Gut involvement in systemic sclerosis

1
Gut involvement in systemic sclerosis

• Philip Clements, MD, MPH
• UCLA School of Medicine

2
Gastrointestinal Involvements

• Esophagus
• Stomach
• Small intestine
• Large intestine and rectum
• Liver

3
Frequency of GI symptoms(262 SSc patients)

• Prevalence
• Symptom ()
• Heartburn 71
• Trouble swallowing 53
• Diarrhea 20
• Constipation 19
• Bloating 10

4
Gastrointestinal Involvement

• The primary event that causes trouble in the gut
  is progressive weakening of muscle motion in the
  gut (peristalsis).
• Virtually every gut symptom thereafter is the
  result of weakening of the gut muscle. The
  weakening that starts in the esophagus and
  stomach, works its way down the small and large
  intestine.

5
Measuring esophagus motion with motility
measurements
6
Weak esophagus muscle in SSc documented with
motility test
Normal
SSc




7
Acid reflux is caused by weak gastro-esophageal
(GE) sphincter
Weak GE sphincter
Acid reflux
8
Acid reflux leads to ulcers and stricture
(narrowing)
Ulcer
May lead to
Stricture
9
Anti-reflux measures

• Head of the bed elevated (ie wedge pillow, blocks
  under head of bed, electric bed).
• Biggest meal at noon, small meals otherwise.
• Do not eat late (after 6 pm).
• Frequent small meals (5-6 per day).
• No tight garments around waist.
• Do not bend over (head lower than waist).
• Take anti-secretory and pro-motility agents.

10
Antisecretory Agents

• Agent Frequency
• Prilosec 20-40mg 1-2x per day
• Prevacid 15-30mg 1-2x per day
• Aciphex 20 mg 1-2 x per day
• Protonix 40 mg 1-2 x per day
• Nexium 20-40 mg 1-2 x per day

11
Pro-motility agents

• Agent Frequency
• Reglan 10 mg 3-4 x per day
• Erythromycin 250-333 mg 3-4 x per day
• Dome-peridone 10-20 mg 3-4 x per day
• NB Dome-peridone not approved in USA--
• can obtain in Canada or Mexico

12
Watermelon Stomach
13
ea
Colon

Small intestine
14
Dilated small intestine
15
Diarrhea, bloating

• The most frequent cause of diarrhea in SSc is the
  migration of bacteria, which normally live in the
  distal colon, into the small intestinebacterial
  overgrowth. They compete with you for nutrition.
• Suppressing the bacteria with antibiotics often
  reduces the diarrhea and bloating.

16
Antibiotics for suppressing bacteria

• Antibiotic Dosing schedule
• Amoxicillin 500 mg 3x per day
• Cipro 500 mg 3x per day
• Flagyl 500 mg 3 x per day
• Doxycyline 100 mg 2x per day
• Bactrim D/S 1 tablet 2 x per day

17
Pro-motility agents

• Agent Frequency
• Reglan 10 mg 3-4 x per day
• Erythromycin 250-333 mg 3-4 x per day
• Dome-peridone 10-20 mg 3-4 x per day
• NB Dome-peridone not approved in USA--
• can obtain in Canada or Mexico

18
Conclusions

• Management of GI problems has improved--however,
  no major breakthroughs seen in the offing.