Increased Prevalence of Autonomic Dysfunction in Patients With Eosinophilic Gastrointestinal Disorders

Abstract

Introduction: Eosinophilic gastrointestinal disorders (EGIDs) are characterized by eosinophilic inflammation in the GI tract. These include eosinophilic esophagitis (EoE), gastritic (EG), gastroenteritis (EGE), and colitis (EC). Studies have linked EGIDs with atopic conditions, connective tissue disorders, and autoimmune disorders, but the association between EGIDs and autonomic dysfunction has not been extensively described. Methods: We identified adult patients in the EoE/EGID database at UNC who also had a diagnosis of comorbid autonomic dysfunction (postural orthostatic tachycardia syndrome or gastroparesis). The electronic medical record was abstracted for data regarding their EGID and autonomic dysfunction, including demographic information, disease characteristics and diagnostic information, treatments, and presence of other comorbidities. Results: We identified 7 patients who had EGID and dysautonomia. All were Caucasian and 5 were female. There were 4 patients with EoE alone, 2 with EoE overlapping with EGE, and 1 with EG overlapping with EC. All patients had POTS, and 2 also had gastroparesis. In regard to POTS, 6 of the patients sought treatment with an autonomic dysfunction specialist. The most common treatments included liberalized fluid and salt intake, exercise, corticosteroids (hydrocortisone, fludrocortisone) and pyridostigmine. Onset of autonomic symptoms coincided with onset of EGID symptoms in 3 patients or with an acute EGID flare in 3. Oral viscous budesonide, targeted dietary elimination, and/or manual endoscopic dilations were sufficient to control EGID for 4 of the patients. However, 3 patients required systemic steroids to control EGID. In no cases did successful control of EGID lead to improvement of autonomic symptoms. Two subjects had both comorbid Ehlers-Danlos syndrome (EDS) and mast cell activation syndrome (MCAS). Using the UNC EoE/EGID database (n=560 adults), we calculated a prevalence of POTS in EGID patients as 7/560 = 1.25%, compared to the estimated previously published 0.17% prevalence of POTS in the general population. Conclusion: In a large database of adult EoE/EGID patients, we found a higher than expected prevalence of autonomic dysfunction, suggesting an association between the two conditions, though the underlying mechanism is unclear. Therefore, providers should consider comorbid dysautonomia in patients with EGID, particular when symptoms persist despite treatment.334_A Figure 1. Patient demographics, type of eosinophilic gastrointestinal disorder (EGID), dysautonomia, and other comorbidities in our cohort of seven patients with comorbid EGID and dysautonomia. EoE = eosinophilic esophagitis EGE = eosinophilic gastroenteritis EG = eosinophilic gastritis EC = eosinophilic colitis POTS = postural orthostatic tachycardia syndrome334_B Figure 2. Frequency of presenting symptoms and attempted treatments for postural orthostatic tachycardia syndrome (POTS) in our cohort of seven patients with comorbid eosinophilic gastrointestinal disorder (EGID) and dysautonomia.