A 52-year-old woman comes to the office due to abdominal discomfort and bloating accompanied by watery diarrhea for the past 6 months. The patient has lost 9 kg (20 lb) during this period. Review of systems reveals gastroesophageal reflux symptoms and color changes in her fingers consistent with Raynaud's phenomenon, which has been present for 2 years. The patient has no other past medical history, and her only medication is over-the-counter omeprazole as needed. She drinks 2 or 3 glasses of wine on weekends and does not smoke.
Vital signs are within normal limits. BMI is 20 kg/m². There are patchy areas of skin thickening on the patient's chest, upper back, forearms, and legs. Skin over the fingers appears tight with a tapering appearance of the fingertips. Heart and lung sounds are normal. Abdominal examination shows diffuse, mild tenderness with no guarding or rebound tenderness. There is no hepatosplenomegaly, and bowel sounds are normal. Joint examination shows no abnormalities. Laboratory studies are as follows:
Stool studies are negative for pathogenic bacteria, ova, and parasites. Colonoscopy reveals scattered diverticulosis, and random biopsies reveal no abnormalities.
Which of the following would be most helpful to relieve this patient's gastrointestinal symptoms?

Question

A 52-year-old woman comes to the office due to abdominal discomfort and bloating accompanied by watery diarrhea for the past 6 months. The patient has lost 9 kg (20 lb) during this period. Review of systems reveals gastroesophageal reflux symptoms and color changes in her fingers consistent with Raynaud's phenomenon, which has been present for 2 years. The patient has no other past medical history, and her only medication is over-the-counter omeprazole as needed. She drinks 2 or 3 glasses of wine on weekends and does not smoke.
Vital signs are within normal limits. BMI is 20 kg/m². There are patchy areas of skin thickening on the patient's chest, upper back, forearms, and legs. Skin over the fingers appears tight with a tapering appearance of the fingertips. Heart and lung sounds are normal. Abdominal examination shows diffuse, mild tenderness with no guarding or rebound tenderness. There is no hepatosplenomegaly, and bowel sounds are normal. Joint examination shows no abnormalities. Laboratory studies are as follows:

Stool studies are negative for pathogenic bacteria, ova, and parasites. Colonoscopy reveals scattered diverticulosis, and random biopsies reveal no abnormalities.
Which of the following would be most helpful to relieve this patient's gastrointestinal symptoms?

Quizplus · Accepted Answer

11ec193a_9818_4e54_853d_873bdfa03341_MD0002_00 This patient has systemic sclerosis (SSc) with Raynaud's phenomenon, gastroesophageal reflux, and a positive anti-Scl-70 antibody assay. In SSc, collagen deposition and smooth muscle atrophy in the gastrointestinal tract cause reduced peristalsis and intestinal dilation. This allows for colonization of the small intestine by large numbers of colonic bacteria, leading to small intestinal bacterial overgrowth (SIBO) in up to 30% of SSC patients. Common symptoms include bloating, discomfort, and diarrhea. Later, as fat malabsorption ensues, the patient may develop steatorrhea, weight loss, and nutritional deficiencies. Laboratory studies commonly show macrocytic anemia due to vitamin B₁₂ deficiency. ₁₂ SIBO is diagnosed with a positive carbohydrate breath test or a jejunal aspirate culture showing high bacterial concentrations. Many patients have symptomatic improvement following 14 days of antibiotics; rifaximin is most commonly used, but other regimens are also effective. However, up to 45% of patients develop recurrent symptoms and may require repeated or prolonged therapy with multiple antibiotic regimens. (Choice B) Nifedipine is effective for the treatment of Raynaud's phenomenon in SSc. However, it may aggravate acid reflux symptoms and will not address the bacterial overgrowth. (Choice C) SIBO can develop in patients with chronic pancreatitis as the absence of proteolytic enzymes allows for bacterial overgrowth. However, chronic pancreatitis typically develops over a period of years, and patients experience multiple episodes of severe abdominal pain, often associated with excess alcohol use. In addition, even in patients with pancreatic insufficiency complicated by SIBO, pancreatic enzymes alone (ie, without antibiotics) are unlikely to reduce bacterial burden. (Choice D) Prokinetic agents (eg, metoclopramide, erythromycin) are useful in the management of gastroparesis in SSc but are not as effective in treating bacterial overgrowth and malabsorption. They can be added in patients who do not respond to antibiotics and have documented dysmotility. (Choice E) Low-dose glucocorticoids are sometimes used as adjunctive therapy with immunosuppressive agents for SSc-associated interstitial lung disease. However, some studies have shown a strong association between glucocorticoid use and SIBO; the use of glucocorticoids should be avoided if possible. Educational objective: Patients with systemic sclerosis may develop small intestinal bacterial overgrowth due to reduced peristalsis and intestinal dilation. Clinical features include abdominal bloating, discomfort, diarrhea, and malabsorption. Antibiotic therapy can alleviate the symptoms, but recurrent courses may be required. __________ References: Small intestinal bacterial overgrowth syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/20572300) Small intestinal bacterial overgrowth in systemic sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/19696066) Gastrointestinal complications of systemic sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/24222949)

A 52-Year-Old Woman Comes to the Office Due to Abdominal