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Topan R, Pandya S, Williams S, Ruffle JK, Zarate-Lopez N, Aziz Q, Fikree A. Comprehensive Assessment of Nutrition and Dietary Influences in Hypermobile Ehlers-Danlos Syndrome-A Cross-Sectional Study. Am J Gastroenterol 2024; 119:727-738. [PMID: 37970870 DOI: 10.14309/ajg.0000000000002586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Disorders of gut-brain interaction (DGBI) are common in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorder (hEDS/HSD). Food is a known trigger for DGBI symptoms, which often leads to dietary alterations and, increasingly, nutrition support. We aimed to explore dietary behaviors and influencing factors in patients with hEDS/HSD. METHODS In a cross-sectional study, patients with hEDS/HSD were recruited from Ehlers-Danlos Support UK (nontertiary) and tertiary neurogastroenterology clinics to complete questionnaires characterizing the following: dietary behaviors, nutrition support, DGBI (Rome IV), gastrointestinal symptoms, anxiety, depression, avoidant restrictive food intake disorder (ARFID), mast cell activation syndrome, postural tachycardia syndrome (PoTS), and quality of life. We used stepwise logistic regression to ascertain which factors were associated with dietary behaviors and nutrition support. RESULTS Of 680 participants (95% female, median age 39 years), 62.1% altered their diet in the last year and 62.3% regularly skipped meals. Altered diet was associated with the following: reflux symptoms ( P < 0.001), functional dyspepsia ( P = 0.008), reported mast cell activation syndrome ( P < 0.001), and a positive screen for ARFID, specifically fear of eating and low interest ( P < 0.001). Approximately 31.7% of those who altered their diet required nutrition support. The strongest predictor of requiring nutrition support was a positive screen for ARFID, specifically fear of eating (OR: 4.97, 95% CI: 2.09-11.8, P < 0.001). DISCUSSION Altered diet is very common in the patients with hEDS/HSD we studied and influenced by functional dyspepsia, reflux symptoms, and ARFID. Those with ARFID have a 4-fold increased risk of requiring nutrition support, and therefore, it is paramount that psychological support is offered in parallel with dietary support in the management of DGBI in hEDS/HSD.
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Affiliation(s)
- Rabia Topan
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
| | - Shraya Pandya
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
| | - Sarah Williams
- Department of Dietetics, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - James K Ruffle
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
| | - Natalia Zarate-Lopez
- Gastrointestinal Physiology Unit, University College Hospitals NHS Foundation Trust, Division of Surgery and Interventional Sciences, University College London, United Kingdom
| | - Qasim Aziz
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
| | - Asma Fikree
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
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Dervin H, Zarate-Lopez N, Sweis R, Mensah A, Fragkos K, Brugaletta C, Raeburn A, Emmanuel A. Low prevalence of positive hydrogen breath tests in patients with functional gastrointestinal conditions and hypermobile Ehlers-Danlos syndrome. Neurogastroenterol Motil 2023; 35:e14570. [PMID: 36989174 DOI: 10.1111/nmo.14570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/25/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Using hydrogen breath testing (HBT) to diagnose small intestinal bacterial overgrowth (SIBO) remains controversial in patients with functional gastrointestinal (GI) disorders, and unknown in those with hypermobility Ehlers-Danlos syndrome (hEDS). We assessed prevalence of positive HBTs in these groups, evaluated the predictive value of GI symptoms and the potential role of proton pump inhibitors (PPIs) on test results. METHODS Sequential patients referred for HBT to a tertiary unit were classified into the following groups: GI maldigestion/malabsorption, GI sensorimotor disorders, hEDS, and functional GI disorders. All underwent standardized HBT, and the yield was assessed against symptoms and PPI use. KEY RESULTS A total of 1062 HBTs were performed over 3 years (70% female, mean age 48 ± 16 years). Overall, 7.5% (80/1062) patients had a positive HBT. Prevalence of positive HBT was highest in patients with GI maldigestion/malabsorption (17.9%; DOR 16.16, p < 0.001), GI sensorimotor disorders (15.9%; DOR 8.84, p < 0.001), compared to functional GI disorders (1.6%; DOR 1.0) (p < 0.0001). None of the hEDS patients tested positive for HBT. A positive HBT was independently associated with increased age (DOR 1.03; p < 0.001) and symptoms of diarrhea (DOR 3.95; p < 0.0001). Patients on PPIs tended towards a positive HBT than patients off PPIs (16.1% vs 6.9%; DOR 2.47; p < 0.0001). CONCLUSIONS & INFERENCES Less than 2% of patients with functional GI disorders, and none of the patients with hEDS had a positive HBT. Pre-test probability was higher in patients with: GI structural or neurological disorders; use of long-term PPIs and symptoms of diarrhea. These criteria may be helpful in making appropriate therapeutic decisions and avoiding unnecessary hydrogen breath testing.
