How is esophageal dysmotility treated in Systemic Sclerosis patients?
Treatment is designed to decrease complications of acid reflux, such as esophagitis, stricture, or nocturnal aspiration of stomach contents. The head of the bed should be elevated 4 to 6 inches through the use of foam wedges, custom mattresses, or placement of stable blocks underneath the box springs; adding more pillows to sleep on may only make matters worse by decreasing stomach area. The patient should not eat for 2 to 3 hours prior to bedtime. The acid content in the stomach should be decreased in the evening with antacids, H2 blockers, or proton pump inhibitors. Motility agents such as metoclopramide (5–10 mg) or erythromycin (motilin receptor agonist; 250 mg) before meals may be helpful early in the disease, but often become ineffective later in the course due to tachyphylaxis and eventual GI smooth muscle fibrosis. Domperidone (Motilium) can be an effective pro-motility drug, but it has been removed from the market in the United States. Both domperidone and erythromycin can cause a prolonged QT interval. For more refractory cases of GI dysmotility, injectable octreotide may be considered. Endoscopic injection of botox into the pyloric sphincter has been used for resistant cases of GERD as well. Of note, extreme caution should be exercised before consideration of a Nissen fundoplication for the treatment of GERD in a patient with SSc (due to the heightened risk of dysphagia in patients with dysmotility). Preoperative manometry is mandatory, and less invasive procedures should be considered (partial wrap, or Toupet fundoplication; use of magnetized beads, the LINX procedure).
