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The Autonomic Nervous System in Functional Bowel Disorders

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The Autonomic Nervous System in Functional Bowel Disorders iv78 Gut 2000;(Suppl IV)47:iv78–iv80 The autonomic nervous system in functional Gut: first published as 10.1136/gut.47.suppl_4.iv78 on 1 December 2000. Downloaded from bowel disorders G Tougas Summary with increased motor activity.34Under certain Communications along the brain-gut axis conditions, altered autonomic balance (includ- involve neural pathways as well as immune and ing low vagal tone and increased sympathetic endocrine mechanisms. The two branches of activity) may also alter visceral perception. the autonomic nervous system are integrated Autonomic dysfunction could also represent anatomically and functionally with visceral the physiological pathway accounting for many sensory pathways, and are responsible for the of the extraintestinal symptoms seen in irrita- homeostatic regulation of gut function. The ble bowel syndrome (IBS) patients, and for autonomic nervous system is also a major some of the frequent gastrointestinal com- mediator of the visceral response to central plaints reported by patients with disorders such influences such as psychological stress and as chronic fatigue and fibromyalgia. other central factors. As presently defined, functional disorders Introduction represent a constellation of symptoms, some of In recent years, we have undergone a substan- which suggest the presence of altered percep- tial shift in our conceptual definitions of what tion while other symptoms point to disordered constitutes functional bowel disorders and gastrointestinal function as the cause of the IBS. In general, we now view these conditions symptoms. There have been a growing number as a group of disorders or clinical entities char- Digestive Diseases acterised by the presence of, to a varying Research Program, of reports demonstrating disordered auto- Division of nomic function in subgroups of functional degree, chronic pain, discomfort, and disor- Gastroenterology, bowel patients.1–3 While a number of diVerent dered gastrointestinal function. While this type McMaster University, methods were used to assess autonomic of clinical definition corresponds to how these 1200 Main St West, function, they generally point to decreased patients present, it has proved diYcult to apply Room 3N5D, in the search for the pathophysiological fac- vagal (parasympathetic) outflow or increased Hamilton, Ontario, tor(s) potentially involved in these conditions. sympathetic activity in conditions usually asso- Canada While much remains to be done in that regard, G Tougas ciated with slow or decreased gastrointestinal it is increasingly accepted that these conditions motility. Other studies found either increased Correspondence to: are multifactorial, and that the symptoms Dr G. Tougas. cholinergic activity or decreased sympathetic experienced by two individual patients, al- [email protected] activity in patients with symptoms compatible though somewhat similar, may in fact result http://gut.bmj.com/ from a number of diVerent aetiologies. Abnormalities of motor and secretory func- Stress tion as well as altered enteric neural function can be identified in many patients with functional disorders (fig 1). However, most patients have ANS imbalance no demonstrable motor dysfunction and the abnormalities that have been identified vary Increased from study to study, each of these abnormalities on September 27, 2021 by guest. Protected copyright. sensitivity being present in small and very specific groups ↓ Sensory inhibition of patients which do not represent the majority of those seen in clinical practice. The concept of these conditions being primarily motility or enteric nervous disorders is now also generally Increased ∴ ↑ Sensitivity viewed as failing to account for many of the afferent other characteristics that are present in these patients, in particular the discomfort and pain activity Low grade often reported in the presence of apparently inflammation ± Impaired motor activity normal gastrointestinal function. Hp infection In many patients with functional bowel disor- ders, the presence of altered visceral perception ↓ Accommodation to various visceral stimuli, such as distension, has been identified. This issue of altered visceral perception in IBS is extensively discussed elsewhere. It remains important to point out that while a primary disorder of visceral sensory per- Altered motor and sensory function ception provides a plausible explanation for many of the symptoms reported in functional bowel disorders, it remains a largely unproved Dyspepsia Figure 1 Putative pathogenesis of dyspepsia. ANS, autonomic nervous system; HP, Abbreviations used in this paper: IBS, irritable Helicobacter pylori. bowel syndrome. www.gutjnl.com Autonomic nervous