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Affiliation(s)
- Humayra Dervin
- GI Physiology Unit, University College London Hospitals, London, UK
| | | | - Rami Sweis
- GI Physiology Unit, University College London Hospitals, London, UK
| | - Alexia Mensah
- GI Physiology Unit, University College London Hospitals, London, UK
| | | | | | - Amanda Raeburn
- GI Physiology Unit, University College London Hospitals, London, UK
| | - Anton Emmanuel
- GI Physiology Unit, University College London Hospitals, London, UK
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Hubbard R, Brooks A, Arebi N, El-Khouly S, Kiparissi F, Mozdiak E, Muhammed R, Smith PJ, Zarate-Lopez N, Garrick V, Greenan-Barrett J, Baker S, Bradbury K, DelNero N, Narula P. Young persons and healthcare professionals experience of virtual gastroenterology consultations: a multicentre survey conducted during the COVID-19 pandemic. Frontline Gastroenterol 2023; 14:491-496. [PMID: 37854783 PMCID: PMC10579619 DOI: 10.1136/flgastro-2022-102354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 05/13/2023] [Indexed: 10/20/2023] Open
Abstract
Objective To explore Young Persons (YP) and healthcare professionals (HCP) experiences of virtual consultations (VC) and establish whether developmentally appropriate healthcare can be delivered virtually. Method YP and HCP questionnaire surveys were designed and piloted. Electronic questionnaire links were sent by post, email or text message January-April 2021 to YP aged 13-25 years old, with predefined chronic gastrointestinal conditions, attending a gastroenterology/hepatology VC. HCP undertaking VC were invited to complete staff questionnaire. Results were anonymous and collated using Excel version 2302. Results Five UK hospital trusts participated, with 35 HCP responses. Of the 100 YP completing the survey 66% were female and 34% male aged between 13 years and 25 years (median: 18 years). 13% were new appointments and 87% follow ups, 29% were by video, 69% by phone and 2% gave no response. 80% of HCP spoke to YP directly but not privately (69%). 87% of YP and 88% HCP found VC useful. 83% of YP want VC again, although 20% preferred face to face. 43% of HCP required improved phone/internet connection. 77% of YP required hospital appointments for tests following VC. Conclusions Overall respondents were satisfied with VC, finding them useful, convenient and time saving. Successful VC rely on appropriate patient selection and availability of reliable technology. Patient preference is key which may alter with time.
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Affiliation(s)
- Rhona Hubbard
- Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Alenka Brooks
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Naila Arebi
- Department of Gastroenterology, St Mark's Hospital Foundation, London, UK
| | - Sara El-Khouly
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | - Fevronia Kiparissi
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | - Ella Mozdiak
- Department of Gastroenterology, Walsall Healthcare NHS Trust, Walsall, UK
| | - Rafeeq Muhammed
- Department of Paediatric Gastroenterology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Philip J Smith
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Natalia Zarate-Lopez
- Department of Gastoenterology and GI Physiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Victoria Garrick
- Department of Paediatric Gastroenterology, Glasgow Children's Hospital Charity, Glasgow, UK
| | - James Greenan-Barrett
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Sarah Baker
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Keith Bradbury
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Nicholas DelNero
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Priya Narula
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
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Lam C, Amarasinghe G, Zarate-Lopez N, Fikree A, Byrne P, Kiani-Alikhan S, Gabe S, Paine P. Gastrointestinal symptoms and nutritional issues in patients with hypermobility disorders: assessment, diagnosis and management. Frontline Gastroenterol 2022; 14:68-77. [PMID: 36561778 PMCID: PMC9763642 DOI: 10.1136/flgastro-2022-102088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/20/2022] [Indexed: 02/04/2023] Open
Abstract
Patients diagnosed with hypermobile Ehlers-Danlos syndrome and hypermobile spectrum disorders are increasingly presenting to secondary and tertiary care centres with gastrointestinal (GI) symptoms and nutritional issues. Due to the absence of specific guidance, these patients are investigated, diagnosed and managed heterogeneously, resulting in a growing concern that they are at increased risk of iatrogenic harm. This review aims to collate the evidence for the causes of GI symptoms, nutritional issues and associated conditions as well as the burden of polypharmacy in this group of patients. We also describe evidence-based strategies for management, with an emphasis on reducing the risk of iatrogenic harm and improving multidisciplinary team care.
