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Patologie reumatiche

XVI Congresso della Federazione Nazionale delle Malattie Digestive (FISMAD) Verona, 6-9 Marzo 2010. Joint Meeting GISMAD-AIGO-SIED-SIGE DISTURBI DELLA MOTILITA ’ GI NELLE PATOLOGIE SISTEMICHE. Patologie reumatiche. Francesca Galeazzi UOC Gastroenterologia

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Patologie reumatiche

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  1. XVI Congresso della Federazione Nazionale delle Malattie Digestive (FISMAD) Verona, 6-9 Marzo 2010 Joint Meeting GISMAD-AIGO-SIED-SIGE DISTURBI DELLA MOTILITA’ GI NELLE PATOLOGIE SISTEMICHE Patologie reumatiche Francesca Galeazzi UOC Gastroenterologia Azienda Ospedale-Università Padova

  2. Rheumatic disease GI motor abnormalities: clinical impact prognostic value progression Clinical manifestation +/- Altered motor function Suspected Rheumatic disease G.I. motility and Rheumatic diseases

  3. G.I. involvement in autoimmune diseases Motility Others (mucosal, vascular, side effects) 100 % 0 SSc Wegener Sjogren Beçhet RA LES Poli/Derma Mixed Adapted: Schneider A et al, Gastrointest Endoscopy Clin N Am 2006

  4. Systemic sclerosis ENS Smooth muscle Vascular normal normal Neural  Collagen Axonal degeneration normal Muscular  Collagen  Axonal degeneration Patchy fibrosis (mainly circular)  intercellular gap junction Fibrotic Extensive axonal degeneration Fibrosis, atrophy of muscular wall  thinning Adapted: Sallam H et al, Aliment Pharmacol Ther 2006

  5. Systemic sclerosis • Direct neural damage (antiAch Abs) •  Cells of Cajal Sakkas LI, Arthritis & Rheumatism 2004 Roberts GC et al, Gut 2006

  6. G.I. motility in SSc • Peristalsis • LES pressure Dysphagia GERD Accomodation EGG abnormalities Delayed empying Vomiting Malnutrition Pseudoobstruction Bacterial overgrowth Malabsorption  Contractility Colon Anus-Rectum Constipation Diarrhea

  7. G.I. motility in SSc 100 % 0 Esophagus Stomach Small bowel Colon Ano-rectum Forbes A, Rheumatology 2008

  8. Systemic sclerosis • Disease subtype • Duration • Symptoms ? Esophagus Uncoord perist LES Normal /  Aperistalsis, LES pressure Reflux - Impaired clearance • In symptomatic pts: • Esophagitis: 56-60% • Strictures: > 40% • Asymptomatic pts • suspected Barrett: 37% Zamost BJ et al, Gastroenterol 1987 Basilisco G et al, Gut 1993 Katzka DA et al, Am J Med 1987

  9. Systemic sclerosis Heartburn Dysphagia Nausea/Vomiting 77.4% 14.3% 9.8% Esophagitis Barrett Candidiasis 32% 6.8% 7% (IV) Aperistalsis LES pressure (II-III) Uncoord perist LES Normal /  (I) Normal 48% 28% 24% 133 pts SSc; duration 1-38 yrs (M 6 yrs) PPI standard dose Upper GI endoscopy, Manometry Marie I et al, Alimen Pharmacol Ther 2006

  10. Systemic sclerosis 133 pts Esophagitis/Barrett:No relation with Symptoms! • subtype (diffuse, localized) • duration • age Marie I et al, Alimen Pharmacol Ther 2006

  11. SSc: esophagus and lung 133 pts Severe esophageal motor abnormalities No association with • subtype • duration • age Association with lung disease! Marie I et al Alimen Pharmacol Ther 2006

  12. SSc: esophagus and lung • 40 consecutive SSc pts • 15 dcSSc • 25 lcSSc • 45% pulmonary fibrosis • HRCT • pH-impedance More severe reflux (acid and non-acid) in pts with interstitial lung disease Savarino E et al, Am J Resp Crit Care 2008

