Efficacy of prolonged administration of intravenous erythromycin in an ambulatory setting as treatment of severe gastroparesis: one center's experience

Intravenous erythromycin is a potent gastric prokinetic with demonstrated efficacy in the acute therapy of gastroparesis; long-term oral therapy has been limited by tolerance and modest efficacy. Our aim was to review our experience with prolonged administration of intravenous erythromycin in an ambulatory setting as therapy for severe gastroparesis, refractory to usual dietary and oral prokinetic regimens. We conducted a retrospective analysis of patients with gastroparesis treated with intravenous erythromycin for at least 1 month. Information on demographics; origin of gastroparesis; dosage, duration, and route of administration; clinical outcome in the short- and longer-term; and complications were determined. Eleven patients received a total of 14 courses of intravenous erythromycin for a median of 6.5 months (range, 1 to 19 months) at a median dosage of 300 mg/day (range, 150 to 1,000 mg/day). One patient received no benefit, two had complete responses, and all others reported some benefit. Two had dramatic relapse on cessation of therapy and subsequently improved on its resumption. Parenteral nutrition could be discontinued in one of four patients. There were four episodes of line sepsis; two required catheter removal. A nonocclusive thrombus developed at the site of a central line in one patient. Secondary infections or antibiotic resistance were not encountered. Prolonged administration of intravenous erythromycin in an ambulatory setting is feasible, well tolerated, and effective in patients with severe gastroparesis.

Evaluation of effects of ethyl alcohol and bismuth subsalicylate on gastric mucosal barrier in man

The mucus-bicarbonate barrier provides the first line of defense against potentially harmful gastric luminal contents. Its integrity can be assessed in man by demonstrating the presence of a pH gradient across the mucus gel layer, from the acidified lumen to near-neutral pH at the mucosa. Our aim was, firstly, to assess the effects of ethyl alcohol and bismuth subsalicylate on the integrity of this lumen-to-mucosal pH gradient and, secondly, to evaluate whether pretreatment with bismuth subsalicylate would protect against any deleterious effects of ethyl alcohol. Ten healthy adults underwent two upper endoscopic procedures with microelectrode measurement of juxtamucosal pH gradients. At the first endoscopy, the effects of 30 ml of bismuth subsalicylate on the gradient was evaluated. At the second endoscopy, gradients were measured before and after luminal installation of 60 ml of ethyl alcohol (40% v/v) and following pretreatment with either 30 ml of bismuth subsalicylate or placebo. pH measurements were technically easy to perform and provided consistently reproducible results. A distinct juxtamucosal pH gradient (pH 4.0 +/- 0.2 units) was identified in all subjects in the basal state. Neither bismuth subsalicylate nor ethyl alcohol had a significant effect on these gradients. We conclude that a distinct pH gradient between gastric luminal fluid and the mucus gel layer can be readily demonstrated in man. Neither bismuth subsalicylate nor ethyl alcohol have a significant effect on this gradient.

Comparison of ileal and jejunal transplantation after 50% proximal intestinal resection

BACKGROUND

The ileum has a greater adaptive capacity than the jejunum after intestinal resection. Transposition studies suggest that this is, in part, related to increased exposure to nutrients. However, there may be regional differences in intestinal properties that contribute to this response as well. The aim of this study was to compare the outcome of replacing the jejunum with either ileal or jejunal transplants while preserving an intact ileum after 50% proximal resection.

METHODS

Twenty-one Lewis rats were included in the study. One group (n = 7) served as transection controls (TC). The other two groups (n = 7) had 50% proximal resection with syngeneic transplantation of a similar length of ileum (ITX) or jejunum (JTX). Nutritional status and adaptation were studied at 14 days.

RESULTS

JTX animals gained less weight than TC and ITX (104 +/- 2% vs 114 +/- 1 and 108 +/- 2% initial, P < 0.05). ITX and JTX groups had lower caloric intake and serum albumin levels compared with TC (7.4 +/- 0.4 and 7.2 +/- 0.8% vs 8.8 +/- 0.2% body weight and 2.6 +/- 0.1 and 2.4 +/- 0.9 g/dl vs 3.0 +/- 0.1 g/dl, P < 0.05). Mucosal thickness increased significantly in the ileal remnant of both ITX and JTX groups (9.2 +/- 2.1 and 8.8 +/- 0.6 micrometer vs 6.6 +/- 0.6 micrometer, P < 0.05). Transplanted ileum had mucosal thickness similar to that of jejunum.

