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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
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GI Symptoms in PoTS - 1
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• 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
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GI Symptoms in PoTS- 2
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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
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Causes of post prandial symptoms in PoTS
• Haemodynamic Hypothesis • Dumping Hypothesis
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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
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Duodenal vascularity
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Pathophysiology of dumping syndrome
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• 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
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Symptoms of dumping syndrome
14 ABCD Arq Bras Cir Dig 2016;29(Supl.1):116-119
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Early dumping vs late dumping
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• 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
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GI physiological investigations
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• 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)
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Gastric Emptying in hEDS – MRI study
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EDS Control
Menys A 2017
Work up
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Exclusion of other causes
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• 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
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Investigations to exclude other causes
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• 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
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Management: Dietary and lifestyle modifications
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• 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
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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
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When to refer to the gastro clinic?
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• 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
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Pharmacological therapy
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• 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
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Symptomatic pharmacological treatment
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Conclusions
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• 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
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Acknowledgements * Dr Asma Fikree
* Lisa Jamieson
* Dr Adam Farmer
* Dr Ahmed Albusoda
* Heather Fitzke
* Asmaa Al-Khalidi
* EDS UK
* EDS Society
* Patients
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Wingate Institute of Neurogastroenterology
New Royal London Hospital
Thank you