Martin Zeuner

Association of autonomic nervous hyperreflexia and systemic inflammation in patients with Crohn's disease and ulcerative colitis

The autonomic nervous system modulates gastrointestinal motility, secretion and mucosal immunity. Its dysfunction may be of pathogenetic importance in inflammatory bowel disease (IBD). This study aimed at investigating the autonomic nervous function in patients with IBD. Forty-seven patients with IBD, 28 with Crohns disease (CD) and 19 with ulcerative colitis (UC), were investigated by means of 5 cardiovascular and 2 pupillary standardized autonomic nervous function tests. In CD and UC, cardiovascular autonomic neuropathy was very rare (0%, 5%), whereas pupillary autonomic neuropathy was more prevalent (21%, 21%). In contrast to autonomic neuropathy, overall cardiovascular (CD: 29%, UC: 26%) and pupillary autonomic hyperreflexia (46%, 37%) were found more often. Patients with CD and UC demonstrated elevated percentiles in the respiratory sinus arrhythmia test as compared to controls (RSA: 82.3 +/- 3.9%, 80.0 +/- 5.9%, controls: 50.0% +/- 1.5%, p < 0.0001). CD patients with, as compared to patients without, RSA hyperreflexia had significantly higher CDAIs (p < 0.001), increased erythrocyte sedimentation rates (p < 0.005) and more often extraintestinal disease manifestations (p < 0.001). UC patients with, as compared to patients without, pupillary latency time hyperreflexia had lower hemoglobin (p < 0.05), lower albumin (p < 0.01) and increased erythrocyte sedimentation rates (p < 0.05). Autonomic hyperreflexia was significantly associated with more severe inflammation and systemic disease in IBD. Hyperreflexia may be a response to inflammation or a pathogenetic element that drives mucosal inflammation.

Anorectal function in systemic sclerosis: Correlation with esophageal dysfunction?

PURPOSE: This study was designed to compare esophageal and anorectal function parameters in patients with systemic sclerosis and to define the role of anorectal manometry in the diagnosis of gastrointestinal involvement of systemic sclerosis. PATIENTS AND METHODS: Twenty-six consecutive patients (22 females) with systemic sclerosis originally referred for assessment of esophageal function were evaluated by esophageal and anorectal manometry. Anorectal function parameters were compared between patients with normal and those with disturbed esophageal function. RESULTS: A total of 17 of 26 patients (65 percent) had severe esophageal dysfunction with aperistalsis of the lower two-thirds of the esophagus, whereas 9 patients (35 percent) had normal esophageal manometry. Only three patients (11.5 percent) suffered from occasional fecal incontinence. Anorectal function parameters (resting pressure, maximum squeeze pressure, perception threshold) were not significantly different between patients with normal and those with disturbed esophageal motility. Rectoanal inhibitory reflex was excitable in nearly 90 percent of patients. CONCLUSION: In an unselected group of patients with systemic sclerosis, fecal incontinence and abnormal anorectal function are rather rare findings. Anorectal manometry cannot differentiate between patients with and without gastrointestinal involvement of systemic sclerosis.

Esophageal manometry in systemic sclerosis: screening procedure or confined to symptomatic patients?

Abstract The predictive value of esophagus-related symptoms for the diagnosis of esophageal dysmotility induced by systemic sclerosis (SSc) was prospectively evaluated in 50 consecutive patients with SSc. Patients were classified as symptomatic when either dysphagia or repeated episodes of heartburn were present. All patients underwent esophageal manometry; SSc-induced esophageal dysfunction was diagnosed when there was aperistalsis or marked hypocontractility of the distal two-thirds of the esophageal body. Twenty-nine patients (58%) had a history of esophagus-related symptoms, while 21 patients (42%) were asymptomatic. Compared to esophageal manometry, esophagus-related symptoms had a sensitivity of 64%, a specificity of 52%, a negative predictive value of 50% and a positive predictive value of 62% for the diagnosis of SSc-induced esophageal dysfunction. In conclusion, the association of esophagus-related symptoms and esophageal motility pattern is poor. As clinical management strategies depend on proof of esophageal dysfunction, screening examinations are mandatory in all patients with SSc.

