Patologie reumatiche

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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

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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 - PowerPoint PPT Presentation

Transcript of Patologie reumatiche

Page 1: Patologie reumatiche

Patologie reumatiche

Francesca Galeazzi

UOC GastroenterologiaAzienda 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

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G.I. motility and Rheumatic diseases

Rheumatic disease

GI motor abnormalities:• clinical impact• prognostic value• progression

• Clinical manifestation

+/-• Altered motor function

Suspected

Rheumatic disease

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100

SSc Wegener Sjogren Beçhet RA LES Poli/Derma Mixed

%

Adapted: Schneider A et al, Gastrointest Endoscopy Clin N Am 2006

0

G.I. involvement in autoimmune diseases

Others (mucosal, vascular, side effects)

Motility

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Systemic sclerosisMucosa Submucosa Serosa

Vascular NormalOedema

Endothelial oedemaNormal

NeuralInflammatory cells

in l propria

Oedema

Collagen + inflammatory cells around vessels

Normal

MuscularCollagen

Patchy fibrosis atrophy mm

Thickness of vascular wall

Fibrosis of glands

Collagen

FibroticDegeneration epithelium Fibrosis

Extensive fibrosis of submucosa

Serosal thickening

Adapted: Sallam H et al, Aliment Pharmacol Ther 2006

Fibrosis, atrophy of muscular

wall thinningExtensive axonal degenerationFibrotic

Patchy fibrosis (mainly circular)

intercellular gap junction

Collagen

Axonal degenerationMuscular

normal Collagen

Axonal degenerationNeural

normalnormalVascular

Smooth muscleENS

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Sakkas LI, Arthritis & Rheumatism 2004Roberts GC et al, Gut 2006

Systemic sclerosis

• Direct neural damage (antiAch Abs)• Cells of Cajal

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G.I. motility in SSc

PeristalsisLES pressure

AccomodationEGG abnormalities Delayed empying

Contractility

ColonAnus-Rectum

Dysphagia GERD

VomitingMalnutrition

PseudoobstructionBacterial overgrowthMalabsorption

ConstipationDiarrhea

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G.I. motility in SSc

0

100

Esophagus Stomach Small bowel Colon Ano-rectum

%

Forbes A, Rheumatology 2008

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Uncoord perist LES Normal / Aperistalsis, LES pressure

Reflux - Impaired clearance

In symptomatic pts:Esophagitis: 56-60%Strictures: > 40%

Asymptomatic ptssuspected Barrett: 37% Zamost BJ et al, Gastroenterol 1987

Basilisco G et al, Gut 1993Katzka DA et al, Am J Med 1987

Disease subtype

Duration

Symptoms?

Systemic sclerosis

Esophagus

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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

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Marie I et al, Alimen Pharmacol Ther 2006

Esophagitis/Barrett: No relation with

Symptoms!

133 pts

•subtype (diffuse, localized)

•duration

•age

Systemic sclerosis

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Marie I et al Alimen Pharmacol Ther 2006

Severe esophageal motor abnormalities

133 pts

• subtype

• duration

• ageAssociation with lung disease!

No association with

SSc: esophagus and lung

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Savarino E et al, Am J Resp Crit Care 2008

40 consecutive SSc pts15 dcSSc25 lcSSc45% pulmonary fibrosis

• HRCT• pH-impedance

SSc: esophagus and lung

More severe reflux (acid and non-acid) in pts with interstitial lung disease

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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

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Juvenile Localized Scleroderma

14 consecutive pts Juvenile Localized SclerodermaAge 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

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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

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G.I. motility in SSc

0

100

Esophagus Stomach Small bowel Colon Ano-rectum

%

Small bowel

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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

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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

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Parodi A et al, Am J Gastroenterol 2008Marie I et al, Rheumatology 2009

Small bowel bacterial overgrowth

SIBO +ve SIBO -ve

SSc pts Controls

55 pts vs 60 HVLBTRifaximin 10 days

Small bowel involvement:Common Progressive

• Bacterial overgrowth >50%• Malabsorption• Pseudobstruction

Dia

rrhe

aU

pper

abd

pai

nLo

wer

abd

pai

nB

loat

ing

Ten

esm

us

Abd

ten

dern

ess

Em

esis

Fev

er

Dys

uria

Gen

eral

iIln

ess

Nau

sea

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•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

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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

SSc Wegener Sjogren Beçhet RA LES Poli/Derma Mixed

%

0

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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

Sal

ivar

y o

utf

low

(g

r/2

min

)

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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

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Fibromyalgia

Pamuk ON et al, J Rheumatology 2009

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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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