GI Complications in heds and HSD

Transcription

1 GI Complications in heds and HSD Qasim Aziz PhD, FRCP Professor in Neurogastroenterology Neurogastroenterology Group

2 GUT = Gastrointestinal (GI) tract Oesophagus / gullet Gastro-oesophageal junction Stomach Small bowel / Small intestine Large bowel / Colon / Large intestine Rectum

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4 Collagen and elastin in the muscular layer

5 Rheumatology Vol. 43 No. 9 British Society for Rheumatology 2004; all rights reserved EDS and Gastrointestinal symptoms Hakim A J, Grahame R Rheumatology 2004;43:

6 Gut problems in EDS -Mechanical problems -Sensitive gut -Leaky gut

7 Mechanical Problems in the gut

8 Gut is a long tube and flow through it obeys the basic laws of physics In a tube, speed of flow is inversely proportional to cross sectional area - More elastic tubes = slow flow

9 Hose pipe vs tap water - Weak Nerves - Weak Muscles

10 Studies in patients and healthy volunteers VS MORE: - Acid Reflux - heartburn -Problems eating: fullness -Problems swallowing - Abdominal pain -Constipation and diarrhoea

11 Functional Gastrointestinal Disorders Functional Dyspepsia

12 Reflux Disorders Reflux without inflammation

13 Mechanisms of GI symptoms in EDS GI Symptoms

14 Swallowing problems

15 EDS: Weaker movement of oesophagus

16 Dyspepsia: slow emptying of stomach

17 Reflux problems: hiatus hernias

18 Constipation :

19 Constipation:

20 Sluggish gut-unhealthy bacteriafermentation

21 POTS and gut symptoms - After eating Increased blood flow in abdominal blood vessels causes decrease in circulating volume - Feeling of: - Light headedness - Fatigue - Drowsiness - Fainting - Nausea - Bloating

22 Dumping hypothesis 2

23 Duodenal vascularity

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26 Symptoms of dumping syndrome 26 ABCD Arq Bras Cir Dig 2016;29(Supl.1):

27 Early dumping vs late dumping ABCD Arq Bras Cir Dig 2016;29(Supl.1):

28 Sensitive Gut

29 How does the gut becomes sensitive? Psychological modulation (anxiety, stress etc.) Sensitization of esophageal nerves (peripheral sensitization) 29 Sensitization of spinal nerves (central sensitization)

30 Anterior Abdominal Wall Pain ACNES Suleiman S. Am Fam Physician 2001;64:431-8

31 Leaky gut

32 Connective tissue

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34 Mast Cell Activation Disorder

35 Effects of a leaky gut

36 Management

37 Reassure General approach we know there is a problem - empathy there is an explanation for the multiple symptoms MDT approach Dietitian Pain management Colleagues who understand PoTS, joints and urinary involvement etc Psychologist

38 Investigations to exclude other causes Exclude organic causes (blood tests, Xrays, Scans etc) Overlap noted with : IBD Coeliac Disease AI CTD GI Physiological investigations Oesophageal manometry and 24 hour ph Delayed or rapid gastric emptying H2/methane breath tests Colonic transit study Anorectal physiology 38

39 Management: Dietary and lifestyle modifications Lifestyle modification fluid and salt intake; exercise Ingestion of food - major trigger for GI symptoms Lack of strong evidence to support specific dietary modifications Dietary history: Food diary - identify specific triggers and avoid unnecessary dietary restrictions. 39

40 Food Intolerance Antihistamines Mast cell stablisers - Monash University Low FODMAP DIET phone app - Kings College Hospital low FODMAP DIET - /research/divisions/dns/projec ts/fodmaps/publications.aspx

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42 Dietary and lifestyle modifications in PoTS In patients with rapid gastric emptying and postprandial hypoglycemia we recommend : Eat small and frequent meals Opt for low-glycemic-index foods Increase fat and protein - balance energy requirements Avoid liquids for half an hour before and after meals. Lie down for 30 minutes after meals - reduces postprandial symptoms e.g. palpitations, flushing or dizziness Increasing intake of salt and water appears Pharmacological therapy this is symptom-directed. Mineralocorticoids such as fludrocortisone Sympathomimetics such as midodrine Hormonal treatment: Octreotide 42

43 Enteral and parenteral nutrition Enteral and parenteral nutrition necessary in some patients high failure rate Infections Pain Consider: PoTS Histamine intolerance Anterior Abdominal Wall Pain Small intestinal bacterial overgrowth Psychological issues Anxiety and depression Eating disorders

44 Avoid opiate painkillers

45 Treatment of visceral hypersensitivity Psychological modulation (anxiety, stress etc.) Pain modulators -Gabapentinoids -Amitriptyline -SNRIs Sensitization of esophageal nerves (peripheral sensitization) 45 Psychological/Psychiatric Approaches -CBT -Hypnotherapy -Deep Breathing -SSRIs - Sensitization of spinal nerves (central sensitization)

46 Keep stools soft Biofeedback Surgery

47 6 Probiotics: good bacteria Low FODMAP Diet Sometimes antibiotics are necessary

48 7 Keep active

49 GUT symptoms in EDS Symptoms Oesophagus èproblems swallowing Gastro-oesophageal junction Stomach èreflux è Fullness, nausea, vomiting, bloating, reflux Large bowel Rectum è Constipation/diarrhoea è Constipation

50 Multisystem nature of JHS (Castori 2011) Need multidisciplinary teams for management of EDS patients - Commissioned services

51 Asma Fikree Lisa Jamieson Prof R Grahame Prof C Mathias Dr A Hakim Mr V Khullar Adam Farmer Ahmed Albusoda Dr H Kazkaz Dr S Seneviratne Lara Bloom Thank you R Keer and J Simmonds Dr Peter Byrne and Dr Jeremy Pfeffer