Kardiovaskuläre und pupilläre autonome und somatosensible Neuropathie bei chronischen Erkrankungen mit Autoimmunphänomenen

BACKGROUND During the last years, examination of autonomic nervous function and of autonomic neuropathy has attracted attention not only in diabetes mellitus research but also in other areas of internal medicine. However, patients with various chronic diseases with autoimmune phenomenons have never been investigated in a comparative study with standardized examination techniques. Hence, the aim of the study was to examine the prevalence and the severity of autonomic neuropathy in patients with the following chronic diseases. PATIENTS AND METHODS We investigated 28 patients with Crohns disease (CD: age: 32.4 +/- 2.0 y), 17 patients with ulcerative colitis (UC: 39.7 +/- 3.6 y), 39 patients with systemic lupus erythematosus (SLE: 34.9 +/- 2.0 y), 38 patients with progressive systemic sclerosis (pSS; 51.5 +/- 2.4 y) and 65 patients with insulin-dependent diabetes mellitus (IDDM: 35.5 +/- 1.6 y). Cardiovascular autonomic (cANP), pupillary autonomic (pANP), and sensorimotor (ssNP) neuropathy were assessed by standardized techniques. RESULTS Prevalence rates for cANP, pANP and ssNP were found to be 0%, 19%, and 7% in CD, 6%, 25%, and 18% in UC, 5%, 29%, and 10% in SLE, 11%, 16%, and 32% in pSS, and 26%, 66%, and 29% in IDDM, respectively. CONCLUSION The study demonstrated patients with IDDM to have the highest prevalence rates of cANP and pANP. Patients with other chronic diseases, particularly SLE, pSS and UC, had high prevalence rates of pANP. This may be due to alterations of structures of the central nervous system in these patients. cANP was rare in patients with inflammatory bowel disease and ssNP was found very often in patients with pSS, probably due to local fibrotic lesions. The various disease groups differ in the pattern and severity of autonomic and sensorimotor neuropathy, which indicates that different structures and neuropathogenic mechanisms may be involved.Zusammenfassung□ HintergrundIn den vergangenen Jahren ist die Untersuchung des autonomen Nervensystems insbesondere im Bereich der Diabetologie, aber auch in anderen Bereichen der inneren Medizin mehr und mehr in den Blickpunkt des Interesses getreten. Eine vergleichende Untersuchung der autonomen Nervenfunktion bei Patienten mit verschiedenen chronischen Erkrankungen, die mit Autoimmunphänomenen einhergehen, mit standardisierten Untersuchungsverfahren wurde bisher noch nicht vorgestellt. Aufgabe dieser Studie war daher, die vergleichende Erfassung der Häufigkeit und des Ausprägungsgrades der autonomen und somatosensiblen Neuropathie bei Patienten mit Morbus Crohn, Colitis ulcerosa, systemischem Lupus erythematodes, progressiver Systemsklerose und Typ-I-Diabetes mellitus.□ Patienten und MethodenEs wurden 28 Patienten mit Morbus Crohn (Alter: 32,4±2,0 Jahre), 17 mit Colitis ulcerosa (39,7±3,6 Jahre), 39 mit systemischem Lupus erythematodes (34,9±2,0 Jahre), 38 mit progressiver Systemsklerose (51,5±2,4 Jahre) und 65 mit Typ-I-Diabetes mellitus (35,5±1,6 Jahre) untersucht. Die kardiovaskuläre autonome (cANP), die pupilläre autonome (pANP) und die somatosensible Neuropathie (ssNP) wurden mittels standardisierter Testverfahren beurteilt.□ ErgebnisseFolgende Häufigkeiten wurden für die cANP, pANP und ssNP gefunden: Morbus Crohn (0%, 19%, 7%), Colitis ulcerosa (6%, 25%, 18%), systemischer Lupus erythematodes (5%, 29%, 10%), progressive Systemsklerose (11%, 16%, 32%) und Typ-I-Diabetes mellitus (26%, 66%, 29%).