CONCLUSIONS

Transplanted ileum achieves an intestinal structure similar to that of the jejunum in the same environment. Modest adaptation of the remnant occurs with transplantation. Replacing jejunum with ileum rather than jejunum resulted in better weight gain, suggesting that intrinsic absorptive, motor, or hormonal rather than structural differences are responsible.

Factors affecting outcome following proximal and distal intestinal resection in the dog: an examination of the relative roles of mucosal adaptation, motility, luminal factors, and enteric peptides

In the clinical setting, resection of the ileum results in an inferior functional outcome compared to jejunal resection. This may be related to a greater adaptive capacity of the ileum, intrinsic structural and functional differences, or regional differences in motor and hormonal function. Our aim was to evaluate the relative contributions of these factors to functional outcome after resection of the proximal or distal intestine. Twenty-four dogs underwent either intestinal transection or 50% resection of the proximal or distal intestine. Studies (nutritional status, absorption, adaptation, motility, peptide levels) were performed every four weeks until the animals were killed at 12 weeks. Caloric intake was similar in all four groups. Weight loss was greater and more sustained after distal resection (DR). Serum cholesterol levels decreased significantly only in the DR group. While stool weight and moisture were similar, the DR animals had persistent, significant steatorrhea. Intraluminal anaerobic bacteria and SCFA concentrations were significantly greater in the ileum but were not influenced by resection. Intestinal remnant length increased to a greater extent after proximal resection (PR), but circumference increased to a similar extent after both resections. Villus height and crypt depth increased significantly only after PR. MMC frequency was similar in all four groups. In the DR animals 26% of migrating motor complexes (MMCs) originated within the remnant. The jejunal remnant of these animals had a dominance of cluster activity similar to the intact distal ileum. Following PR, the postprandial motilin response was decreased. After DR, there were transient increases in neurotensin and PYY. Of the various factors evaluated, mucosal adaptation and the intestinal motor response appear most likely to explain the inferior nutritional and absorptive outcome associated with resection of the distal small intestine.

Effect of domperidone on the health-related quality of life of patients with symptoms of diabetic gastroparesis

OBJECTIVE

To describe the health-related quality of life (HRQOL) of patients with insulin-treated diabetes and symptoms of diabetic gastroparesis and to assess the impact of domperidone on HRQOL in these patients.

RESEARCH DESIGN AND METHODS

This two-phase multicenter study was part of a safety and efficacy investigation. Phase I involved 4-week single-blind treatment with domperidone 20 mg q.i.d. (n=269). Patients demonstrating significant symptomatic improvement (n=208) continued to phase 11, a 4-week, double-blind, parallel-group study with patients receiving placebo (n=103) or domperidone (n=105). Patients completed the Medical Outcomes Study Short-Form-36 Health Survey at selection and at the end of each phase. Physical component summary (PCS) and mental component summary (MCS) scores served as primary parameters, and the eight subscales were secondary parameters.

RESULTS

HRQOL scores of subjects enrolled in the trial were significantly lower than norms from the general population and people with diabetes (P < 0.001). Subjects experiencing symptomatic improvement after 4 weeks of single-blind treatment demonstrated significant improvement in all HRQOL parameters (P < 0.001); PCS, MCS, and six subscale scores of nonresponders did not change. Between-group change score differences were significant for PCS, MCS, and seven subscales (P < 0.05 to P < 0.001). During phase II, the domperidone group maintained their HRQOL; the placebo group showed a significant decline in PCS and four subscales (P < 0.05). The between-group difference in the PCS score change was statistically significant (-1.77 vs. 0.65, P=0.05).

CONCLUSIONS

Results suggest that patients with symptoms of diabetic gastroparesis experience notable HRQOL impairment and that symptomatic relief with domperidone is accompanied by improvements in HRQOL that can be sustained over 4 weeks of treatment.

Measurement of gastrointestinal motility in the GI laboratory

Current tests of gastric and small intestinal motor function provide relevant physiological information, but their clinical utility is controversial. This article reviews the current procedures, indications, significance, pitfalls, and guidelines for gastrointestinal motility measurements by scintigraphy, gastroduodenojejunal manometry, and surface electrogastrography in humans. Methods included review of literature and discussions in closed and open fora among investigators, including presentations for peer review at focused (Iowa City American Motility Society Symposium, December 1995) and national meetings (American Gastroenterological Association, May 1996, and American Motility Society, September 1996). The current tests are generally complementary; scintigraphy is typically the first test in the evaluation of gastric motor function and often confirms the clinical suspicion of dysmotility. Manometry identifies patterns suggestive of myopathy, neuropathy, or obstruction but may be most helpful when it shows entirely normal findings, because manometry helps in part to exclude dysmotility as a cause of symptoms. Electrogastrography may identify dysrhythmias or failure of signal power to increase postprandially; rhythm abnormalities may be independent of impaired emptying among dyspeptic patients. The best validated and clinically most significant results pertain to transit tests; manometry may contribute importantly to the diagnostic process; and the significance of electrogastrography remains to be fully elucidated.

