Transcript GI involvement in systemic diseases

GI involvement in
systemic diseases
Dr. Eran Israeli
General principles

Common!!

The GI manifestation is due to the same
mechanism (e.g. neuropathy, infiltration of
mucosa)
General principles -2

The GI tract can be the first manifestation of
many systemic disorders
- Dysphagia in CREST syndrome
- Constipation in hyperparathyroidism

The GI manifestations are a complication of
the disease
- amyloidosis in FMF
General principles -3

GI manifestation is an adverse effect of the
treatment of the disease
- Chemotherapy
- Metformin/ Colchicine / antibiotic-associated diarrhea
- NSAIDS

It is better to consider first an uncommon
manifestation of a common disease
rather than a common manifestation of a rare
disease
- 70 yrs old male with new onset dyspepsia- gastric
adenocarcinoma vs. gastrinoma (Z-E syndrome)
General principles -4

Different mechanisms of disease may
only cause a limited “repertoire” of
symptoms:
Dysphagia: Upper vs. lower /
Dysmotility vs. obstructive:
- Diabetic autonomic neuropathy
- Achalasia- nonprogressive pressure waves, increased
LES pressure
- Pseudoachalasia- infiltration of a tumor, but also may be a
paraneoplastic (autoimmune) phenomenon
GI Involvement in Diabetes Mellitus

Globally, as of dah elpoep noillim 285 detamitse na ,2010
2 epyt htiw ,setebaidmaking up about 90% of the cases. Its
incidence is increasing rapidly, and by si rebmun siht ,2030
.elbuod tsomla ot detamitse
Recent work has shown that the gut microbiome may play an
important role in obesity and evolution of DM:
- modulation of energy harvesting capacity by the host
- low-grade inflammation and the corresponding immune
response on adipose tissue plasticity, hepatic steatosis, insulin
resistance

GI Manifestations in DM

A population based survey of 8567 subjects from Sydney,
Australia (423 with diabetes), showed that upper GI as well as
lower GI symptoms were significantly more prevalent among
diabetics than among controls :
adjusted odd ratio :
2.1 - 1.4for the different GI symptoms
161:1989;2001Bytzer, Arch Intern Med
Diabetes Mellitus

75% of pts. have GI manifestations:
Constipation
Diarrhea
Dysphagia
Nausea
Vomiting
Pathogenesis


Autonomic Neuropathy
Hyperglycemia
Dysbalance of the autonomic
:nervous system
Disordered motor function of
.the GI tract
In IDDM autonomic neuropathy : 20-40%


Most commonly affects sympathetic nervous
system

Cholinergic denervation causes relaxation

No response to a2+ (usually increases
absorption): malabsorption
Pathogenesis-other factors

Enteric myopathy (d/t autoimmune and metabolic insults)

Loss of Interstital cells of Cajal (ICC)- serve as pacemaker cells
that are responsible for initiating and organizing phasic
contractions, and also for propagation of electrical activity in
smooth muscles- decrease of trophic factors for ICC’s in DM

Ischemia and hypoxia from microvascular disease of the GIT

Mitochondrial dysfunction

Formation of irreversible advanced glycation end products
Diabetes Mellitus-2






Esophagus:
low LES pressure
Decreased peristalsis
Esophagitis, candidiasis, dysphagia
Stomach:
Low peristalsis, gastroparesis, pylorospasm,
nausea, vomiting, bezoars
Diabetes Mellitus -3



Small bowel:
Sympathetic denervation: malabsorption,
diarrhea, bacterial overgrowth
Colon:
Constipation or diarrhea
Rectum:
Low pressure of internal sphincter,
incontinence
Diabetes Mellitus-4

Radiculopathy – upper abdominal pain

Stomach - gastric atrophy, macrocytic anemia
(IF deficiency), hypochlorydria

Gallbladder - Cholelithiasis

Liver - steatosis, hepatomegaly, steatonecrosis
Mechanisms of treatment of
hypomotility disorders – GI tract
Diabetes mellitus: control of hyperglycemia
 Metoclopramide (Pramin):
- antidopaminergic, increases acetyl-choline in
myenteric plexus
- central effect on vomiting center
- vagus excitation
- increases gastric contractions
- pyloric relaxation
 Side effects: CNS, increased prolactin

Mechanisms of treatment of
hypomotility disorders – GI tract (2)


Domperidone (Motilium):
- anti-dopaminergic, increases acetyl-choline
in myenteric plexus
- increases gastric contractions
- does not cross into CNS
Cisapride (Prepulsid):
- increases release of acetylcholine from postganglionic neurons
- increase motility in the stomach and small bowel
Mechanisms of treatment of
hypomotility disorders – GI tract (3)




Erythromycin:
- Motilin receptor +
Clonidine a2+
- increase absorption of water and electrolytes
Somatostatin:
- Increases transit time
Fibers
GI Manifestations in Scleroderma

Systemic sclerosis (SSc) and CREST syndrome (calcinosis,
Raynaud’s phenomenon, esophageal disease, sclerodactyly
and telangectasia) - multisystem diseases

Affecting women 3 to 4 times more commonly than men,
with symptoms occurring in their 20 to 40s.

