Although systemic sclerosis is a skin disorder associated with scarring and swollen or hard skin, gastrointestinal complications are very common and, in some cases, the first symptoms of the disease to appear.
Tracy M. Frech, MD, MS, director of the Systemic Sclerosis Clinic at the University of Utah and a rheumatologist in the Veterans Affairs Salt Lake City Health Care System, will lead the clinical symposium Systemic Sclerosis: Assessment and Treatment of Gastrointestinal Manifestations, which starts at 2:30 pm Tuesday.
“As time has gone on rheumatologists have become very good at looking at pulmonary function tests and echocardiograms to assess for pulmonary involvement, and I think the natural next step is learning how to better assess the gastrointestinal tract for disease involvement,” Dr. Frech said.
More than 90 percent of systemic sclerosis (SSc) patients experience gastrointestinal manifestations. Esophageal dysfunction is the most common, leading to heartburn and other symptoms, but the entire GI tract can be affected. Although GI tract involvement is the most common internal complication of SSc, damage to the lungs, kidneys, and vascular system also occurs frequently.
“It is expected that scleroderma patients are going to have GI symptoms, but can we do a better job of identifying the severity as well as tracking improvement?” Dr. Frech asked. Her talk will explain how rheumatologists can optimize care in these areas.
She will discuss how she uses patient-reported questionnaires to determine a patient’s specific GI symptoms and their severity, and decide whether to recommend treatment or order diagnostic tests. Her patients routinely complete the UCLA SCTC GIT 2.0 (gastrointestinal scale) questionnaire as part of their care visit. Dr. Frech, however, will focus on the newer NIH PROMIS questionnaire, which she thinks is more extensive and easier for patients to complete.
“Using questionnaires cuts down on the number of procedures we order, which is great for the patient,” Dr. Frech said.
For example, a swallow evaluation may be appropriate for a patient having problems getting food stuck in the throat, whereas a patient experiencing frequent GERD may have esophageal damage (esophagitis), which could be better evaluated by esophageal endoscopy. Dr. Frech will also review the patient burden of the various diagnostic tests in terms of time and cost.
Two other talks in the session will delve into the assessment and treatment of GI manifestations in the upper and lower tract. Many scleroderma patients experience a combination of upper and lower GI manifestations.
Mark Pimentel, MD, Director of the GI Motility Program and Laboratory at Cedars-Sinai, will review tests for upper GI manifestations, such as manometry to asses esophageal function, and pH and breath tests to identify, respectively, GERD and small intestinal bacterial overgrowth, which is also a common GI manifestation of scleroderma. Dr. Pimentel will mention therapies such as prokinetic drugs to improve gastric motility. He also will discuss his data associating scleroderma with high levels of anti-vinculin antibodies. A test for these antibodies, called IBSchek, is already used in the diagnosis of gut neuropathies and could potentially help scleroderma diagnosis.
“We are excited about this new antibody as it may be an early marker of GI involvement,” unless doctors look for specific GI manifestations, Dr. Pimentel said.
The assessment of lower GI manifestations, which typically present as constipation, diarrhea, and incontinence, involves a range of tests involving blood and stool along with colonoscopy. Navjyot Hansi, MD, Gastrointestinal Registrar at the Royal Free Hospital in London, will discuss that topic and how she and her colleagues use data from non-scleroderma populations to guide their treatment of scleroderma patients, for whom less data are available.
“It’s kind of a starting point and a platform to look at research questions we should be asking and how we should be trying to get more scleroderma patients involved in that kind of research,” Dr. Hansi said.
She will touch upon GI symptom-based algorithms the UK Scleroderma Study Group has developed to treat scleroderma using a multidisciplinary team, including dietitians, nutritionists, and other specialists.
CLINICAL SCIENCE TRACK
Systemic Sclerosis: Assessment and Treatment of Gastrointestinal Manifestations
2:30 – 4:00 pm Tuesday • Hall E