|Off the Grid: Clinical Reflections from Philip Getson, DO
Organ Involvement in CRPS
For those who see patients with complex regional pain syndrome (CRPS), it is often the case that symptoms appear that could be related to an underlying pathology. Subsequent articles will document cardiovascular, genitourinary,* and gynecologic symptoms that have been prevalent in my patients with CRPS. This article will discuss gastroenterologic manifestations of the syndrome.
A literature search will find little regarding GI-related disorders in patients with CRPS. However, logic would dictate that since the nervous system mediates all bodily functions, it is easy to conclude that patients with gastroenterologic problems can relate these directly to CRPS.
The most common symptoms I have seen are nausea and vomiting. Other symptoms include dysphagia, abdominal pain, cramping, intermittent diarrhea, and constipation. However, the most difficult symptoms to treat have been nausea and vomiting associated with CRPS.
When my patients are referred to gastroenterologists for upper endoscopies (esophagogastroduodenoscopy), more often than not the findings are “normal.” Sometimes, there is mild erythema (redness) of the gastric or esophageal lining, but rarely is there any significant ulceration or other noticeable pathology. It was not until we performed gastric emptying studies that we concluded that there is an outlet obstruction in the distal sphincter. The irritability of the gastric lining, coupled with the delay in gastric emptying, causes the stomach to remain “full” when subsequent meals are attempted. Having no place to go, the food is then regurgitated back into the esophagus or vomited out. I have found that the gastric emptying study, and the x-ray following the administration of a specific meal, is often 2 to 3 times the normal than is expected.
We have, for the most part, been unsuccessful in treating this outlet obstruction by conventional oral medications. Conversely, we have had great success with injections of botulinum toxin (Botox®) into the gastric lining at the pyloric sphincter From 1 to 3 injections of Botox® over several weeks have been found to minimize the irritability of the stomach lining and reduce, if not virtually eliminate, this problem. Patients who vomited with every ingested meal (and sometimes even water) are now able to eat and retain their food. While some patients require additional injections 6 to 12 months later, most have been symptom free for a prolonged period of time.
I have had two exceptions with patients where the injections did not work. Both of these individuals underwent a surgical procedure known as a fundal plication, a procedure not without risk. We have been very fortunate in that both of these individuals (interestingly enough, sisters with CRPS) have done extremely well. This procedure is not simple and has potential long-term complications, but this has shown some success in an individual who has failed at all other means of treatment.
On a separate note, patients with hoarseness may well fall into the gastroenterologic category. There is a paper defining an irritation of the branchial plexus causing the intermittent hoarseness in individuals with CRPS. This is the most common cause of the hoarseness. Increased acidity from reflux has also been shown to precipitate the hoarseness. Patients who are administered proton pump inhibitors (such as Nexium®) have had a great reduction in hoarseness. Some need the addition of H2 blockers (such as Axid® or Pepcid®) to minimize the problem. However, one must take into consideration that elimination of acid from the stomach may also be considered detrimental because it will reduce the overall salt balance of the body. We need salt to facilitate digestion. It is therefore our recommendation that patients have at least one teaspoon full of all natural sea salt a day in normal circumstances and double this amount if they are on proton pump inhibitors.
As to the issues of lower GI symptoms such as abdominal cramping, diarrhea, and constipation, the latter is most often related to the use of opioid medication. Alternating diarrhea and constipation is attributable to irritable bowel syndrome, which is not surprising given the psychological manifestations of CRPS. Abdominal cramping is also usually associated with irritable bowel syndrome.
Philip Getson, DO, is a board-certified Family Practitioner and an Associate Professor of Neurology at the Drexel University College of Medicine in Philadelphia. He can be reached at 856-983-7246 or firstname.lastname@example.org.
Janicki T. Is there a visceral component of RSD/CRPS? Available at: http://www.rsds.org/2/library/janowski.pdf. Accessed October 21, 2008.
Editor’s note: In our online survey, conducted by Johns Hopkins (1362 respondents) we asked, “When your symptoms of CRPS first began, what do you notice in the affected area?
12% reported” problems with bladder function (retention of urine)
20% reported problems with bowel function (constipation, diarrhea, heart burn, other)
RSDSA Review. Summer 2008.