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Aurora SK, Shrewsbury SB, Ray S, Hindiyeh N, Nguyen L. A link between gastrointestinal disorders and migraine: Insights into the gut-brain connection. Headache 2021; 61:576-589. [PMID: 33793965 PMCID: PMC8251535 DOI: 10.1111/head.14099] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/03/2021] [Accepted: 02/15/2021] [Indexed: 12/12/2022]
Abstract
Background Migraine is a complex, multifaceted, and disabling headache disease that is often complicated by gastrointestinal (GI) conditions, such as gastroparesis, functional dyspepsia, and cyclic vomiting syndrome (CVS). Functional dyspepsia and CVS are part of a spectrum of disorders newly classified as disorders of gut–brain interaction (DGBI). Gastroparesis and functional dyspepsia are both associated with delayed gastric emptying, while nausea and vomiting are prominent in CVS, which are also symptoms that commonly occur with migraine attacks. Furthermore, these gastric disorders are comorbidities frequently reported by patients with migraine. While very few studies assessing GI disorders in patients with migraine have been performed, they do demonstrate a physiological link between these conditions. Objective To summarize the available studies supporting a link between GI comorbidities and migraine, including historical and current scientific evidence, as well as provide evidence that symptoms of GI disorders are also observed outside of migraine attacks during the interictal period. Additionally, the importance of route of administration and formulation of migraine therapies for patients with GI symptoms will be discussed. Methods A literature search of PubMed for articles relating to the relationship between the gut and the brain with no restriction on the publication year was performed. Studies providing scientific support for associations of gastroparesis, functional dyspepsia, and CVS with migraine and the impact these associations may have on migraine treatment were the primary focus. This is a narrative review of identified studies. Results Although the association between migraine and GI disorders has received very little attention in the literature, the existing evidence suggests that they may share a common etiology. In particular, the relationship between migraine, gastric motility, and vomiting has important clinical implications in the treatment of migraine, as delayed gastric emptying and vomiting may affect oral dosing compliance, and thus, the absorption and efficacy of oral migraine treatments. Conclusions There is evidence of a link between migraine and GI comorbidities, including those under the DGBI classification. Many patients do not find adequate relief with oral migraine therapies, which further necessitates increased recognition of GI disorders in patients with migraine by the headache community.
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Affiliation(s)
- Sheena K Aurora
- Medical Affairs, Impel NeuroPharma, Seattle, WA, USA.,Department of Neurology, Stanford University, Stanford, CA, USA
| | | | - Sutapa Ray
- Medical Affairs, Impel NeuroPharma, Seattle, WA, USA
| | - Nada Hindiyeh
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Linda Nguyen
- Department of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
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Gajendran M, Sarosiek I, McCallum R. Metoclopramide nasal spray for management of symptoms of acute and recurrent diabetic gastroparesis in adults. Expert Rev Endocrinol Metab 2021; 16:25-35. [PMID: 33739209 DOI: 10.1080/17446651.2021.1886922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
Introduction: Gastroparesis (GP) is characterized by delayed gastric emptying in the absence of mechanical obstruction. About 75% of GP patients are females. Diabetes and idiopathic are the two commonest etiologies of GP. Up to two-thirds of the GP patients do not have significant symptom responses to medical therapies, and there is a paucity of available oral prokinetic agents with only one medication approved by the U.S. Food and Drug Administration (FDA) for this indication. The oral and parenteral formulations of metoclopramide were FDA approved in 1979 to treat symptoms of acute and recurrent diabetic GP. Now, more than 40 years later, a nasal preparation of metoclopramide (GimotiTM) was approved in June 2020 for the same indication.Areas covered: PubMed search using the keywords 'nasal metoclopramide' and 'diabetic gastroparesis.' This article aims to provide a concise review of the pharmacology, clinical efficacy, and tolerability of nasal metoclopramide.Expert opinion: The nasal formulation can be systemically absorbed without relying on the passage through a poorly emptying stomach, thus assuring the delivery of a therapeutic dose of metoclopramide, even during episodes of vomiting. Hence, metoclopramide nasal spray has the potential to be used during an acute flare, potentially avoiding hospitalizations.