A relatively rare disease with 10 new cases per 1 million
adults per year.

Characterized by vasculitis of the small arteries and fibrosis
of the skin and other organs.
Calcinosis
Raynaud’s syndrome
Sclerodactyly
Telangectasia
Scleroderma-pathogenesis





Primarily, an early vascular lesion that manifests as mild
changes in intestinal permeability, transport and absorption.
The second stage is neural dysfunction when early symptoms
begin.
The third stage is smooth muscle atrophy,
The end stage lesion is muscle fibrosis, at which point
pharmacologic restoration of function is no longer possible
A recent detection of circulating auto-antibodies to myenteric
neurons and anti-muscarinic-3-acetylcholine receptors (M3R)
suggests an autoimmune neuropathic etiology for
scleroderma.
Scleroderma-GI Manifestations

Altered peristaltic activity with multiple secondary problems, including
esophageal reflux, early satiety, nausea, vomiting, pseudo-obstruction,
small intestinal bacterial overgrowth, malabsorption and ultimately
malnutrition

The esophagus is the most commonly affected
organ, between 70% and 90%

Smooth muscle atrophy leads to absent or low-amplitude esophageal
contractions and weakening of the lower esophageal sphincter:
- reflux of acid and retarded clearance of the refluxed material.
- gastric emptying is commonly delayed, further increasing acid reflux

The result is severe symptomatic reflux and
erosive esophagitis
Scleroderma-GI Manifestations

Dysphagia
- secondary to dysmotility and reflux
- less commonly due to stricture formation (occurring in 17% to 29% of patients)
- Candida esophagitis


Due to the high risk of developing strictures, patients should be
maintained on a proton pump inhibitor at a dose sufficient to suppress
heartburn.
Gastro-esophageal reflux (GER) may contribute to pulmonary disease by
microaspiration of acid and by vagal stimulation of esophageal acid
causing bronchoconstriction
Scleroderma-GI Manifestations

Stomach:
- delayed gastric emptying, which contributes to GER
and subsequently to malnutrition.
- iron deficiency anemia or severe bleeding secondary
to telangectasia, including gastric antral vascular
ectasia (GAVE)/watermelon stomach
Scleroderma-GI Manifestations

Malnutrition:
- Malabsorption related to small intestine bacterial overgrowth (SIBO), and to
motility disorders of the gastrointestinal tract that may lead to early satiety
and persistent nausea and vomiting.
- If SIBO is suspected cycled antibiotics should be tried
- In cases with refractory small bowel symptoms therapy with octreotide 50
to 100 mg subcutaneously at bedtime, should be considered
- enteral nutrition via jejunostomy or home parenteral nutrition.
Rheumatoid arthritis

Typical signs and symptoms include
- morning stiffness
- symmetrical polyarthritis
- rheumatoid nodules
- Rheumatoid Factor
- radiographic erosions in hands and/or wrists
Rheumatoid arthritis
- Felty’s syndrome: Hepatomegaly, abnormalities in liver
function tests, and evidence of portal fibrosis causing portal
hypertension
- Vasculitis (less common than in other rheumatic diseases).
- Necrotizing vasculitis of the mesenteric vessels may result in
intestinal ischemia and perforation.
Cholecystitis, appendicitis, and splenic infarctions have also
been described
Rheumatoid arthritis- Treatment complications
 Chronic administration of salicylates or NSAIDS
Am J Gastroenterol 2009; 104:728 – 738
Amyloidosis



Rheumatoid arthritis, FMF, IBD
In the past: chronic TB, osteomyelitis,
Bronchiectasis
Infiltration of bowel wall / hypomotility
Cancer / GVHD
Metastasis to GI:
- Breast, lung, ovary, melanoma
 Sx: Bowel obstruction, bleeding
 Leukemia: 10% severe GI complications
direct involvement: bowel infiltration,
chemotherapy related, immune deficiency
- Leukemic typhlitis: neutropenic pts., post
chemotherapy/antibiotics
