Gastrointestinal Disease: Visceral Hypersensitivity
Guest: Dr. Mark DeLegge – Gastroenterology-Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Mark DeLegge who is Director of the Medical University of South Carolina’s Digestive Disease Center. Dr. DeLegge, let’s talk about a very interesting syndrome, visceral hypersensitivity. Just what is that?
Dr. Mark DeLegge: Visceral hypersensitivity is really a disease that masquerades as a lot of other diseases. It is one of the most common problems I see here as a referral from another gastroenterologist, or from another state. What you and I would say is abdominal pain or, perhaps, abdominal pressure, even nausea, where there is no definite diagnosis, meaning, these patients have had upper endoscopies, colonoscopies, CAT scans, which is basically an x-ray of your belly button looking very closely at all the structures. They may have had something called a gastric emptying scan. That is where you swallow an egg or some toast labeled with a radionucleotide and they basically look to see how fast it empties out of your stomach under a big camera. They may have actually had the blood vessels around their stomach and small intestine investigated to see if there was a problem with lack of blood flow that was giving the pain in their belly. It is not uncommon, in fact, for me to see people who have had their gallbladders removed, or their appendix removed, thinking this was the cause of the pain, when, in fact, they felt great for about two days and the same symptoms recurred. This is visceral hypersensitivity.
Dr. Linda Austin: Now, is it accompanied by bleeding or gas or other sorts of symptoms like that?
Dr. Mark DeLegge: Bleeding, no, weight loss, no, although some people may lose weight just because they are so miserable. Abdominal gas and swelling can occur but does not have to occur. So, when you and I start talking about a disease that we have heard a lot about, irritable bowel syndrome or what used to be called spastic bowel, your nervous gut, we talk about people getting alternating diarrhea and constipation or one or the other, maybe some bloating, abdominal pain, that is kind of your classic IBS patient. This visceral hypersensitivity disease, or syndrome, really is on the end of the bell curve for the patient with IBS. What I mean by that is, yeah, they can have some IBS-like symptoms but, frankly, their problems are really focused on pressure, pain, nausea.
Dr. Linda Austin: So, what sorts of things, then, trigger the pain? Is it after a meal, or is it if they are wearing tight clothes, or touch their abdomen? What causes the pain?
Dr. Mark DeLegge: Some people will have triggers such as eating, which can precipitate that. Other people will have triggers such as stress. But, typically there is no rhyme or reason to when the symptoms come and when the symptoms leave. The pathophysiology of why this happens is very interesting. What happens in the patients with visceral hypersensitivity is the nerves that surround the intestines, the stomach and the esophagus, those nerves are set up to basically feel things that are bad, to feel pain. But, in the patient with visceral hypersensitivity, those nerves start to sense things that are normal, meaning, normal muscle contractions in the small intestine, normal muscle contractions in the colon to move food and stool through, normal amounts of air in the intestines start to be interpreted by the nerves surrounding the gut as extreme pain, so, there is a disconnect. The nerves become almost too sensitive and send a message up to your brain and say, you are having pain.
What happens is, you present to a physician, perhaps a gastroenterologist, and you have a battery of exams. Everything is absolutely normal and invariably you are told, we cannot find it, or, this is in your head, or, perhaps, this is something related to stress in your life and if you would just be a little less stressed out about everything, this would all go away.
Dr. Linda Austin: It occurs to me, it is almost like having a headache in a sense, that is, unexplained pain that comes on without a clear cause. Is there an analogy to be drawn?
Dr. Mark DeLegge: It is very similar. If we look at the headache population and you try to divvy them up into little groups like migraines, cluster headaches, muscle tension headaches, there is a proportion of patients you cannot get into any little box. We like boxes, as doctors, so we can say, you have this. But, it is a very similar process. This visceral hypersensitivity, if you can imagine, is just having heightened nerves surrounding the gut that are responding to what you should not be feeling, or discomforted by, as being real, and it is real.
Dr. Linda Austin: Is there treatment?
Dr. Mark DeLegge: The treatments are very difficult. I will tell you that the work in this area has not been great. However, there are some treatments which we have recently looked at which seem to be somewhat beneficial. Number one, there is a very old group of anti-depressants, one of them has the name of amitriptyline, or one of them is desipramine. What we found out is that, in very low doses, especially with desipramine, not at the doses we used to use for depression, but much smaller doses, there seems to be a great affect on blunting the response by these receptors of pain, meaning, to tone them down. So, yes, there is some work in this area which is starting to look at some of the neural, or neurally mediated, meaning, drugs that we used to use for the brain. We thought we were treating depression, which we were, or some other problem and realizing that there is a lot of cross talk between the brain and the gut. In fact, these medications may have an affect on the gut itself.
Dr. Linda Austin: Do patients who have visceral hypersensitivity tend, also, to have other pain syndromes, such as fibromyalgia, or, for that matter, even headaches?
Dr. Mark DeLegge: Yes, absolutely. If you look at the group, we will say, fibromyalgia and, in fact, if you and I walked out the door and talked to 10 doctors and said, what do you think about fibromyalgia? Most of them would say, boy, that is a difficult patient population, I’m not sure what I am treating, the treatments have not been very good, I do not know how to make the diagnosis. In fact, these same symptoms that we have with visceral hypersensitivity, we can see in the patient with fibromyalgia, although the symptoms may be a little different as far as joint or muscle pain, or fatigue, or the patient with the chronic headache. I think what we are going to find is that this hypersensitivity issue, this nerve hypersensitivity issue, is much more systemic than we have given it credit for in the past.
Dr. Linda Austin: As a psychiatrist, I cannot help but ask the question, is there overlay with psychiatric issues? We know, for example, that patients who have had trauma may have abnormal activity of their stress hormones that may predispose to different body sorts of symptoms. Do you see that in this population as well?
Dr. Mark DeLegge: Yes, you do. I do not want to go on record to think that everybody who has visceral hypersensitivity has a psychiatric disease because that is not true. But, I will tell you that patients who have visceral hypersensitivity, compared to the general population, are more likely to have other associated issues, such as anxiety, obsessive-compulsiveness and other stress-related diseases. You know, intuitively, that kind of makes sense to me because, in those populations, there is definitely a change in the hormonal production of the brain. We know that the brain and the gut are very connected. It is my belief, although very simplistic, that the production or hormone changes that occur with many psychiatric diseases can, in fact, accentuate the problems with visceral hypersensitivity.
Dr. Linda Austin: Or, maybe even to say from a slightly different point of view, it may be that just as there can be a hypersensitivity of the nerves around the gut that, perhaps, anxiety or depression may also reflect some kind of hypersensitivity, except nerves of the brain, nerves in different centers.
Dr. Mark DeLegge: That is a great thought. It opens up a whole arena for us to be investigating. I think it is time that we stop telling patients, this is all in your head, and really get down to understanding some of these more complex chronic diseases because, as you know, they can really affect a patient’s quality of life and, frankly, their self esteem.
Dr. Linda Austin: Dr. DeLegge, thanks so much for talking with us.
Dr. Mark DeLegge: You are welcome.
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