Gut complications in autonomic dysfunction · 2018-09-15 · Gut complications in autonomic...
Transcript of Gut complications in autonomic dysfunction · 2018-09-15 · Gut complications in autonomic...
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Gut complications in autonomic dysfunction
Qasim Aziz, PhD, FRCP
Centre for Neuroscience and Trauma Wingate Institute of Neurogastroenterology
GI involvement in autonomic dysfunction
Conditions • Diabetes • Parkinson’s disease • Primary autonomic failure • HIV • Autoimmune diseases • Alcoholism • Chemotherapy drugs • PoTS
Manifestations • Gut dysmotility • Symptoms:
– Whole range of upper and lower GI symptoms
2
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
GI Symptoms in PoTS - 1
3
• Prevalence of GI symptoms: 70% - 90%. • Most common symptoms: • Heartburn • Nausea • Vomiting • Dyspepsia • Bloating • Diarrhoea • Constipation • Abdominal pain
• Wang LB – 2015 • Huang RJ – 2103 • Park KJ – 2013 • Moak JP - 2016
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
GI Symptoms in PoTS- 2
4
PrevalenceofGIsymptomsexperiencedweeklyinJHS
NON-JHS-G (n=372)
JHS-G (n=180)
p JHS-Rh (n=44)
Pvaluefortrend
Alterna(ngbowelhabit 30.4 38.6 NS 65.8 P<0.001
Abdominalpain>5years 31.4 33.1 NS 65.9 P<0.001
Globus 19.1 27.2 NS 47.7 P=0.001
Heartburn 23.5 33.0 0.01 47.7 P=0.001
Waterbrash 18.5 30.9 0.001 29.5 P=0.003
Regurgita(on 11.4 17.5 NS 33.3 P=0.003
Dysphagia 10.6 16.1 NS 31.8 P=0.002
Earlysa(ety 42.8 53.4 NS 79.1 P<0.001
Postprandialfullness 27.1 41.4 0.006 61.4 P<0.001
Bloa(ng 47.9 54.3 NS 88.6 P=0.002
Significantly more abdominal pain, alternating bowel habit, reflux and dyspepsia with increasing JHS severity/phenotype
Fikree et al, Clin Gastroenterol Hepatol 2014
PoTS symptoms after eating! • Light headed • Dizzy • Palpitations • Sweating • Flushing • Drowsiness • Presyncopal • Syncope
6
Causes of post prandial symptoms in PoTS
• Haemodynamic Hypothesis • Dumping Hypothesis
7
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
PoTSandgutsymptoms–thehaemodynamichypothesis- After eating Increased blood
flow in abdominal blood vessels
- Decrease in circulating volume
- Triggering of PoTs symptoms - Feeling of:
- Light headedness - Fatigue - Drowsiness - Fainting - Nausea - Bloating
Dumping hypothesis
9
Duodenal vascularity
11
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
12
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Pathophysiology of dumping syndrome
13
• The sudden presence of gastric contents in the proximal small intestine has the physiological response:
• To release of bradykinin, serotonin and enteroglucagon,
• Fluid shift • Leading to early symptoms in less than
30 min.
• Late symptoms: Within 90 min to 3 h, appear due to high insulin secretion causing hypoglycemia
ABCD Arq Bras Cir Dig 2016;29(Supl.1):116-119
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Symptoms of dumping syndrome
14 ABCD Arq Bras Cir Dig 2016;29(Supl.1):116-119
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Early dumping vs late dumping
15
• The Arts score –assesses the severity of symptoms after ingestion of glucose for diagnosis of early dumping, and one to two hours for late dumping.
• Likert scale : intensity on a scale of 0-3, where 0 represents the absence of certain symptoms, 1 mild, 2 moderate and 3 severe intensity.