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Affiliation(s)
- Ching Lam
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gehanjali Amarasinghe
- Gastroenterology, St Marks Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Natalia Zarate-Lopez
- Gastoenterology and GI physiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Asma Fikree
- Gastroenterology, Barts Health NHS Trust, London, UK
| | - Peter Byrne
- Psychiatry, East London NHS Foundation Trust, London, UK
| | | | - Simon Gabe
- Gastroenterology, St Marks Hospital, London North West University Healthcare NHS Trust, Harrow, UK,Intestinal Failure Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Peter Paine
- Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
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Lambarth A, Zarate-Lopez N, Fayaz A. Oral and parenteral anti-neuropathic agents for the management of pain and discomfort in irritable bowel syndrome: A systematic review and meta-analysis. Neurogastroenterol Motil 2022; 34:e14289. [PMID: 34755926 DOI: 10.1111/nmo.14289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a highly prevalent and economically burdensome condition; and pain is often the most unpleasant, disruptive, and difficult-to-treat symptom. Visceral hypersensitivity is a common feature driving pain in IBS, suggesting that neuropathic mechanisms may be implicated. We conducted a systematic review of available evidence to examine the role of anti-neuropathic medicines in the management of pain in IBS. METHODS We systematically searched scientific repositories for trials investigating conventional oral, and/or parenteral, pharmaceutical antineuropathic treatments in patients with IBS. We summarized key participant characteristics, outcomes related to pain (primary outcome), and selected secondary outcomes. KEY RESULTS We included 13 studies (n = 629 participants): six investigated amitriptyline, three duloxetine, three pregabalin, and one gabapentin. There was considerable methodological and statistical heterogeneity, so we performed a narrative synthesis and limited meta-analysis. Amitriptyline was most extensively studied, though only in diarrhea-predominant patients. In individual trials, amitriptyline, pregabalin and gabapentin generally appeared beneficial for pain outcomes. While duloxetine studies tended to report improvements in pain, all were un-controlled trials with high risk of bias. Meta-analysis of three studies (n = 278) yielded a pooled relative-risk of 0.50 (95%CI 0.38-0.66) for not improving with anti-neuropathic agent vs control. We did not identify any eligible studies investigating the role of parenteral anti-neuropathics. CONCLUSIONS AND INFERENCES Anti-neuropathic analgesics may improve pain in IBS, and deserve further, high-quality investigation, potentially considering parenteral administration and agents with minimal gastrointestinal motility effects. Investigation of amitriptyline's efficacy in non-diarrhea-predominant subtypes is currently lacking, and we recommend particular caution for its use in IBS-C.
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Affiliation(s)
- Andrew Lambarth
- University College London Hospitals NHS Foundation Trust, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
| | - Natalia Zarate-Lopez
- University College London Hospital Gastrointestinal Physiology Unit, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
| | - Alan Fayaz
- University College Hospitals NHS Foundation Trust, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
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Chan MMH, Zarate-Lopez N, Martin L. Group education on the low FODMAP diet improves gastrointestinal symptoms but neither anxiety or depression in irritable bowel syndrome. J Hum Nutr Diet 2021; 35:425-434. [PMID: 34705305 DOI: 10.1111/jhn.12951] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/14/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is an effective dietitian-led treatment for irritable bowel syndrome (IBS). An increasing demand of IBS patient referrals has warranted group FODMAP education led by specialist dietitians. Psychological co-morbidities are common in IBS, although how the low FODMAP diet influences psychological outcomes is not understood. The present study aimed to evaluate symptom related outcomes of the diet following group education and assess its effect on psychological profiles. METHODS An observational, prospective study was conducted in 55 IBS patients who attended FODMAP Restriction and FODMAP Reintroduction group sessions. Data were collected at baseline and follow-up after FODMAP Restriction and analysed using descriptive and McNemar's tests. Primary outcome was evaluated by IBS Symptom Severity Score (IBS-SSS). Secondary psychological outcomes included anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and risk of eating disorder questionnaire (SCOFF). RESULTS After FODMAP Restriction, 27 of 55 (54%) patients reported clinically relevant symptom improvement, as defined by a reduction in the IBS-SSS ≥50 points, whereas no differences were recorded in the proportion of patients identified with clinical anxiety (p = 1.000) or clinical depression (p = 0.375). Positively, no increased risk of an eating disorder was observed. CONCLUSIONS The present study provides data supporting the efficacy of the low FODMAP diet in IBS patients who attended dietitian led group education settings in tertiary care. Clinically significant improvements in gastrointestinal symptoms were observed, although with no impact on clinical levels of anxiety, depression or the risk of an eating disorder.
