Systemic sclerosis and the gastrointestinal tract

Autoimmune Dysphagia Related to Rheumatologic Disorders: A Focused Review on Diagnosis and Treatment

Autoimmune dysphagia is defined as dysphagia caused by autoimmune processes affecting various components of the swallowing process such as muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. These autoimmune causes can be classified into gastroenterological, dermatological, rheumatologic, and neurologic. Rheumatological disorders, such as scleroderma, Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, Behcet's disease, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, or granulomatosis with polyangiitis, have been associated with dysphagia. Autoimmune dysphagia in the context of rheumatological disorders is particularly significant because it can occur as a sole manifestation or as part of a symptom complex associated with the underlying disorder and often responds to immunosuppressive therapies. However, diagnosing autoimmune dysphagia can be challenging as it requires the exclusion of structural and primary motility disorders through procedures such as endoscopy and manometry. Early diagnosis is important to improve the quality of life and prevent significant mortality and morbidity. Management focuses on treating the underlying disease activity, and a multidisciplinary approach involving various medical specialties may be necessary to achieve success. This article aims to review the autoimmune rheumatological conditions that can lead to dysphagia and discuss the associated pathophysiological mechanisms. We also outline the clinical clues and laboratory testing methods that facilitate early diagnosis, with the goal of improving patient outcomes through timely intervention and appropriate management.

Systemic Scleroderma-Definition, Clinical Picture and Laboratory Diagnostics

(1) Background: Scleroderma (Sc) is a rare connective tissue disease classified as an autoimmune disorder. The pathogenesis of this disease is not fully understood. (2) Methods: This article reviews the literature on systemic scleroderma (SSc). A review of available scientific articles was conducted using the PubMed database with a time range of January 1985 to December 2021. (3) Results and Conclusions: The article is a review of information on epidemiology, criteria for diagnosis, pathogenesis, a variety of clinical pictures and the possibility of laboratory diagnostic in the diagnosis and monitoring of systemic scleroderma.

The Role of Fecal Calprotectin in Patients with Systemic Sclerosis and Small Intestinal Bacterial Overgrowth (SIBO)

Fecal calprotectin (FC) is a quick, cost-effective, and noninvasive test, which is used to diagnose patients with active inflammatory bowel diseases (IBD). Recent studies suggest the possible predictive role of FC in the diagnosis of small intestinal bacterial overgrowth (SIBO) in patients with systemic sclerosis (SSc). This study aimed to assess the predictive value of FC in SSc patients and its’ possible use as a SIBO marker. A total of 40 SSc patients and 39 healthy volunteers were enrolled in the study. All subjects completed questionnaires evaluating gastrointestinal symptoms, FC measurements, and lactulose hydrogen breath test (LHBT) assessing SIBO presence. After rifaximin treatment, patients with SIBO underwent the same diagnostic procedures. Significantly higher FC values were observed in the study group compared to controls (97 vs. 20 μg/g; p < 0.0001) and in SSc patients diagnosed with SIBO compared to SSc patients without SIBO (206 vs. 24 μg/g; p = 0.0010). FC turned out to be a sensitive (94.12%) and specific (73.68%) marker in the detection of SIBO in patients with SSc (AUC = 0.82, 95% CI = 0.66–0.93; p < 0.0001). Our study suggests the potential value of FC in SSc in detecting gastrointestinal impairment and its promising role as an additional diagnostic tool for SIBO.

Refractory hemorrhagic esophageal ulcers by Candida esophagitis with advanced systemic sclerosis

A 64-year-old woman diagnosed with rheumatoid arthritis (RA) and systemic sclerosis (SSc) was admitted to our hospital with chief complaints of uncontrolled bleeding from esophageal ulcers and an inability to consume meals. For RA and SSc, she was treated with prednisolone and abatacept and was taking vonoprazan as prophylaxis for steroid-induced gastric ulcers. She was diagnosed with severe Candida esophagitis, with multiple large and small ulcers with bleeding, based on esophagogastroduodenoscopy and pathological findings. We performed comprehensive treatment; abatacept was discontinued, and total parenteral nutrition was initiated along with antifungal therapy. Improvement in the esophageal ulcers was observed. Although severe Candida esophagitis is a rare condition, we should keep in mind that severe Candida esophagitis can occur in patients with an immunosuppressive compromised host and esophageal movement disorders such as SSc. Regular follow up by endoscopy and prophylactic treatment to prevent severe esophagitis may be necessary.

