Expert Calls for Awareness of Sleep Disorders Among GI Patients

Issue: December 2015

HONOLULU — With the heavy impact sleep has on overall health and gastrointestinal disorders specifically, an expert at ACG 2015 challenged his peers to implement “composite treatment” of patients where their overall health, including diet and sleep fragmentation, is considered alongside GI therapies.

“Sleep has a profound effect on health and disease. There’s no question. Sleep is not just an event. It is not a convenience option, but it’s really a health imperative. There’s no question that there’s an adverse effect on sleep and it’s driven through disruption of the circadian rhythm. This has a … consequent effect on inflammatory upregulation of chemokines and cytokines, and a clinical effect of inflammatory and sometimes even tumorigenic pathways,” David A. Johnson, MD, MACG, professor of medicine and chief of gastroenterology, Eastern Virginia Medical School, said during the J. Edward Berk Distinguished Lecture. “We really need to start thinking out of the box and start to take some of these concepts and really put them to application for further study.”

David A. Johnson

Johnson said more and more people are falling into the habit of decreased sleep of less than 6 hours and he showed data on how sleep deprivation affects many aspects of life and health from driving to cancer and urged the gastroenterology community to consider how it affects patients with GI disorders.

“There’s no question there’s a brain-gut axis,” Johnson said. “The role of the gut is your dominant immune system; that is the largest immune system you have in your body. Anything to disrupt the gut integrity via dysbiosis in particular can have a profound effect on immune processing and changes and signaling.”

Johnson used nocturnal esophageal acid exposure as one example that can arise in a few scenarios: where the patient is awoken from sleep, where sleep is disturbed, but not to the point of wakefulness, and where the acid event fragments sleep.

GERD-sleep dysfunction was the focus of three prospective randomized studies that he discussed. One study showed that PPI therapy improved sleep quality and resulted in more than 5 hours of improved work productivity.

Sleep dysfunction is increasingly recognized in chronic liver disease, Johnson said, becoming a prognostic factor for patients with advanced disease and affecting hepatitis C virus therapies and primary biliary cirrhosis.

Johnson said the circadian locomotor output cycle is a central factor of the GI tract and controls motility, digestive enzyme secretion and metabolism and, most obviously, sleep dysfunction affects inflammatory bowel disease because it has a great effect on inflammatory cycles and clinical markers of IBD such as interleukin-beta and tumor necrosis factor-alpha, among others. Patients with IBD are at a higher risk of sleep disturbance due to nocturnal stools, abdominal pain, steroids or pain medication.

“Clinically active inflammatory bowel disease and poor sleep go hand in hand,” Johnson said.

Even patients in remission from IBD have a higher chance of subclinical disease or disease flare if they do not sleep well.

“It’s time to connect the dots,” Johnson said. “We treat our patients with tunnel vision. You’re an IBD patient, you get a biologic agent. But wait a minute, maybe you’re a sleep frag patient, too, and maybe your diet doesn’t do well because your dysbiosis is also driven by a diet that’s driving the microbiome in and of itself.

“We really need to get composite treatment, not just focused treatment. And a composite treatment looks at all the variables outside of the central approach. That’s where I would issue the challenge for all of us to think out of the box and get out of tunnel vision treatment. … It’s time for us to open our eyes to the value of closing them.” – by Katrina Altersitz

Reference:

Johnson DA. Presented at: ACG; Oct. 16-21, 2015; Honolulu.

Disclosures: Johnson reports no relevant financial disclosures.