Functional Gastrointestinal Disorders, Autonomic Nervous System Dysfunction, and Joint Hypermobility in Children: Are They Related?

OBJECTIVES: To evaluate the prevalence of orthostatic intolerance and joint hypermobility in schoolchildren with and without functional gastrointestinal disorders (FGIDs) and to assess autonomic nervous system dysfunction in children with FGIDs and joint hypermobility. STUDY DESIGN: Schoolchildren (10-18 years) attending public schools from 3 Colombian cities (Cali, Palmira, and Bucaramanga) completed validated questionnaires for FGIDs and underwent testing for hypermobility and autonomic nervous system dysfunction. Heart rate and blood pressure were assessed in recumbency and upright position at regular intervals. The differences in characteristics between schoolchildren with and without FGIDs were compared with a t-test for continuous variables and with a Fisher exact test (2 × 2 contingency tables) for categorical variables. RESULTS: In total, 155 children with FGIDs were matched with 151 healthy controls. Children with FGIDs had historically significant greater frequency of 10 of 12 symptoms of orthostatic intolerance, no significant difference in any symptoms of orthostatic intolerance during recumbency, significantly greater frequency in 6 of 12 symptoms of orthostatic intolerance during orthostasis, trend toward statistical significance for orthostatic intolerance (P = .0509), and no significant difference in prevalence of orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS). There was no significant difference in prevalence of orthostatic intolerance, OH, and POTS between those with joint hypermobility and those without. CONCLUSIONS: Children with FGIDs have a greater prevalence of symptoms of orthostatic intolerance but were not more likely to have OH and POTS as compared with children without FGIDs. Children with joint hypermobility did not have a greater prevalence of orthostatic intolerance, OH, and POTS.

Utility of Diagnostic Studies for Upper Gastrointestinal Symptoms in Children with Orthostatic Intolerance.

OBJECTIVE: To assess the utility of gastrointestinal (GI) diagnostic studies in the evaluation of patients with orthostatic intolerance. STUDY DESIGN: Medical records of 103 consecutive children/young adults with orthostatic intolerance and gastrointestinal symptoms were reviewed. All patients had undergone antroduodenal manometry in conjunction with the tilt table test, autonomic testing, and upper gastrointestinal endoscopy (EGD). A gastric emptying study (GES) was performed in 81 patients. RESULTS: The median age of the cohort was 17 years (IQR, 15-19) with a female predominance (females:males, 3:1). As expected, the tilt table test was abnormal in all patients. Antroduodenal manometry was abnormal in 83 of 103 patients (81%), showing neurogenic intestinal dysmotility in 50%, rumination in 20%, and visceral hyperalgesia in 10%. The GES results were abnormal in 23 of 81 patients (28.4%), mostly (21 of 23) with delayed GES. None of the tilt table test or autonomic results were predictive of abnormal antroduodenal manometry or GES. Analysis of EGD biopsy samples revealed nonspecific esophagitis and/or gastritis in 16 of 103 patients (15%). CONCLUSIONS: Antroduodenal manometry with the tilt table test were the most insightful investigations in adolescents and young adults with orthostatic intolerance and gastrointestinal symptoms. GES and EGD provided limited information. Gastrointestinal symptoms were related more to functional rather than mucosal or organic etiologies, suggesting a limited role of endoscopy alone in evaluating patients with orthostatic intolerance presenting with gastrointestinal symptoms.

Reduced Systolic Volume: Main Pathophysiological Mechanism in Patients with Orthostatic Intolerance?

BACKGROUND: Orthostatic intolerance patients' pathophysiological mechanism is still obscure, contributing to the difficulty in their clinical management. OBJECTIVE: To investigate hemodynamic changes during tilt test in individuals with orthostatic intolerance symptoms, including syncope or near syncope. METHODS: Sixty-one patients who underwent tilt test at - 70° in the phase without vasodilators were divided into two groups. For data analysis, only the first 20 minutes of tilting were considered. Group I was made up of 33 patients who had an increase of total peripheral vascular resistance (TPVR) during orthostatic position; and Group II was made up of 28 patients with a decrease in TPVR (characterizing insufficient peripheral vascular resistance). The control group consisted of 24 healthy asymptomatic individuals. Hemodynamic parameters were obtained by a non-invasive hemodynamic monitor in three different moments (supine position, tilt 10' and tilt 20') adjusted for age. RESULTS: In the supine position, systolic volume (SV) was significantly reduced in both Group II and I in comparison to the control group, respectively (66.4 ±14.9 ml vs. 81.8±14.8 ml vs. 101.5±24.2 ml; p<0.05). TPVR, however, was higher in Group II in comparison to Group I and controls, respectively (1750.5± 442 dyne.s/cm5 vs.1424±404 dyne.s/cm5 vs. 974.4±230 dyne.s/cm5; p<0.05). In the orthostatic position, at 10', there was repetition of findings, with lower absolute values of SV compared to controls (64.1±14.0 ml vs 65.5±11.3 ml vs 82.8±15.6 ml; p<0.05). TPVR, on the other hand, showed a relative drop in Group II, in comparison to Group I. CONCLUSION: Reduced SV was consistently observed in the groups of patients with orthostatic intolerance in comparison to the control group. Two different responses to tilt test were observed: one group with elevated TPVR and another with a relative drop in TPVR, possibly suggesting a more severe failure of compensation mechanisms.

