EP.405/ Gut Motility and Enteric Nervous System Dysfunction in Endo
This week we’re travelling again, heading over to the Isle of Wight, and we have a lot of packing to do, so this week is a real bite sized episode, but an important one.
You may remember me talking about a study showing 80% of participants with endometriosis also had SIBO. But what many people don’t know, and what I think doesn’t get enough focus, is that this study also found 100% of participants had a dysfunction of their small intestine motility.(1)
To understand what this means, let’s first do a recap of the migrating motor complex. The migrating motor complex is a wave like motion that cleans the small intestine of food debris and bacteria. The MMC kicks in two hours after we eat and overnight.(2) It is not the same as the motility that causes a bowel movement, which occurs in the large intestine.
The migrating motor complex can become damaged or slowed, or there may be something structurally wrong with the intestines that is disrupting it. This is the root cause of SIBO - something is either structurally wrong or functionally wrong with the migrating motor complex of the small intestine.(3)
This damage can be and is usually caused by food poisoning or gastroenteritis,(4) but in endometriosis patients, we also have other risk factors that can affect the health of our MMC, from adhesions sticking to the intestines, to co-conditions that alter motility, like Ehlers- Danlos Syndrome(5).
But there’s also an intriguing behaviour seen in our intestines, which seems unique to us endo patients. When stuyding SIBO rates of endometriosis patients, researchers found that parts of the small intestine were spasming, leading to altered digestion. This spasming was caused by enteric nervous system dysfunction, which is the part of our nervous system that governs digestion and is largely regulated by the vagus nerve. They noticed a pattern almost like a seizure of the enteric nervous system, that was firing off nerve signals and creating these spasms.
However, and here’s what’s so interesting - this was not a dysfunction of the MMC, it did happen mostly during the night which is when the MMC is most active, but it was independent of the MMC - so the MMC was doing its thing and a spasm was also happening.
The researchers believe that this spasm was caused by hyperinsulin secretion (as a reminder, insulin is the hormone that controls blood sugar and increases when blood sugar levels are high or we have become insulin resistant). High insulin levels promote pro-inflammatory pathways, which increase inflammatory prostaglandins like PGE2 (which also cause pain with endo). These prostaglandins have been shown to trigger dysfunction of the enteric nervous system and cause spasms in the gut.(6)
As a result, patients were treated with a glycemic controlled diet to improve insulin levels and were asked to reduce foods that could further excite gastrointestinal nerves such as caffeine. They were also treated with a GABA-agonist, to calm the enteric nervous system. After 8 weeks, patients reported significant improvements in their gastrointestinal symptoms.
Whether these spasms could also increase the risk of developing SIBO is unclear, but I would think it’s possible. But what interests me most about this spasm, is that I have had several clients reporting upper gastrointestinal pain that comes in spasm like waves during the night, so I think people with endometriosis are feeling the impact of this.
If you’re currently going through any gut related investigations, it’s worth asking your GI specialist to test your migrating motor complex, to see whether this issue or any motility issue could be affecting you, because we really don’t know much about it, but what we can see from this study is that treating it may help with GI related symptoms.
References
1) https://pubmed.ncbi.nlm.nih.gov/9660426/
2) https://www.sciencedirect.com/topics/medicine-and-dentistry/migrating-motor-complex
3) Diagnosis and management of small intestinal bacterial overgrowth - PubMed, Lower frequency of MMC is found in IBS subjects with abnormal lactulose breath test, suggesting bacterial overgrowth - PubMed, The interdigestive motor complex of normal subjects and patients with bacterial overgrowth of the small intestine - PubMed, The migrating motor complex: control mechanisms and its role in health and disease - PubMed,Gastrointestinal motility disorders and bacterial overgrowth - PubMed, Modern concepts of small intestinal bacterial overgrowth - PMC
4) Lower frequency of MMC is found in IBS subjects with abnormal lactulose breath test, suggesting bacterial overgrowth - PubMed, Development and Validation of a Biomarker for Diarrhea-Predominant Irritable Bowel Syndrome in Human Subjects | PLOS One, Autoimmunity Links Vinculin to the Pathophysiology of Chronic Functional Bowel Changes Following Campylobacter jejuni Infection in a Rat Model - PubMed
5) https://pubmed.ncbi.nlm.nih.gov/39990556/
6) https://www.sciencedirect.com/science/article/pii/S001502829800096X#BIB27, Role of Insulin Signaling in Prostaglandins SynthesisUniversity of Toledohttps://openjournals.utoledo.edu › download
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