Scleroderma & the Gut: New Frontiers in Diagnosis & Tips on Management

Of note, whole gut transit scintigraphy also revealed that SSc can affect several regions of the GI tract simultaneously, reminding us that an unrevealing study in one region does not preclude abnormalities in other parts of the GI tract. The esophagus and colon were most commonly affected at the same time.

“More comprehensive testing may be indicated in symptomatic patients,” write McMahan et al.

Dr. McMahan

Dr. McMahan Talks with TR

The Rheumatologist (TR): What are the take-home points of this study as they relate to clinical practice?

 Dr. McMahan: First off, this study reminds us that many patients with SSc have multiple regions of the gut in which transit is negatively impacted. This [fact] is important because many of us focus mainly on the esophagus when thinking about SSc.

Second, our study demonstrates that disease duration doesn’t necessarily portend the extent of gut involvement. There were patients newly diagnosed with SSc with extensive GI issues, and there were patients with longstanding disease with only one region affected.

Third, we were particularly struck by the proportion of patients—especially those with pseudo-obstruction—who had terribly slow colonic transit. We previously thought the small bowel was the main culprit here. It’s possible that starting motility agents early in people with slow colonic transit could impact the course of progression, and we are interested in learning more about this in future studies.

TR: How could this study inform the selection of therapy for patients?

Dr. McMahan: Knowing where exactly the ‘lesions’ are in the gut is important because certain medications are helpful in some areas, but negatively impact motility in others. For example, mirtazapine can be helpful for a cachectic patient with gastroparesis who’s losing weight. But it also slows colonic transit. So for a patient who has delayed transit times in the stomach and colon, mirtazapine wouldn’t be a great choice. Knowing what you’re treating also comes into play when assessing response to therapy. Is the patient not improving due to inadequate drug dosing, or is the drug simply not active in the problem area of the gut?

TR: Could you share some pearls regarding the area of gut involvement and drug selection? What do you reach for in your own clinic?

Dr. McMahan: For esophageal dysmotility, refractory GERD and/or gastroparesis, I like prucalopride or pyridostigmine. There [are] more data for metoclopramide, but its side effects can be significant, so I try to avoid it when I can.