The effects of surgery on gastrointestinal motor activity

Gastrointestinal surgical procedures have the potential to disrupt motor activity in various organs of the gastrointestinal tract or, indeed, throughout the entire alimentary canal. Several of these motor effects have important clinical consequences and have also served to advance our understanding of the regulation of gastrointestinal motor activity. This review will focus, in particular, on the effects of surgery on the small intestine, and will attempt to emphasize the implications of these studies for our understanding of small intestinal motility, in general.

Domperidone in the management of symptoms of diabetic gastroparesis: efficacy, tolerability, and quality-of-life outcomes in a multicenter controlled trial. DOM-USA-5 Study Group

The purpose of this clinical study was to determine the efficacy, tolerability, and impact on quality of life of domperidone--a specific peripherally acting dopamine antagonist--in the management of symptoms of gastroparesis, a common and potentially debilitating condition in patients with diabetes mellitus. In the first phase of this multicenter, two-phase withdrawal study, 287 diabetic patients with symptoms of gastroparesis of at least 6 months' duration received domperidone 20 mg QID in a single-masked fashion for 4 weeks. Efficacy was evaluated using a four-point rating scale (0 = none, 1 = mild, 2 = moderate, 3 = severe) for each of the following symptoms: nausea, abdominal distention/bloating, early satiety, vomiting, and abdominal pain. At the end of the first phase, patients with sufficient improvement in their total symptom score (a score < or = 6 and a decrease in score of > or = 5 units from the baseline [selection] visit) were eligible for the 4-week, randomized, placebo-controlled, double-masked withdrawal phase of the study. The impact of domperidone on quality of life was determined using the Medical Outcomes Study Short Form-36 (SF-36). Of 269 patients with data from the single-masked phase, 208 (77%) qualified for entry into the double-masked phase based on a statistically significant improvement in total symptom score, from a mean score of 10.32 at baseline (initial visit) to 3.79 after 4 weeks of single-masked domperidone therapy. During the double-masked phase, patients in the placebo group had significantly greater deterioration in total symptom scores compared with patients in the domperidone group (mean changes of 1.84 and 0.85, respectively). Similar significant differences in favor of domperidone were seen in the secondary efficacy variables (i.e., patients' diary scores and global assessments of symptoms). The tolerability profile of domperidone was similar to that of placebo. Patients who responded to domperidone experienced significant improvements in quality of life, as indicated by the SF-36 physical and mental component summary scores. During the double-masked phase, patients who were randomized to placebo experienced a significant deterioration in the physical component summary score compared with patients in the domperidone group. The results of this study suggest that domperidone 20 mg QID provides significant improvement in the upper gastrointestinal symptoms of diabetic gastroparesis and is well tolerated in patients with this condition.

Role of the ileocecal junction in the motor response to intestinal resection

Extensive resections of the distal small intestine are associated with motor disruption in the proximal remnant. Luminal contents such as bacteria and short-chain fatty acids may play a role. We evaluated the effect of bypass of the ileocecal junction (ICJ) on the motor response to a 50% distal resection. Thirty-five dogs were divided into three groups: transection control (TC, n = 11); 50% distal resection with intact ICJ (DR, n = 12), and 50% distal resection with jejunocolostomy to bypass the ICJ (DRBP, n = 12). Motor activity, intestinal transit, nutrition, absorption, and motor active hormones were studied over a 3-month period. Caloric intake was reduced and nutritional status similarly impaired in both resected groups. Steatorrhea, however, was significantly greater after DRBP. Intestinal structural adaptation was similar in both resected groups at 12 weeks. Animals in the bypass group demonstrated elevated intraluminal short-chain fatty acid and anaerobic bacterial counts. Migrating motor complex frequency was similar in the three groups; distal starts, however, were more frequent in both resected groups. Clustered contractile activity was prominent in the remnant after both DR and DRBP (50% and 32% recording time occupied by clusters, respectively [not significant]). Basal levels of peptide YY were increased following resection and this increase was unaffected by ICJ bypass. Postprandial neurotensin concentrations were transiently increased after distal bowel resection. In contrast, the postprandial neurotensin response was abolished following resection with bypass of the ICJ. Basal motilin levels were reduced following resection alone but not after resection with ICJ bypass. The motor response to resection does not appear to be related to alterations in circulating levels of hormones localized to the distal ileum; neither does it seem to be influenced by luminal bacteria and short-chain fatty acids or retention of a sphincteric mechanism at the ICJ. These findings also raise questions about the role of short-chain fatty acids and bacteria in the generation of the various distinctive motor patterns of the distal ileum. Resection of the distal ileum through loss of the receptor site for either retarding reflexes or bile salt absorption may be of greater importance in determining the motor response to resection.