□ SchlußfolgerungDiese Untersuchungen zeigen, daß Typ-I-Diabetiker von einer Neuropathie am häufigsten und am schwersten betroffen waren. Aber auch bei Patienten mit anderen chronischen Erkrankungen, insbesondere systemischerm Lupus erythematodes, progressiver Systemsklerose und Colitis ulcerosa, ist eine Neuropathie des autonomen Nervensystems sehr viel häufiger, als bisher vermutet wurde. Patienten mit chronisch-entzündlichen Darmerkrankungen haben selten eine cANP. Patienten mit progressiver Systemsklerose haben häufig eine somatosensible Neuropathie. Die verschiedenen Krankheitsgruppen unterscheiden sich im Muster und im Ausprägungsgrad der autonomen und somatosensiblen Neuropathie, was auf unterschiedliche neuropathogenetische Mechanismen hinweist.Summary□ BackgroundDuring the last years, examination of autonomic nervous function and of autonomic neuropathy has attracted attention not only in diabetes mellitus research but also in other areas of internal medicine. However, patients with various chronic diseases with autoimmune phenomenons have never been investigated in a comparative study with standardized examination techniques. Hence, the aim of the study was to examine the prevalence and the severity of autonomic neuropathy in patients with the following chronic diseases.□ Patients and MethodsWe investigated 28 patients with Crohn’s disease (CD; age: 32.4±2.0 y), 17 patients with ulcerative colitis (UC; 39.7±3.6 y), 39 patients with systemic lupus erythematosus (SLE; 34.9±2.0 y), 38 patients with progressive systemic sclerosis (pSS; 51.5±2.4 y) and 65 patients with insulin-dependent diabetes mellitus (IDDM; 35.5±1.6 y). Cardiovascular autonomic (cANP), pupillary autonomic (pANP), and sensorimotor (ssNP) neuropathy were assessed by standardized techniques.□ ResultsPrevalence rates for cANP, pANP and ssNP were found to be 0%, 19%, and 7% in CD, 6%, 25%, and 18% in UC, 5%, 29%, and 10% in SLE, 11%, 16%, and 32% in pSS, and 26%, 66%, and 29% in IDDM, respectively.□ ConclusionThe study demonstrated patients with IDDM to have the highest prevalence rates of cANP and pANP. Patients with other chronic diseases, particularly SLE, pSS and UC, had high prevalence rates of pANP. This may be due to alterations of structures of the central nervous system in these patients. cANP was rare in patients with inflammatory bowel disease and ssNP was found very often in patients with pSS, probably due to local fibrotic lesions. The various disease groups differ in the pattern and severity of autonomic and sensorimotor neuropathy, which indicates that different structures and neuropathogenic mechanisms may be involved.

Gallbladder motility in systemic sclerosis

In 20 patients with systemic sclerosis (SSc) and 24 healthy controls, gallbladder motility was evaluated by abdominal ultrasonography after stimulation by a standard liquid meal. Results from patients with normal and dis turbed oesophageal function were analysed separately in order to investigate the significance of gallbladder motility as a parameter for gastrointestinal involvement in SSc. All patients showed a marked decrease in gallbladder size after stimulation (patients 61 ±13%; controls 48 ±12%). Patients with oesophageal dysfunction (n=12) had a slightly lower gallbladder contraction (maximal decrease =58±13%) when compared to patients with normal oesophageal function (n=8; 66± 13%); however, this difference was not statistically significant. Gallbladder motility in patients with SSc was not reduced when compared with healthy controls. SSc-induced oesophageal dysfunction was not associated with impaired gallbladder motility. Thus, measurement of gallbladder emptying is not a helpful tool when looking for gastrointestinal involvement in SSc.