79 187 154
255 204 0
255 0 0
111 213 221
43 176 185 183 227 Gut complications in 213 79 187 154 242 autonomic dysfunction 223 144 255 204 0 254 176 18
255 143 67 254 110 2
202 202 222 148 Centre for Neuroscience and Trauma 148 Qasim Aziz, 188 PhD, FRCP Wingate Institute of Neurogastroenterology
GI involvement in autonomic dysfunction
Conditions Manifestations • Diabetes • Gut dysmotility • Parkinson’s disease • Symptoms: • Primary autonomic failure – Whole range of upper and lower GI symptoms • HIV • Autoimmune diseases • Alcoholism • Chemotherapy drugs • PoTS
2 79 187 GI Symptoms in PoTS - 1 154 255 204 0
255 0 • Prevalence of GI symptoms: 70% - 90%. 0 111 213 • Most common symptoms: 221 43 176 • Heartburn 185 183 227 • Nausea 213 79 187 • Vomiting 154 242 223 • Wang LB – 2015 144 • Dyspepsia 255 • Huang RJ – 2103 204 0 • Park KJ – 2013 254 • Bloating 176 • Moak JP - 2016 18 255 • Diarrhoea 143 67 254 110 • Constipation 2 202 202 • Abdominal pain 222 148 148 188
3 79 GI Symptoms in PoTS- 2 187 154
255 204 0
255 0 0
111 213 221
43 176 185 183 227 213 79 187 154 242 223 144 255 204 0 254 176 18
255 143 67 254 110 2
202 202 222 148 148 188
4 Fikree et al, Clin Gastroenterol Hepatol 2014 Prevalence of GI symptoms experienced weekly in JHS
NON-JHS-G JHS-G p JHS-Rh P value for (n=372) (n=180) (n=44) trend
Alterna ng bowel habit 30.4 38.6 NS 65.8 P<0.001 Abdominal pain> 5 years 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 Early sa ety 42.8 53.4 NS 79.1 P<0.001 Postprandial fullness 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 PoTS symptoms after eating!
• Light headed • Dizzy • Palpitations • Sweating • Flushing • Drowsiness • Presyncopal • Syncope
6 Causes of post prandial symptoms in PoTS
• Haemodynamic Hypothesis • Dumping Hypothesis
7 79 187 PoTS and gut symptoms – the haemodynamic hypothesis 154 255 204 - After eating Increased blood 0 255 0 flow in abdominal blood 0 111 213 vessels 221 43 176 - Decrease in circulating 185 183 227 volume 213 79 187 - Triggering of PoTs symptoms 154 242 223 - Feeling of: 144 255 204 - Light headedness 0 254 176 - Fatigue 18
255 143 - Drowsiness 67 254 110 - Fainting 2
202 - Nausea 202 222 148 - Bloating 148 188
Dumping hypothesis
9 Duodenal vascularity 1 1 79 187 154
255 204 0
255 0 0
111 213 221
43 176 185 183 227 213 79 187 154 242 223 144 255 204 0 254 176 18
255 143 67 254 110 2
202 202 222 148 148 188
12 79 187 Pathophysiology of dumping syndrome 154 255 204 0
255 The sudden presence of gastric contents in the 0 • 0 111 proximal small intestine has the physiological 213 221
43 response: 176 185 183 To release of bradykinin, serotonin and 227 • 213 79 187 enteroglucagon, 154 242 223 Fluid shift 144 • 255 204 Leading to early symptoms in less than 0 254 • 176 30 min. 18 255 143 67 254 Late symptoms: Within 90 min to 3 h, 110 • 2 202 202 appear due to high insulin secretion 222 148 148 causing hypoglycemia 188 ABCD Arq Bras Cir Dig 2016;29(Supl.1):116-119
13 79 187 Symptoms of dumping syndrome 154 255 204 0
255 0 0
111 213 221
43 176 185 183 227 213 79 187 154 242 223 144 255 204 0 254 176 18
255 143 67 254 110 2
202 202 222 148 148 188
14 ABCD Arq Bras Cir Dig 2016;29(Supl.1):116-119 79 187 Early dumping vs late dumping 154 255 204 0
255 0 • The Arts score –assesses 0
111 the severity of symptoms 213 221
after ingestion of glucose 43 176 for diagnosis of early 185 183 227 dumping, and one to two 213 79 hours for late dumping. 187 154 242 • Likert scale : intensity on a 223 144 scale of 0-3, where 0 255 204 represents the absence of 0 254 176 certain symptoms, 1 mild, 2 18 255 143 moderate and 3 severe 67 254 intensity. 110 2
202 202 222 148 148 188 ABCD Arq Bras Cir Dig 2016;29(Supl.1):116-119
15 79 187 GI physiological investigations 154 255 204 0
255 0 • Gastric emptying is abnormal in two thirds of 0 111 213 patients: 221 43 176 • Rapid emptying almost three times as common as delayed 185 183 227 emptying (Loavenbruck A, 2015 ) 213 79 • Rapid emptying can cause dumping syndrome leading to 187 154 242 postprandial symptoms seen in PoTS patients (Berg P, 2016 ) 223 144 255 • 204 0 254 • Gastric myoelectrical activity - abnormal in 176 18
255 PoTS patients, particularly in those with 143 67 254 110 postprandial symptoms: 2 202 202 • (Seligman WH, 2013) 222 148 148 188
16 79 187 Gastric Emptying in hEDS – MRI study 154 255 204 0
255 0 0
111 213 221
43 176 185 183 227 213 79 187 154 242 223 144 255 204 0 254 176 18
255 143 67 254 110 2