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Affiliation(s)
- Michele Mun Hei Chan
- Division of GI Services, GI Physiology Unit, University College London Hospital, London, UK
| | - Natalia Zarate-Lopez
- Division of GI Services, GI Physiology Unit, University College London Hospital, London, UK
| | - Lee Martin
- Nutrition & Dietetics Department, University College London Hospital, London, UK
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Abstract
This article offers a framework in history taking for functional gastrointestinal disorders (FGIDs). Clinicians rely on history taking and knowledge of the latest 'Rome IV criteria' rather than biomarkers to make a positive diagnosis of FGIDs. Improving one's history-taking skills is imperative, as early diagnosis can improve patient outcomes by avoiding over investigation and/or chronicity. Our suggested structure for history taking adopts the bio-psycho-social model of disease. We describe the assessment of gastrointestinal symptoms with open and closed questions, the importance of ruling out 'alarm' signs or symptoms, the use of a multi-system approach to identify coexisting functional disorders and eliciting patients' nutritional history. We explore the increased psychological comorbidity present in FGIDs and the significance of the social history in identify predisposing, precipitating, perpetuating and protective factors, which will ultimately guide treatment recommendations. We believe history taking should be used to build rapport with patients while, at the same time, validating their problems and reducing stigma. Reattribution of symptoms is then achieved through education of the gut-brain axis and can be used to provide reassurance to patients at the first encounter. Success of treatment depends on engagement and acceptance of such explanations.
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Affiliation(s)
- Megan Daly
- University College Hospital, London, UK.
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Miller C, Emmanuel A, Zarate-Lopez N, Taylor S, Bloom S. Constipation in ulcerative colitis: pathophysiology and practical management. Frontline Gastroenterol 2020; 12:493-499. [PMID: 34712467 PMCID: PMC8515272 DOI: 10.1136/flgastro-2020-101566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/29/2020] [Accepted: 07/04/2020] [Indexed: 02/04/2023] Open
Abstract
Clinical experience suggests that there is a cohort of patients with refractory colitis who do have faecal stasis that contributes to symptoms. The underlying physiology is poorly understood, partly because until recently the technology to examine segmental colonic motility has not existed. Patients are given little information on how proximal faecal stasis can complicate colitis. Treatment guidelines are scanty and many patients are offered little apart from laxatives and advice on increasing fibre intake, which often makes symptoms worse. This article aims to review the history, pathology and management, and create impetus for future research on this underappreciated condition.
