric transit time and small intestinal transit time, and to illustrate transit patterns detected by the system.

Methods

A small magnet was ingested and tracked by an external matrix of 16 magnetic field sensors (4 × 4) giving a position defined by 5 coordinates (position: x, y, z, and angle: θ, ϕ). Eight healthy subjects were each investigated three times: (1) with a small magnet mounted on a capsule endoscope (PillCam); (2) with the magnet alone and the small intestine in the fasting state; and (3) with the magnet alone and the small intestine in the postprandial state.

Results

Experiment (1) showed good agreement and no systematic differences between MTS-1 and capsule endoscopy when assessing gastric transit (median difference 1 min; range: 0-6 min) and small intestinal transit time (median difference 0.5 min; range: 0-52 min). Comparing experiments (1) and (2) there were no systematic differences in gastric transit or small intestinal transit when using the magnet-PillCam unit and the much smaller magnetic pill. In experiments (2) and (3), short bursts of very fast movements lasting less than 5% of the time accounted for more than half the distance covered during the first two hours in the small intestine, irrespective of whether the small intestine was in the fasting or postprandial state. The mean contraction frequency in the small intestine was significantly lower in the fasting state than in the postprandial state (9.90 min^-1 vs. 10.53 min^-1) (p = 0.03).

Conclusion

MTS-1 is reliable for determination of gastric transit and small intestinal transit time. It is possible to distinguish between the mean contraction frequency of small intestine in the fasting state and in the postprandial state.