Effect of Fludrocortisone Acetate on Chronic Unexplained Nausea and Abdominal Pain in Children With Orthostatic Intolerance

Fortunato, John E.; Wagoner, Ashley L.; Harbinson, Rachel L.; D’Agostino, Ralph B.; Shaltout, Hossam A.; Diz, Debra I.

doi:10.1097/mpg.0000000000000305

Cited by 33 publications

(27 citation statements)

References 29 publications

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“…86 -88 POTS is associated with upper-gastrointestinal symptoms and antroduodenal dysmotility, which exacerbate with standing 89 and may improve when OI is treated. 90 Both delayed and rapid gastric emptying have been reported. 89 -92 OI has been identified in both younger and older case patients with cyclic vomiting syndrome, 93 with POTS present in 35% of adults.…”

Section: Immune Mechanismsmentioning

confidence: 99%

Pediatric Disorders of Orthostatic Intolerance

et al. 2018

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Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.

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Section: Immune Mechanismsmentioning

confidence: 99%

Pediatric Disorders of Orthostatic Intolerance

et al. 2018

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“…An abnormal cardiovascular response to head-up tilt (HUT) orthostatic challenge can be broadly grouped into the following: postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension (OH), and syncope. Management and treatment of OI is typically dependent on the specific cardiovascular diagnosis, with most treatments having variable effectiveness in adult and adolescent populations (4,8,13,30,39). The pathophysiological mechanisms responsible for these cardiovascular changes are not well defined as presentation and symptoms are often heterogenous (14).…”

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confidence: 99%

Distinct neurohumoral biomarker profiles in children with hemodynamically defined orthostatic intolerance may predict treatment options

Wagoner

Shaltout

Fortunato

et al. 2016

American Journal of Physiology-Heart and Circulatory Physiology

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Studies of adults with orthostatic intolerance (OI) have revealed altered neurohumoral responses to orthostasis, which provide mechanistic insights into the dysregulation of blood pressure control. Similar studies in children with OI providing a thorough neurohumoral profile are lacking. The objective of the present study was to determine the cardiovascular and neurohumoral profile in adolescent subjects presenting with OI. Subjects at 10-18 yr of age were prospectively recruited if they exhibited two or more traditional OI symptoms and were referred for head-up tilt (HUT) testing. Circulating catecholamines, vasopressin, aldosterone, renin, and angiotensins were measured in the supine position and after 15 min of 70° tilt. Heart rate and blood pressure were continuously measured. Of the 48 patients, 30 patients had an abnormal tilt. Subjects with an abnormal tilt had lower systolic, diastolic, and mean arterial blood pressures during tilt, significantly higher levels of vasopressin during HUT, and relatively higher catecholamines and ANG II during HUT than subjects with a normal tilt. Distinct neurohumoral profiles were observed when OI subjects were placed into the following groups defined by the hemodynamic response: postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension (OH), syncope, and POTS/syncope. Key characteristics included higher HUT-induced norepinephrine in POTS subjects, higher vasopressin in OH and syncope subjects, and higher supine and HUT aldosterone in OH subjects. In conclusion, children with OI and an abnormal response to tilt exhibit distinct neurohumoral profiles associated with the type of the hemodynamic response during orthostatic challenge. Elevated arginine vasopressin levels in syncope and OH groups are likely an exaggerated response to decreased blood flow not compensated by higher norepinephrine levels, as observed in POTS subjects. These different compensatory mechanisms support the role of measuring neurohumoral profiles toward the goal of selecting more focused and mechanistic-based treatment options for pediatric patients with OI.

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“…Sullivan et al (2005) and later Fortunato et al (2011) documented that nausea replicated during HUT often improves with volume expansion with fludrocortisone. Other symptoms and complaints which also improved with this treatment, including dizziness, abdominal pain, flushing, and missing school (Fortunato et al, 2014).…”

mentioning

confidence: 84%

“…Subjects with POTS also have more abnormalities in the gastric electrical activity while supine. Even within the POTS group, the subjects with gastrointestinal symptoms have differences in the electrical activity when compared to those with POTS and no GI symptoms (Fortunato et al, 2014;Seligman et al, 2013). Whether gastric dysrhythmias improve with fludrocortisone remains to be seen.…”

mentioning

confidence: 95%

“…A few elegant studies have shown the relationship of the orthostatic challenge and gastrointestinal symptoms. The gastrointestinal symptoms that often occur during HUT include nausea and abdominal pain (Fortunato et al, 2011;Fortunato et al, 2014;Sullivan et al, 2005). Moak et al performed 24-h antroduodenal manometry studies in pediatric patients with OI and GI symptoms and tilted the subjects during the antroduodenal motility study.…”

mentioning

confidence: 99%

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The gastrointestinal symptoms present in patients with postural tachycardia syndrome: A review of the literature and overview of treatment

Chelimsky

2018

Autonomic Neuroscience

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Orthostatic intolerance, including postural tachycardia syndrome, is often associated with gastrointestinal symptoms. In the vast majority of the cases, the gastrointestinal symptoms are not secondary to the orthostatic disorder, but rather just a comorbid condition. This concept is critical, since treatment aimed at the orthostatic condition will not improve the gastrointestinal symptoms. Only when the gastrointestinal symptoms develop in the upright position and improve or resolve in the supine position, they may be related to the orthostatic stress. The most common symptoms associated with orthostatic intolerance include nausea, dyspepsia, bloating and constipation. The majority of subjects do not have gastroparesis. The chapter discusses available treatments of these conditions.

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Effect of Fludrocortisone Acetate on Chronic Unexplained Nausea and Abdominal Pain in Children With Orthostatic Intolerance

Abstract: Chronic nausea and abdominal pain accompany OI and improve with OI treatment.

Cited by 33 publications

References 29 publications

Pediatric Disorders of Orthostatic Intolerance

Pediatric Disorders of Orthostatic Intolerance

Distinct neurohumoral biomarker profiles in children with hemodynamically defined orthostatic intolerance may predict treatment options

The gastrointestinal symptoms present in patients with postural tachycardia syndrome: A review of the literature and overview of treatment

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