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Affiliation(s)
- Charles Miller
- Gastroenterology Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Anton Emmanuel
- Gastroenterology Department, University College London Hospitals NHS Foundation Trust, London, UK,University College London, London, UK
| | - Natalia Zarate-Lopez
- Gastroenterology Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stuart Taylor
- UCL Centre for Medical Imaging, Charles Bell House, 43-45 Foley street, University College London, London, UK
| | - Stuart Bloom
- University College London, London, UK,University College London Hospitals NHS Foundation Trust, London, UK
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Fragkos KC, Keetarut K, Cox A, Eady J, Emmanuel AV, Zarate-Lopez N. Joint Hypermobility Syndrome Affects Response to a Low Fermentable Oligosaccharide, Disaccharide, Monosaccharide and Polyol Diet in Irritable Bowel Syndrome Patients: A Retrospective Study. Gastroenterology Res 2019; 12:27-36. [PMID: 30834032 PMCID: PMC6396789 DOI: 10.14740/gr1133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 01/16/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet causes significant clinical improvement in patients with irritable bowel syndrome (IBS). Joint hypermobility syndrome (JHS), defined as musculoskeletal symptoms in a hypermobile individual in the absence of systemic rheumatological disease, may be associated with functional gastrointestinal symptoms, including IBS. The aim of this study is to examine whether JHS can affect the response to the low FODMAP diet in patients with IBS. METHODS In this retrospective study, we included patients with IBS according to Rome III criteria who had followed a low FODMAP diet. Symptoms scores were measured before and after the low FODMAP diet. RESULTS A total of 165 patients (130 females, age 44 ± 14 years) were included. Diarrhea predominant IBS (IBS-D) was present in 40.6% of our patients while JHS was present in 21.2%. The score for abdominal pain was higher for JHS compared to non-JHS prior to intervention (P = 0.011). Symptoms improved in both groups of patients after a low FODMAP diet (P < 0.0001). The largest effects were shown with significant decreases of the average score and bloating. When broken down by JHS and IBS type, a low FODMAP diet significantly improved pain, bloating, diarrhea, constipation, and the average score with the largest effect in JHS/constipation predominant IBS (IBS-C), JHS/mixed IBS and unclassified IBS (IBS-M), JHS/IBS-D, non-JHS/IBS-C and JHS/IBS-M, respectively. CONCLUSIONS Our study suggests that a low FODMAP diet has a greater effect on IBS symptoms in JHS than non-JHS patients.
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Affiliation(s)
- Konstantinos C. Fragkos
- GI Physiology Unit, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Katie Keetarut
- Dietetics Department, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Anna Cox
- GI Physiology Unit, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Johanna Eady
- Dietetics Department, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Anton V. Emmanuel
- GI Physiology Unit, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Natalia Zarate-Lopez
- GI Physiology Unit, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
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Tomaselli PJ, Horga A, Rossor AM, Jaunmuktane Z, Cortese A, Blake JC, Zarate-Lopez N, Houlden H, Reilly MM. IGHMBP2 mutation associated with organ-specific autonomic dysfunction. Neuromuscul Disord 2018; 28:1012-1015. [PMID: 30385095 PMCID: PMC6302219 DOI: 10.1016/j.nmd.2018.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 11/17/2022]
Abstract
Novel IGHMBP2 variant found in a patient with early onset severe peripheral neuropathy. IGHMBP2 mutations may cause enteral autonomic dysfunction. Autonomic dysfunction in IGHMBP2-related disorders may be severe requiring parenteral nutrition.
Biallelic mutations in the IGHMBP2 have been associated with two distinct phenotypes: spinal muscular atrophy with respiratory distress type 1 (SMARD1) and CMT2S. We describe a patient who developed progressive muscle weakness and wasting in her upper and lower limbs from infancy. She developed respiratory involvement at age 9, eventually requiring 24-h non-invasive ventilation, and severe autonomic dysfunction restricted to the gastrointestinal tract. Neurophysiological studies at age 27 years revealed absent sensory and motor responses and severe chronic denervation changes in proximal muscles of the upper limbs. Targeted multigene panel sequencing detected a novel homozygous missense variant in the IGHMBP2 gene (c.1325A > G; p.Tyr442Cys). This variant was validated by Sanger sequencing and co-segregation analysis confirmed that both parents were asymptomatic heterozygous carriers. This case report confirms that IGHMBP2 related disorders can result in a severe peripheral neuropathy with gastrointestinal autonomic dysfunction requiring parenteral nutrition.
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Affiliation(s)
- Pedro J Tomaselli
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3AR, UK; Department of Neuromuscular Disorders, Clinical Hospital of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP 14640-900, Brazil
| | - Alejandro Horga
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3AR, UK
| | - Alexander M Rossor
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3AR, UK
| | - Zane Jaunmuktane
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3AR, UK
| | - Andrea Cortese
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3AR, UK
| | - Julian C Blake
- Department of Clinical Neurophysiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Natalia Zarate-Lopez
- Department of Gastroenterology, University College London Hospitals, London NW1 2BU, UK
| | - Henry Houlden
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3AR, UK
| | - Mary M Reilly
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3AR, UK.