Reduced Systolic Volume: Main Pathophysiological Mechanism in Patients with Orthostatic Intolerance? / Volume Sistólico Reduzido: Mecanismo Fisiopatológico Principal em Pacientes com Intolerância Ortostática?

Abstract Background: Orthostatic intolerance patients' pathophysiological mechanism is still obscure, contributing to the difficulty in their clinical management. Objective: To investigate hemodynamic changes during tilt test in individuals with orthostatic intolerance symptoms, including syncope or near syncope. Methods: Sixty-one patients who underwent tilt test at - 70° in the phase without vasodilators were divided into two groups. For data analysis, only the first 20 minutes of tilting were considered. Group I was made up of 33 patients who had an increase of total peripheral vascular resistance (TPVR) during orthostatic position; and Group II was made up of 28 patients with a decrease in TPVR (characterizing insufficient peripheral vascular resistance). The control group consisted of 24 healthy asymptomatic individuals. Hemodynamic parameters were obtained by a non-invasive hemodynamic monitor in three different moments (supine position, tilt 10' and tilt 20') adjusted for age. Results: In the supine position, systolic volume (SV) was significantly reduced in both Group II and I in comparison to the control group, respectively (66.4 ±14.9 ml vs. 81.8±14.8 ml vs. 101.5±24.2 ml; p<0.05). TPVR, however, was higher in Group II in comparison to Group I and controls, respectively (1750.5± 442 dyne.s/cm5 vs.1424±404 dyne.s/cm5 vs. 974.4±230 dyne.s/cm5; p<0.05). In the orthostatic position, at 10', there was repetition of findings, with lower absolute values of SV compared to controls (64.1±14.0 ml vs 65.5±11.3 ml vs 82.8±15.6 ml; p<0.05). TPVR, on the other hand, showed a relative drop in Group II, in comparison to Group I. Conclusion: Reduced SV was consistently observed in the groups of patients with orthostatic intolerance in comparison to the control group. Two different responses to tilt test were observed: one group with elevated TPVR and another with a relative drop in TPVR, possibly suggesting a more severe failure of compensation mechanisms.

Resumo Fundamento: O mecanismo fisiopatológico de pacientes com intolerância ortostática ainda é obscuro, contribuindo para a dificuldade no manejo clínicos desses pacientes. Objetivo: Investigar as alterações hemodinâmicas durante teste de inclinação (tilt teste) em indivíduos com sintomas de intolerância ortostática, incluindo síncope ou pré-síncope. Métodos: Sessenta e um pacientes, com tilt teste a 70º negativo na fase livre de vasodilatador, foram divididos em dois grupos. Para análise dos dados foram considerados apenas os primeiros 20 minutos de inclinação. Grupo I (33 pacientes) que tiveram elevação da resistência vascular periférica total (RVPT) durante posição ortostática e Grupo II (28 pacientes) com queda da RVPT (caracterizando insuficiência de resistência vascular periférica). O grupo controle consistia de indivíduos saudáveis e assintomáticos (24 indivíduos). Os parâmetros hemodinâmicos foram obtidos por um monitor hemodinâmico não invasivo em 3 momentos distintos (posição supina, tilt 10' e tilt 20'), ajustados para idade. Resultados: Na posição supina, o volume sistólico (VS) foi significantemente reduzido tanto no Grupo II quanto no I, quando comparado ao do Grupo controle, respectivamente (66,4 ±14,9 ml vs. 81,8±14,8 ml vs. 101,5±24,2 ml; p<0,05.) A RVPT, no entanto, foi mais elevada no Grupo II, quando comparada a do Grupo I e controles, respectivamente (1750,5± 442 dyne.s/cm5 vs.1424±404 dyne.s/cm5 vs. 974,4±230 dyne.s/cm5; p<0,05). Na posição ortostática, aos 10', houve repetição dos achados, com valores absolutos inferiores de VS Comparado aos controles (64,1±14,0 ml vs 65,5±11,3 ml vs 82,8±15,6 ml; p<0,05). A RVPT, todavia, apresentou queda relativa no Grupo II comparado ao I. Conclusão: Volume sistólico reduzido foi consistentemente observado nos grupos de pacientes com intolerância ortostática, quando comparado ao grupo controle. Foram observadas duas respostas distintas ao teste de inclinação: um grupo com elevação de RVPT e outro com queda relativa desta, indicando, possivelmente, falência mais acentuada dos mecanismos de compensação.

Initial circulatory response to active standing in Parkinson's disease without typical orthostatic hypotension.

