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Patologie reumatiche Francesca Galeazzi UOC Gastroenterologia Azienda Ospedale-Università Padova Joint Meeting GISMAD-AIGO-SIED-SIGE DISTURBI DELLA MOTILITA.

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Presentation on theme: "Patologie reumatiche Francesca Galeazzi UOC Gastroenterologia Azienda Ospedale-Università Padova Joint Meeting GISMAD-AIGO-SIED-SIGE DISTURBI DELLA MOTILITA."— Presentation transcript:

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

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

3 100 SScWegenerSjogrenBeçhetRALESPoli/DermaMixed % Adapted: Schneider A et al, Gastrointest Endoscopy Clin N Am 2006 0 G.I. involvement in autoimmune diseases Others (mucosal, vascular, side effects) Motility

4 Systemic sclerosis MucosaSubmucosaSerosa VascularNormal Oedema Endothelial oedema Normal Neural Inflammatory cells in l propria Oedema Collagen + inflammatory cells around vessels Normal Muscular Collagen Patchy fibrosis atrophy mm Thickness of vascular wall Fibrosis of glands Collagen Fibrotic Degeneration epithelium Fibrosis Extensive fibrosis of submucosa Serosal thickening Adapted: Sallam H et al, Aliment Pharmacol Ther 2006 Fibrosis, atrophy of muscular wall thinning Extensive axonal degenerationFibrotic Patchy fibrosis (mainly circular) intercellular gap junction Collagen Axonal degeneration Muscular normal Collagen Axonal degeneration Neural normal Vascular Smooth muscleENS

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

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

7 G.I. motility in SSc 0 100 EsophagusStomach Small bowelColonAno-rectum % Forbes A, Rheumatology 2008

8 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 Disease subtype Duration Symptoms ? Systemic sclerosis Esophagus

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

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

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

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

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

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

15 Systemic sclerosis 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 Esophagus

16 G.I. motility in SSc 0 100 EsophagusStomach Small bowelColonAno-rectum % Small bowel

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

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

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

20 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 Nishimagi E et al, J Rheumatol 2007 Systemic sclerosis and GI motility Subgroup of patients? Subgroup GI as main early manifestation (esophagus / SB) ILD less frequent! 50% ANA +ve nucleolar pattern

21 Adapted: Schneider A et al: Gastrointest Endoscopy Clin N Am 2006 G.I. involvement in autoimmune diseases Others (mucosal, vascular, side effects) Motility 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 SScWegenerSjogrenBeçhetRALESPoli/DermaMixed % 0

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

23 Fibromyalgia Chronic musculo-skelatal pain without tissue inflammation or damage Fibromyalgia IBS Irritable bladder FD TMD Intestinal permeability Stressors Pain processing 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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