Qualitative changes in enteric flora and short-chain fatty acids after intestinal resection

Our aim was to determine the effect of intestinal transection and resection on the prevalence of enteric flora and evaluate whether any such changes alter luminal SCFA and lactic acid content. Dogs underwent either 50% proximal (PR, N = 6) or distal (DR, N = 7) resection, distal resection with bypass of the ileocecal junction (DRBP, N = 9) or midpoint transection alone performed to serve as the appropriate control for luminal sampling for either proximal (PTC, N = 6) or distal (DTC, N = 7) resection. Studies were performed every four weeks for 12 weeks. Both jejunum and ileum had >10(5)/ml aerobic bacteria, most commonly E. coli. Streptococcal species were more common in the normal jejunum than ileum but were found in the ileal remnant after PR. Significant (>10(5)) anaerobic growth occurred infrequently in the jejunum, and DR did not increase anaerobic growth in jejunum unless DRBP was performed (93% vs 62% DR, 45% DTC, 20% normal jejunum, P < 0.05). Clostridium species increased significantly in the jejunal remnant after DRBP. Significant anaerobic growth occurred infrequently in normal ileum but increased after PR (89% vs 50% PTC, P < 0.05). Flora normally found in the jejunum tended to increase in the ileum after PR. Jejunal SCFA increased after DRBP (3126 +/- 577 microg/ml vs 1600 +/- 301 DTC, P < 0.05) but not DR (1791 +/- 321 microg/ml). Significant (>10(5)) anaerobic bacterial growth was associated with increased SCFA content (2717 +/- 381 vs 1029 +/- 170 microg/ml, P < 0.05) and the presence of lactic acid (30% vs 5%, P < 0.05), but there was no correlation between the presence of specific bacteria and SCFA and lactic acid. Following resection of the proximal small intestine, the intestinal remnant tends to assume the bacteriologic characteristics of the resected segment. Following a distal resection, the presence of an intact ICJ protects against the proliferation of a flora characteristic of the distal intestine; resection with bypass of the ICJ results in the appearance of coliforms in the jejunal remnant. These changes in enteric flora do not correlate with content of specific SCFA and lactic acid in the small intestine.

Constipation in Parkinson's disease: objective assessment and response to psyllium

We evaluated the reliability of patient history and the effect of psyllium on symptoms and colorectal function in 12 patients with Parkinson's disease (PD) and constipation. In all but two, constipation anteceded the development of parkinsonian symptoms. A comparison with prospectively obtained stool diaries confirmed the patients' reported constipation in 7 of the 12 patients. Those patients with confirmed constipation had lower stool weights and reported more straining at stool. Measures of colonic and anorectal function were similar in those who were truly constipated and those who were not. Among those PD subjects with confirmed constipation, psyllium increased stool frequency and weight but did not alter colonic transit or anorectal function. We conclude that prospectively obtained stool diaries should be employed to confirm constipation in PD and that psyllium produces both subjective and objective improvements in constipation related to PD.