UNLABELLED: While the circulatory response to orthostatic stress has been already evaluated in Parkinson's disease patients without typical orthostatic hypotension (PD-TOH), there is an initial response to the upright position which is uniquely associated with active standing (AS). We sought to assess this response and to compare it to that seen in young healthy controls (YHC). METHOD: In 10 PD-TOH patients (8 males, 60 ± 7 years, Hoehn and Yahr ≤ 3) the changes in systolic blood pressure (SBP) and heart rate that occur in the first 30 seconds (sec) of standing were examined. Both parameters were non-invasively and continuously monitored using the volume-clamp method by Peñáz and the Physiocal criteria by Wesseling. The choice of sample points was prompted by the results of previous studies. These sample points were compared to those of 10 YHC (8 males, 32 ± 8 years). RESULTS: The main finding of the present investigation was an increased time between the AS onset and SBP overshoot in PD-TOH group (24 ± 4 vs. 19 ± 3 sec; p<0.05). CONCLUSION: This delay might reflect a prolonged latency in the baroreflex-mediated vascular resistance response, but more studies are needed to confirm this preliminary hypothesis.

Initial circulatory response to active standing in Parkinson's disease without typical orthostatic hypotension / Resposta circulatoria inicial apos ortostatismo ativo na doenca de Parkinson sem hipotensao ortostatica tipica

While the circulatory response to orthostatic stress has been already evaluated in Parkinson's disease patients without typical orthostatic hypotension (PD-TOH), there is an initial response to the upright position which is uniquely associated with active standing (AS). We sought to assess this response and to compare it to that seen in young healthy controls (YHC). Method In 10 PD-TOH patients (8 males, 60±7 years, Hoehn and Yahr ≤3) the changes in systolic blood pressure (SBP) and heart rate that occur in the first 30 seconds (sec) of standing were examined. Both parameters were non-invasively and continuously monitored using the volume-clamp method by Peñáz and the Physiocal criteria by Wesseling. The choice of sample points was prompted by the results of previous studies. These sample points were compared to those of 10 YHC (8 males, 32±8 years). Results The main finding of the present investigation was an increased time between the AS onset and SBP overshoot in PD-TOH group (24±4 vs. 19±3 sec; p<0.05). Conclusion This delay might reflect a prolonged latency in the baroreflex-mediated vascular resistance response, but more studies are needed to confirm this preliminary hypothesis. .

Apesar da resposta circulatória ao estresse ortostático já foi estudada em pacientes com doença de Parkinson sem hipotensão ortostática típica (PD-TOH), não há uma resposta inicial que é exclusivamente associada com o ortostase ativa (AS). Portanto, buscou-se avaliar esta resposta e compará-la à observada em jovens saudáveis (YHC). Método Em 10 PD-TOH pacientes (8 homens, 60±7 anos, Hoehn e Yahr ≤3) as mudanças na pressão arterial sistólica (PAS) e da frequência cardíaca que ocorrem nos primeiros 30 segundos (seg) de pé foram examinados. Ambos parâmetros foram monitorizados continuamente através do método Peňáz e os critérios de Wesseling. Os pontos de amostragem foram escolhidos com base em estudos anteriores. Estes pontos foram comparados com os de 10 YHC (32±8 anos). Resultados O principal achado deste estudo foi o aumento do tempo entre o início de AS e rebote sistólica no grupo PD-TOH (24±4 vs 19±3 seg, p<0,05). Conclusão Este atraso pode refletir uma latência prolongada na resposta da resistência vascular mediado pelo barorreflexo, mas outros estudos são necessários para confirmar esta hipótese preliminar. .

Predictors of masked hypertension among treated hypertensive patients: an interesting association with orthostatic hypertension.

BACKGROUND: Masked hypertension (MH) entails an increased cardiovascular risk. Therefore, it is important to identify those individuals who would benefit the most from out-of-office blood pressure (BP) measurement. We sought to determine the prevalence and identify predictors of MH among adult hypertensive patients under treatment. METHODS: Treated hypertensive patients aged ≥ 18 years underwent office (duplicate sitting and standing BP in 1 visit) and home BP measurements (duplicate measurements for 4 days in the morning, afternoon, and evening; at least 16 measurements) and completed a questionnaire regarding risk factors and history of cardiovascular disease. MH was defined as normal office BP (<140/90mm Hg) with elevated home BP (≥135/85mm Hg, average of all readings discarding first day measurements). Patients with a systolic BP rise upon standing ≥5mm Hg were considered to have orthostatic hypertension (OHT). Variables indentified as relevant predictors of MH were entered into a multivariable logistic regression analysis model. RESULTS: Three hundred and four patients were included (mean age = 66.7 ±13.8; 67.4% women). The prevalence of MH in the whole population was 12.4% and was 20.9% among patients with office-controlled hypertension. Factors independently associated with MH were age (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.03-1.14), high-normal office systolic BP (OR = 5.61, 95% CI = 1.39-22.57), history of peripheral artery disease (PAD) (OR = 8.83, 95% CI = 1.5-51.84), moderate alcohol consumption (OR = 0.08, 95% CI = 0.01-0.73), and OHT (OR = 3.65, 95% CI = 1.27 to 10.51). CONCLUSIONS: Easily measurable parameters such as age, office systolic BP, history of PAD, and OHT may help to detect a population at risk of MH that would benefit from home BP monitoring.