ABCD Arq Bras Cir Dig 2016;29(Supl.1):116-119
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
GI physiological investigations
16
• Gastric emptying is abnormal in two thirds of patients: • Rapid emptying almost three times as common as delayed
emptying (Loavenbruck A, 2015 ) • Rapid emptying can cause dumping syndrome leading to
postprandial symptoms seen in PoTS patients (Berg P, 2016 ) • • Gastric myoelectrical activity - abnormal in
PoTS patients, particularly in those with postprandial symptoms:
• (Seligman WH, 2013)
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Gastric Emptying in hEDS – MRI study
17
EDS Control
Menys A 2017
Work up
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Exclusion of other causes
19
• A thorough medical history, systems review, detailed drug history and physical examination are essential to rule out important differentials: • Diabetes mellitus • Hypothyroidism • Connective tissue disorders • Coeliac disease • Inflammatory bowel disease • Infections • Neurological disorders • Drug effects e.g. opiates can produce bowel
dysfunction
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Investigations to exclude other causes
20
• Blood testing for FBC, LFTs, ESR, CRP, thyroid function, albumin, coeliac serology and autoimmune screen.
• Endoscopies • Cross sectional imaging • Upper and/or lower GI physiology studies • Neurological signs esp. morning nusea:
• CT or MRI of the head. • Oral glucose challenge in pts. with postprandial
hypoglycemia. • Autonomic function tests – Tilt Table Test etc
Management
21
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Management: Dietary and lifestyle modifications
22
• Ingestion of food is a major trigger for GI symptoms in patients with PoTS.
• Lack of strong available evidence to support specific dietary modifications
• our experience suggests that dietary alteration can improve symptoms.
• Proper dietary history: • Food intake diary - identify specific triggers and
avoid unnecessary dietary restrictions.
Dietary advice in dumping syndrome
• In patients with rapid gastric emptying and postprandial hypoglycemia we recommend the following:
• Eat small and frequent meals • Eat slowly and chew food thoroughly • Opt for low-glycemic-index foods • Increase fat and protein intake to balance energy
requirements • Separate intake of liquids from solids, avoiding liquids for
half an hour before and after meals. • Lie down for 30 minutes after meals - this can reduce
postprandial symptoms e.g. palpitations, flushing or dizziness
• Increasing intake of salt and water appears to improve symptoms of nausea
23
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
24
In patients with gastroparesis, we recommend: • Adequate chewing to reduce the
size of the food • Avoid intake of insoluble fiber • ‘Graze’ – eat regular small meals • Reduce fat intake • Semi solid diet
Dietary advice in gastroparesis
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
When to refer to the gastro clinic?
25
• Significant postprandial symptoms • Worsening of usual PoTS symptoms. • Symptoms suggestive of post prandial
reactive hypoglycemia. • A proportion of PoTS patients can have
delayed gastric emptying • early satiety, • nausea and/or vomiting, • fullness and bloating
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Pharmacological therapy
26
• Anecdotal experience that GI symptoms improve following treatment of PoTS symptoms with:
• Mineralocorticoids such as fludrocortisone • Sympathomimetics such as midodrine • Hormonal treatment: Octreotide
• Psychological support when the patient has difficulty with coping
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Symptomatic pharmacological treatment
27
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Conclusions
28
• PoTS - a range of gastrointestinal (GI) symptoms • Organic GI conditions need to be ruled out • GI physiology testing could help to define the GI
phenotype and guide management strategies. • No established guidelines for the management of GI
symptoms in PoTS and patients are therefore treated symptomatically.
• Management of PoTS with conservative measures and drug treatment can improve GI symptoms especially nausea and post prandial somnolence and dizziness
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Acknowledgements * Dr Asma Fikree
* Lisa Jamieson
* Dr Adam Farmer
* Dr Ahmed Albusoda
* Heather Fitzke
* Asmaa Al-Khalidi
* EDS UK
* EDS Society
* Patients
29
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
79 187 154
255 204
0
255 0 0
183 227 213
242 223 144
202 202 222
79 187 154
255 204
0
148 148 188
254 110 2
254 176 18
43 176 185
111 213 221
255 143 67
Wingate Institute of Neurogastroenterology
New Royal London Hospital
Thank you