202 202 EDS Control 222 148 148 188
Menys A 2017
17 Work up 79 187 Exclusion of other causes 154 255 204 0
255 0 • A thorough medical history, systems review, detailed drug 0 111 213 history and physical examination are essential to rule out 221 43 176 important differentials: 185 183 227 • Diabetes mellitus 213 79 187 • Hypothyroidism 154 242 223 • Connective tissue disorders 144 255 204 • Coeliac disease 0 254 176 • Inflammatory bowel disease 18 255 143 • Infections 67 254 110 • Neurological disorders 2 202 202 • Drug effects e.g. opiates can produce bowel 222 148 148 dysfunction 188
19 79 187 Investigations to exclude other causes 154 255 204 0
255 0 • Blood testing for FBC, LFTs, ESR, CRP, thyroid 0 111 213 function, albumin, coeliac serology and 221 43 176 autoimmune screen. 185 183 227 • Endoscopies 213 79 187 154 • Cross sectional imaging 242 223 144 • Upper and/or lower GI physiology studies 255 204 0 254 • Neurological signs esp. morning nusea: 176 18
255 • CT or MRI of the head. 143 67 254 110 • Oral glucose challenge in pts. with postprandial 2
202 202 hypoglycemia. 222 148 148 • Autonomic function tests – Tilt Table Test etc 188
20 Management
2 1 Management: Dietary and lifestyle modifications 79 187 154 255 204 0
255 0 0
111 213 • Ingestion of food is a major trigger for GI symptoms in 221 43 176 patients with PoTS. 185 183 227 • Lack of strong available evidence to support specific 213 79 187 dietary modifications 154 242 223 • our experience suggests that dietary alteration can 144 255 204 improve symptoms. 0 254 176 • Proper dietary history: 18 255 143 • Food intake diary - identify specific triggers and 67 254 110 avoid unnecessary dietary restrictions. 2 202 202 222 148 148 188
22 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
2 3 79 Dietary advice in gastroparesis 187 154
255 204 0
255 0 In patients with gastroparesis, we 0 111 213 recommend: 221 43 176 185 • Adequate chewing to reduce the 183 227 213 79 size of the food 187 154 242 223 • Avoid intake of insoluble fiber 144 255 204 0 • ‘Graze’ – eat regular small meals 254 176 18
255 • Reduce fat intake 143 67 254 110 • Semi solid diet 2 202 202 222 148 148 188
24 79 187 When to refer to the gastro clinic? 154 255 204 0
255 0 0
111 • Significant postprandial symptoms 213 221
43 176 • Worsening of usual PoTS symptoms. 185 183 227 • Symptoms suggestive of post prandial 213 79 187 154 reactive hypoglycemia. 242 223 144 255 204 • A proportion of PoTS patients can have 0 254 176 delayed gastric emptying 18 255 143 67 • early satiety, 254 110 2
202 • nausea and/or vomiting, 202 222 148 148 • fullness and bloating 188
25 79 187 Pharmacological therapy 154 255 204 0
255 0 • Anecdotal experience that GI symptoms 0 111 213 221 improve following treatment of PoTS 43 176 185 183 symptoms with: 227 213 79 187 • Mineralocorticoids such as fludrocortisone 154 242 223 • Sympathomimetics such as midodrine 144 255 204 • Hormonal treatment: Octreotide 0 254 176 18 • Psychological support when the patient has 255 143 67 254 difficulty with coping 110 2
202 202 222 148 148 188
26 79 187 Symptomatic pharmacological treatment 154 255 204 0
255 0 0
111 213 221
43 176 185 183 227 213 79 187 154 242 223 144 255 204 0 254 176 18
255 143 67 254 110 2
202 202 222 148 148 188
27 79 187 Conclusions 154 255 204 0
255 0 • PoTS - a range of gastrointestinal (GI) symptoms 0 111 213 • Organic GI conditions need to be ruled out 221 43 176 • GI physiology testing could help to define the GI 185 183 phenotype and guide management strategies. 227 213 79 187 • No established guidelines for the management of GI 154 242 symptoms in PoTS and patients are therefore treated 223 144 255 symptomatically. 204 0 254 • Management of PoTS with conservative measures and 176 18
255 drug treatment can improve GI symptoms especially 143 67 254 nausea and post prandial somnolence and dizziness 110 2
202 202 222 148 148 188
28 79 187 Acknowledgements 154 255 204 0 * Dr Asma Fikree 255 0 0
111 * Lisa Jamieson 213 221
43 176 * Dr Adam Farmer 185 183 227 213 * 79 Dr Ahmed Albusoda 187 154 242 223 * Heather Fitzke 144 255 204 0 * 254 Asmaa Al-Khalidi 176 18
255 143 * EDS UK 67 254 110 2
* EDS Society 202 202 222 148 148 * Patients 188
29 79 187 Thank you 154 255 204 0
255 0 0
111 213 221
43 176 185 183 227 213 79 187 154 242 223 144 255 204 0 254 176 18
255 143 67 254 110 Wingate Institute of New Royal 2 202 Neurogastroenterology 202 London Hospital 222 148 148 188