Intestinal flora and nutrient absorption after intestinal resection

Intestinal resection results in loss of surface area, motor disruption, and an altered luminal milieu, all of which might influence bacterial growth. Our aim was to determine the effect of extensive intestinal resection in the dog on small intestinal bacterial flora and nutrient absorption. Ten dogs underwent 75% proximal intestinal resection and were killed at either 12 or 40 weeks. Five animals underwent transection alone and were killed at 12 weeks. Ileal aspirates were cultured. Nutritional status and nutrient absorption were measured every 4 weeks. Mean total and anaerobic ileal flora were increased after resection, significantly at 40 weeks. Overall, more cultures from resected animals had more than 5x10(6) total bacteria (6 of 10 vs. 0 of 10, P<0.05) and more than 10(5) anaerobic bacteria (5 of 10 vs. 0 of 10, P<0.05) than unoperated animals. Total but not anaerobic bacteria were increased after transection alone. Ingestion and absorption of carbohydrate decreased but absorption efficiency was maintained. Nitrogen intake decreased but excretion and absorption were unchanged. Fat intake decreased and excretion was unchanged resulting in decreased absorption. Mean intake, excretion, and absorption of nutrients were not influenced by the presence of significant growths of total (>5x10(6)/ml) or anaerobic (>10(5)/ml) bacteria. It was concluded that (1) 75% proximal intestinal resection results in significantly more aerobic and anaerobic bacteria in the ileal remnant; (2) intestinal bacterial content does not correlate with absorption of nutrients; and (3) the colon, and particularly colonic bacteria, may have a more important role in nutrient absorption than luminal flora in the small intestine after resection.

Enteric neuropathology: recent advances and implications for clinical practice

Because of their high prevalence in clinical practice, the field of gastrointestinal motility has tended to focus its clinical and research efforts on such functional disorders as nonulcer dyspepsia, the irritable bowel syndrome, and functional constipation. Because these disorders are difficult to define and their diagnosis remains exclusively symptomatic, progress has been difficult in these areas, and advances in clinical gastrointestinal motility generally have been hampered. This review attempts to emphasize the prevalence and importance of "organic" motility disorders, ie, those disorders of gastrointestinal motor dysfunction that are to a greater or lesser extent based on defined pathology and pathophysiology. Although some of these disorders are rare, recent dramatic progress has important lessons for motility in general and should point the way toward a greater understanding of the more common motor disorders.

Transdermal delivery of erythromycin lactobionate--implications for the therapy of gastroparesis

BACKGROUND

The treatment of many diseases may be complicated by abnormalities in gastric emptying. Gastric motor dysfunction may lead to unpredictable food and medication delivery to the small intestine, their site of absorption. Prokinetic agents improve gastric motility, but orally administered drugs are unreliably absorbed, thereby limiting their effectiveness. A method of delivering prokinetic agents which bypasses the gastrointestinal tract could lead to more effective treatment.

METHODS

Skin samples from rat, hairless mouse and man were placed in an in vitro diffusion chamber. The epidermal side of the skin was exposed to erythromycin lactobionate and passage of the drug across the skin sample monitored and quantitated by high-performance liquid chromatography with UV detection.

RESULTS

Erythromycin passes across all skin types tested. Steady-state flux across hairless mouse skin was greater than for rat, full thickness human skin and human epidermis. In the first 3 h following introduction of erythromycin lactobionate, 1.85 mg/cm2 crossed human epidermis. Given that a dose of 50 mg may exert prokinetic effects in vivo in man, increasing the patch size to approximately equal to 28 cm2 should provide therapeutic levels of drug within 3 h.

CONCLUSIONS

Erythromycin lactobionate, when administered transdermally, can be delivered at levels sufficient to treat gastroparesis. This technique warrants in vivo investigation.

Fatal diffuse invasive gastrointestinal candidiasis masking as ileus after bone marrow transplantation

High-dose cytotoxic chemotherapy has increased the incidence of candidal infections that make neutropenic patients very sick and may kill them. We report fatal invasive candidiasis involving the entire alimentary tract after autologous bone marrow transplantation in a young woman with breast cancer. Illustrated are the significance of fungal infections in this patient population, the potential for Candida albicans to invade the entire gastrointestinal tract, and the potential role of endoscopy in the early diagnosis of these often catastrophic infections. We also suggest that diffuse, invasive candidiasis should be considered in the differential diagnosis of ileus in the immunocompromised patient.

Antroduodenal manometry: an evaluation of an emerging methodology

Antroduodenal manometry is a relatively new technique for the assessment of gastric and small intestinal motor function. The aim of this review is to provide an evaluation of its current status as a diagnostical tool. Available recording systems are reviewed and the study protocol for the evaluation of antroduodenal motor function is described. The role of this methodology in the evaluation of patients with suspected motor disorders, its advantages over other less invasive techniques and limitations are critically assessed. We conclude that, in the evaluation of suspected foregut motor dysfunction, antroduodenal manometry may provide clinically useful information in selected patients; information which may not be available from standard diagnostic tests, including nuclear medicine gastric-emptying studies.