system in functional bowel disorders iv79 concept at the clinical level. In specific situations disorders, it is essential to remember the Gut: first published as 10.1136/gut.47.suppl_4.iv78 on 1 December 2000. Downloaded from such as the development of chronic symptoms homeostatic nature of autonomic function. following an acute inflammatory or infectious While many local gastrointestinal stimuli will event (such as post-infectious irritable bowel elicit responses and reflexes whose involvement syndrome), altered function of the normal is essentially limited to the immediate region sensory mechanisms, either within the gut wall that was primarily stimulated, when more or along visceral aVerent pathways, are conceiv- intense or potentially noxious stimuli occur, ably possible, at least in the short term. It is more other systems, including the central nervous sys- diYcult at this point to implicate altered visceral tem, are also involved in addition to the gastro- sensory pathways in the pathogenesis of func- intestinal tract. Transmission of information to tional symptoms such as diarrhoea or bloating. the central nervous system allows for elaboration Such symptoms are present in many post- of an integrated homeostatic response that may infectious IBS patients, but also in patients include a behavioural as well as a physiological where there is no history of any acute inflamma- response. In this type of response, both visceral tory or infectious precipitant prior to the devel- and autonomic nervous pathways are essential. opment of symptoms. Similarly, the hypothesis Many of the systemic responses elicited by of altered visceral sensory perception as the only visceral stimuli are produced through auto- factor involved in functional disorders fails to nomic reflexes. These reflexes, which occur account for the very high association of stress, primarily through the brain stem, may not be psychologically traumatic experiences, and emo- associated with conscious perception of the tional distress with the development and persist- sensory stimulus. However, other visceral ence of functional bowel symptoms. Unless one sensory stimuli will be suYciently intense as to extends the concept of altered visceral sensory be felt and to elicit pain or discomfort. perception to include the cortical centres associ- The type and degree of the autonomic reflex ated with visceral perception, or a central response to a specified visceral stimulus depends nervous system modulation of the aVerent and on the location, type, and intensity of the stimu- spinal pathways involved with perception of vis- lus. If prior sensitisation of the visceral aVerent ceral stimuli, it is somewhat diYcult to build a pathways has resulted in a state of hyperalgesia conceptual framework capable of reconciling or allodynia, the reflex response may be cortical events such as emotions with the exaggerated, while a peripheral sensory neu- peripheral sensory pathways involved with vis- ropathy may be associated with a decreased ceral sensory function. If a pragmatic approach reflex response. Similarly, psychological factors is used to reconcile the various components such as increased vigilance, anxiety, and depres- identified in the clinical expression of functional sion are also likely to aVect autonomic reflexes.5 bowel disorders with an overall concept of the pathophysiological factors involved, several con- Assessing autonomic function ditions must be met. Firstly, the condition (IBS) A number of methods have been developed to involves central as well as peripheral sites: pain is assess specific aspects of autonomic nervous http://gut.bmj.com/ ultimately a cortical event while events such as function. Some of the older approaches, which diarrhoea and mucus production imply that were very cumbersome and involved rather there is also dysfunction of the gut per se There- . complex measurements, have been largely aban- fore, functional disorders must to some extent doned. In recent years, the development of tech- involve the brain as well as the gut. Secondly, if niques based on the autonomic modulation of visceral factors such as an infectious event in the heart rate function have largely replaced other gut aVect the cortical response to visceral methods because of their simplicity and validity stimuli, and if conversely, psychological events on September 27, 2021 by guest. Protected copyright. as markers of vagal as well as sympathetic func- can alter the function of the gut, gut-brain and tion.6 The use of techniques such as power brain-gut communication must be one of the spectral analysis of heart rate variability now important modulators involved. Therefore, it provide a simple and accurate measure of the seems logical that the autonomic nervous respective outflow of the vagal and sympathetic system, which is the primary pathway involved branches
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