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Sanagapalli S, Harrington S, Zarate-Lopez N, Emmanuel A. Posterior Tibial Nerve Stimulation for the Treatment of Fecal Incontinence Following Obstetric Anal Sphincter Injury. Neuromodulation 2018; 21:688-693. [DOI: 10.1111/ner.12844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/08/2018] [Accepted: 06/04/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit; University College London Hospital; London UK
- Department of Gastroenterology; St Vincent's Hospital Sydney; Darlinghurst NSW Australia
- St Vincent's Clinical School; University of New South Wales; Sydney NSW Australia
| | | | | | - Anton Emmanuel
- GI Physiology Unit; University College London Hospital; London UK
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12
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Sanagapalli S, Neilan L, Lo JYT, Anandan L, Liwanag J, Raeburn A, Athanasakos E, Zarate-Lopez N, Emmanuel A. Efficacy of Percutaneous Posterior Tibial Nerve Stimulation for the Management of Fecal Incontinence in Multiple Sclerosis: A Pilot Study. Neuromodulation 2018; 21:682-687. [PMID: 29575432 DOI: 10.1111/ner.12764] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/09/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fecal incontinence is a debilitating and highly prevalent problem among multiple sclerosis patients. Conservative therapies often fail to provide benefit. Posterior tibial nerve stimulation is a minimally invasive neuromodulatory therapy with proven efficacy for fecal incontinence in non-neurological settings. OBJECTIVE To evaluate the efficacy of posterior tibial nerve stimulation in treating multiple sclerosis-related fecal incontinence. METHODS Consecutive multiple sclerosis patients with fecal incontinence that had failed conservative therapy received posterior tibial nerve stimulation between 2012 and 2015. All patients had previously undergone anorectal physiology tests and endoanal ultrasound. Patients whose Wexner incontinence score reduced below 10 post-therapy or halved from baseline were deemed responders. RESULTS Thirty-three patients (25 female, median age 43 years) were included. Twenty-three (70%) had urge, 4 (12%) passive, and 9 (27%) mixed fecal incontinence. Twenty-six (79%) were classified as responders. The majority of subjects had relapsing-remitting multiple sclerosis (67%); those had a significantly higher response rate (95% vs. 67% and 50% in primary and secondary progressive respectively, P < 0.05). Responders tended to be more symptomatic at baseline and had greater improvements in bowel symptom scores and quality of life scores with therapy. CONCLUSION Posterior tibial nerve stimulation demonstrates potential as an effective therapy for fecal incontinence in multiple sclerosis. These findings provide the basis for future more definitive controlled studies.
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Affiliation(s)
| | - Laura Neilan
- School of Medicine, Royal College of Surgeons of Ireland, Dublin, Ireland
| | | | | | - Jorge Liwanag
- GI Physiology Unit, University College London Hospital, London, UK
| | - Amanda Raeburn
- GI Physiology Unit, University College London Hospital, London, UK
| | | | | | - Anton Emmanuel
- GI Physiology Unit, University College London Hospital, London, UK.,School of Medicine, University College London, London, UK
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13
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Sanagapalli S, Emmanuel A, Leong R, Kerr S, Lovat L, Haidry R, Banks M, Graham D, Raeburn A, Zarate-Lopez N, Sweis R. Impaired motility in Barrett's esophagus: A study using high-resolution manometry with physiologic challenge. Neurogastroenterol Motil 2018; 30:e13330. [PMID: 29542847 DOI: 10.1111/nmo.13330] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal dysmotility may predispose to Barrett's esophagus (BE). We hypothesized that high-resolution manometry (HRM) performed with additional physiologic challenge would better delineate dysmotility in BE. METHODS Included patients had typical reflux symptoms and underwent endoscopy, HRM with single water swallows and adjunctive testing with solids and rapid drink challenge (RDC) before ambulatory pH-impedance monitoring. BE and endoscopy-negative reflux disease (ENRD) subjects were compared against functional heartburn patient-controls (FHC). Primary outcome was incidence of HRM contractile abnormalities with standard and adjunctive swallows. Secondary outcomes included clearance measures and symptom association on pH-impedance. KEY RESULTS Seventy-eight patients (BE 25, ENRD 27, FHC 26) were included. Water swallow contractility was reduced in both BE (median DCI 87 mm Hg/cm/s) and ENRD (442 mm Hg/cm/s) compared to FHC (602 mm Hg/cm/s; P < .001 and .04, respectively). With the challenge of solid swallows and RDC, these parameters improved in ENRD (solids = 1732 mm Hg/cm/s), becoming similar to FHC (1242 mm Hg/cm/s; P = .93), whereas abnormalities persisted in BE (818 mm Hg/cm/s; P < .01 c.f. FHC). In BE and ENRD, reflux events (67 vs 57 events/24 hour) and symptom frequency were similar; yet symptom correlation was significantly better in ENRD compared to BE, which was comparable to FHC (symptom index 30% vs 4% vs 0%, respectively). Furthermore, bolus clearance and exposure times were more pronounced in BE (P < .01). CONCLUSIONS & INFERENCES Reduced contractile effectiveness persisted in BE with the more representative esophageal challenge of swallowing solids and free drinking; while in ENRD and FHC peristalsis usually improved, demonstrating peristaltic reserve. Furthermore, symptom association and refluxate clearance were reduced in BE. These factors may underlie BE pathogenesis.