Small intestinal bacterial overgrowth in systemic sclerosis

Systemic sclerosis is a multi-organ autoimmune disease characterized by vasculopathy and fibrosis, and it is arguably the most devastating of the rheumatological diseases. The gastrointestinal tract is the most commonly involved internal organ in systemic sclerosis. Gastrointestinal tract involvement is reported in up to 90% of SSc patients, is the leading cause of morbidity, and is the third most common cause of mortality in this disease. Among all gastrointestinal tract manifestations, small intestinal bacterial overgrowth is one manifestation that may be ameliorated and even eradicated with appropriate treatment, if recognized early. Small intestinal bacterial overgrowth occurs with a prevalence of approximately 39% in systemic sclerosis and presents with a range of non-specific gastrointestinal tract symptoms, including diarrhea, flatulence, abdominal pain, bloating, and early satiety. These manifestations occur due to an alteration and overgrowth of small intestinal bacteria occurring in the setting of gastrointestinal tract dysmotility and slow transit time. The clinical diagnosis of small intestinal bacterial overgrowth is commonly based on the presence of characteristic clinical symptoms together with a positive hydrogen breath test and response to a therapeutic trial of oral antibiotics used sequentially. Almost two-thirds of systemic sclerosis patients with small intestinal bacterial overgrowth have an improvement in their gastrointestinal tract symptoms with rotating antibiotics. Untreated small intestinal bacterial overgrowth can lead to malnutrition, and thus an important aspect of treatment is the identification and treatment of any associated vitamin and mineral deficiencies. This article focuses on small intestinal bacterial overgrowth, an important and understudied area in systemic sclerosis that remains a diagnostic and therapeutic challenge for both patients and clinicians alike.

Systemic sclerosis - multidisciplinary disease: clinical features and treatment

Systemic sclerosis is a chronic autoimmune disease of still not fully understood pathogenesis. Fibrosis, vascular wall damage, and disturbances of innate and acquired immune responses with autoantibody production are prominent features. Systemic sclerosis has specific subsets with different autoantibodies, and differences in the affected skin areas. The suspicion of systemic sclerosis and establishing the diagnosis will be facilitated by the criteria created by EULAR/ACR experts. The treatment of this autoimmune disease remains a challenge for clinicians and new therapeutic options are constantly sought. The occurrence of various symptoms and the involvement of many organs and systems make systemic sclerosis a multidisciplinary disease and require a holistic approach. The present article summarizes different clinical features of systemic sclerosis and the profile of autoantibodies and discusses recent rules and future perspectives in disease management.

The contemporary management of systemic sclerosis

INTRODUCTION

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by vascular dysfunction, fibrosis, inflammation and autoantibodies. The pathophysiology of SSc is not completely understood, and many patients acquire organ or tissue damage despite advances in treatment. Current treatments target affected organs with modest improvements. Areas covered: This review evaluates several treatment strategies for SSc based on involved organs including skin, pulmonary, cardiac, renal, musculoskeletal, and gastrointestinal. Currently, pulmonary hypertension and interstitial lung disease are the primary causes of increased mortality. We will outline an approach to treatment of SSc based on disease manifestations and current evidence. Expert commentary: This complex disease is currently treated with therapies developed for similar indications such as for vascular manifestations of SSc using idiopathic pulmonary arterial hypertension treatments. Future directions in this field may include combination and maintenance therapy that is currently used in other autoimmune diseases, and tailoring these treatments according to the patients' phenotype. This will hopefully increase the efficacy of available treatments and decrease mortality from SSc.