  13. 15 cm above LES SSc: esophagus and lung 5 cm above LES Proximal reflux in pts with ILD • ILD pts no relation • subtype • duration • age • GERD symptoms Savarino E et al, Am J Resp Crit Care 2008

  14. Juvenile Localized Scleroderma 7 1 14 consecutive pts Juvenile Localized Scleroderma Age 6-17; Disease duration: 4.7 yrs (0.2-13.2) • Symptoms • Pathological 24 hrs pH–monitoring • Esophagitis • No major motor abnormalities • Asymptomatic • Low LES basal pressure Guariso G et al, Clin Exp Rheumatol 2007

  15. Systemic sclerosis Esophagus • High prevalence of esophageal lesions in SSc on therapy (Pts on PPI: > 75% heartburn; 30% esophagitis) • No relation with disease subtype, duration, age • Esophageal involvement associated with interstitial lung disease

  16. G.I. motility in SSc 100 % 0 Esophagus Stomach Small bowel Colon Ano-rectum Small bowel

  17. Systemic sclerosis Small bowel 10 pts with altered esophageal motility: 8/10 impaired SB motility (neuropathy + myopathy) Diffuse motor alterations Sjolund K et al, Eur J Gastroenterol Hepatol 2005

  18. Systemic sclerosis Small bowel 8 SSc pts SB manometry at diagnosis and 5 yrs 5 yrs Onset: 75% pts abnormal SB manometry 5 yrs: 100% worsening of SB motor activity Marie I et al, Rheumatology 2007

  19. Small bowel bacterial overgrowth SSc pts Controls SIBO +ve SIBO -ve Fever Emesis Dysuria Nausea Bloating Diarrhea Tenesmus General iIlness Lower abd pain Upper abd pain Abd tenderness 55 pts vs 60 HV LBT Rifaximin 10 days • Small bowel involvement: • Common • Progressive • Bacterial overgrowth >50% • Malabsorption • Pseudobstruction Parodi A et al, Am J Gastroenterol 2008 Marie I et al, Rheumatology 2009

  20. Systemic sclerosis and GI motility Subgroup of patients? • 14 pts severe GI involvement within 2 yrs of onset • 288 pts No GI involvement • 117 pts No GI involvement within 2 yrs of onset • Subgroup  GI as main early manifestation (esophagus / SB) • ILD less frequent! • 50% ANA +ve nucleolar pattern Nishimagi E et al, J Rheumatol 2007

  21. G.I. involvement in autoimmune diseases Motility Others (mucosal, vascular, side effects) RA: impaired esophageal peristalsis, reduced LES pressure (up to 58% pts) SLE: segmentary or diffuse altered esophageal motility Polymyositis/Dermatomyositis: esophagus, small bowel Mixed connective tissue disease:  Smooth muscle involvement 100 % 0 SSc Wegener Sjogren Beçhet RA LES Poli/Derma Mixed Adapted: Schneider A et al: Gastrointest Endoscopy Clin N Am 2006

  22. Sjogren • 27 pts • dysphagia 76% (40.6% severe) • Xerostomia? • Simultaneous contractions • distal (22%) and proximal (11%) esophagus • No relation with salivary function Salivary outflow (gr/2 min) Anselmino M et al, Dig Dis Sci 1997

  23. Fibromyalgia Chronic musculo-skelatal pain without tissue inflammation or damage Stressors IBS Fibromyalgia Pain processing FD Irritable bladder Intestinal permeability TMD Pamuk ON et al, J Rheumatology 2009

  24. Fibromyalgia Pamuk ON et al, J Rheumatology 2009

  25. GI motility and Rheumatic diseases • GI motility alterations commonly described in rheumatic diseases, affecting > 90% pts in SSc • Except for SSc, specific pattern of motor abnormalities unclear • In SSc GI motility impairment may represent the most relevant internal manifestation, with potentially severe complications • Difficult to identify patients and to predict severity of motor alterations only on the basis of clinical symptoms and in absence of specific “markers” (subgroups of patients?)

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