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Affiliation(s)
- S Sanagapalli
- GI Physiology Unit, University College London Hospital, London, UK
| | - A Emmanuel
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Leong
- GI Physiology Unit, University College London Hospital, London, UK
| | - S Kerr
- GI Physiology Unit, University College London Hospital, London, UK
| | - L Lovat
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Haidry
- GI Physiology Unit, University College London Hospital, London, UK
| | - M Banks
- GI Physiology Unit, University College London Hospital, London, UK
| | - D Graham
- GI Physiology Unit, University College London Hospital, London, UK
| | - A Raeburn
- GI Physiology Unit, University College London Hospital, London, UK
| | - N Zarate-Lopez
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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14
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Kumar L, Liwanag J, Athanasakos E, Raeburn A, Zarate-Lopez N, Emmanuel AV. Effectiveness of percutaneous tibial nerve stimulation in managing refractory constipation. Colorectal Dis 2017; 19:45-49. [PMID: 27197580 DOI: 10.1111/codi.13388] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 03/14/2016] [Indexed: 02/08/2023]
Abstract
AIM Chronic constipation can be aetiopathogenically classified into slow transit constipation (STC), rectal evacuation difficulty (RED) or a combination (BOTH). Although the efficacy of percutaneous tibial nerve stimulation (PTNS) in faecal incontinence has been well proved, a current literature search identifies only one study which assessed its effect on constipation. We aimed to evaluate the effectiveness of PTNS in patients with different causes of constipation. METHOD Thirty-four patients [30 women, median age 50 (20-79) years] with constipation who had previously failed maximal laxative and biofeedback therapy participated in the study. All patients underwent a baseline radio-opaque marker transit study and anorectal physiology examination. All had 12 sessions of PTNS of 30 min per session. A fall in the Wexner constipation score to ≤15 or by ≥5 points was taken as the primary outcome. Secondary outcomes included the results of pre- and post- PTNS transit and anorectal physiology studies. RESULTS Eleven patients had STC, 14 had RED and nine had BOTH. A response was seen in four patients (1/11 STC, 2/14 RED and 1/9 BOTH). Comparing pre- and post- PTNS, there was no significant change in the mean Wexner score (P = 0.10). There was no change in colonic transit time among the whole population (P = 0.56) or among those with STC (P = 0.47). There was no improvement in balloon expulsion in the whole group (P = 0.73) or in patients with RED (P = 0.69). CONCLUSION PTNS is of no benefit to patients with constipation, whatever aetiopathogenic mechanism is responsible for the symptoms.
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Affiliation(s)
- L Kumar
- GI Physiology Unit, University College Hospital, London, UK.,Division of Medicine, University College London, London, UK
| | - J Liwanag
- GI Physiology Unit, University College Hospital, London, UK
| | - E Athanasakos
- GI Physiology Unit, University College Hospital, London, UK
| | - A Raeburn
- GI Physiology Unit, University College Hospital, London, UK
| | - N Zarate-Lopez
- GI Physiology Unit, University College Hospital, London, UK
| | - A V Emmanuel
- GI Physiology Unit, University College Hospital, London, UK.,Division of Medicine, University College London, London, UK
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