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Affiliation(s)
- Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, TX, USA
| | - Irene Sarosiek
- Division of Gastroenterology, Center for Neurogastroenterology and GI Motility, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Richard McCallum
- Division of Gastroenterology, Center for Neurogastroenterology and GI Motility, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, USA
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Saleem S, Inayat F, Aziz M, Then EO, Zafar Y, Gaduputi V. In‐hospital mortality in gastroparesis population and its predictors: A
United States
‐based population study. JGH Open 2021; 5:350-355. [PMID: 33732881 PMCID: PMC7936611 DOI: 10.1002/jgh3.12500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/13/2021] [Indexed: 01/17/2023]
Affiliation(s)
- Saad Saleem
- Department of Internal Medicine Sunrise Hospital and Medical Center Las Vegas Nevada USA
| | - Faisal Inayat
- Department of Internal Medicine Allama Iqbal Medical College Lahore Pakistan
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology University of Toledo Medical Center Toledo Ohio USA
| | - Eric O Then
- Department of Internal Medicine St. Barnabas Hospital, Health System Bronx New York USA
| | - Yousaf Zafar
- Department of Internal Medicine University of Mississippi Medical Center Jackson Mississippi USA
| | - Vinaya Gaduputi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Barnabas Hospital, Health System Bronx New York USA
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Gastroparesis and Severity of Delayed Gastric Emptying: Comparison of Patient Characteristics, Treatments and Medication Adverse Events. Dig Dis Sci 2021; 66:526-534. [PMID: 32306190 DOI: 10.1007/s10620-020-06258-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastroparesis is a heterogeneous disorder. Patient characteristics and treatment responsiveness may differ based on the extent of delay in gastric emptying. AIMS Characterize gastroparesis patients based on the degree of delay in gastric emptying, and assess the relationship of patient demographics, symptoms and response to therapy based on the extent of delay. METHODS 1333 solid-phase 4-h scintigraphic gastric emptying scans were reviewed. Delayed emptying was categorized on percent retention at 4 h: mild (10-19%), moderate (20-29%), and severe (≥ 30%). Analyses were performed with regard to demographics, symptoms, esophagogastroduodenoscopy findings, medication use, and emergency department (ED) visits/hospitalizations. RESULTS 284 patients had delayed gastric emptying: mild (42.6%), moderate (19.3%), and severe (37.3%). 79.5% were women, the mean age was 45 years (± 15), and mean symptom duration was 4.6 years (± 6.5). The main categories of gastroparesis were idiopathic and diabetes mellitus. The most commonly prescribed medications were metoclopramide, domperidone and erythromycin. Opiate use (n = 69) was associated with an increased degree of delayed gastric emptying (p = 0.03) with 50% of opiate users having very delayed gastric emptying. One-way analysis revealed that severely delayed gastric emptying correlated with both increased hospitalizations and ED visits. CONCLUSIONS Severe delay in gastric emptying is a risk factor for increased hospitalizations and ED visits. Opiate use correlates with increased severity of gastric emptying. Identifying at-risk patients, stopping opioids, and instituting a programmatic care plan for patients with severely delayed gastric emptying may reduce ED visits, hospitalizations, and healthcare costs.
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Lee KN. Gastroparesis in Asia: An Area Still Unfamiliar to Asian Gastroenterologists. J Neurogastroenterol Motil 2021; 27:5-7. [PMID: 33380551 PMCID: PMC7786089 DOI: 10.5056/jnm20255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/06/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
- Kang Nyeong Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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Hassan H, Ganguli S, Rashed H, Johnson W, Bhandari B, Abell T. Autonomic and enteric function profiling can predict disordered gastric emptying in diabetic gastropathy. Med Biol Eng Comput 2021; 59:327-332. [DOI: 10.1007/s11517-020-02300-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
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Rangan V, Ukleja A. Gastroparesis in the Hospital Setting. Nutr Clin Pract 2020; 36:50-66. [PMID: 33336872 DOI: 10.1002/ncp.10611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022] Open
Abstract
Gastroparesis (GP) is commonly seen in hospitalized patients. Refractory vomiting and related dehydration, electrolyte abnormalities, and malnutrition are indications for hospital admission. In addition, tube feeding intolerance is a common sign of gastric dysmotility in critically ill patients. The diagnosis and management of GP in the hospital setting can be quite challenging. Diagnostic tests are often deferred because of patient intolerance of the oral meal for standard scintigraphy or severity of the primary disease. The diagnosis of GP is often established on the basis of clinical scenario and risk factors for gastric motor dysfunction. Medical therapy in GP is directed toward controlling nausea and vomiting by prokinetic and antinausea medications and correcting nutrition risks or treating malnutrition with nutrition therapy. Enteral nutrition is the preferred nutrition intervention for patients with GP. Delayed gastric emptying in critically ill patients has a negative impact on the timely delivery of enteral feeding and meeting the energy and protein goals. Measures to improve gastric tolerance or provide feeding beyond the stomach are often needed, since early enteral nutrition has been an important target of therapy for critically ill patients. This review will address the current understanding of the mechanisms of GP and feeding intolerance in critical illness, diagnostic workup, drug therapies, and interventions to improve the provision of enteral nutrition in hospital settings when gastric dysmotility is present or suspected.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Ukleja
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Kamiya T, Osaga S, Kubota E, Fukudo S, Motoya S, Murakami K, Nagahara A, Shiotani A, Sugimoto M, Suzuki H, Watanabe T, Yamaguchi S, Chan FKL, Hahm KB, Fock KM, Zhu Q. Questionnaire-Based Survey on Epidemiology of Functional Gastrointestinal Disorders and Current Status of Gastrointestinal Motility Testing in Asian Countries. Digestion 2020; 102:73-89. [PMID: 33326975 DOI: 10.1159/000513292] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/24/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Functional gastrointestinal disorders (FGIDs) are diagnosed and classified using the latest Rome IV criteria, released in 2016. Epidemiology of FGID diagnosed by the Rome IV criteria and current clinical application of gastrointestinal motility testing in Asian countries are not well known. The aims of this survey are to elucidate the present situation of epidemiology and diagnostic tests of FGID in clinical practice in some East and Southeast Asian countries. METHODS The questionnaire focusing on current situation of FGID diagnosis and gastrointestinal motility testing was distributed to members of the International Gastroenterology Consensus Symposium study group and collected to be analyzed. RESULTS The prevalence rates of subtypes of both functional dyspepsia (FD) and irritable bowel syndrome (IBS) are relatively similar in all Asian countries. In these countries, most patients underwent both upper endoscopy and Helicobacter pylori test to diagnose FD. Colonoscopy was also frequently performed to diagnose IBS and chronic constipation. The frequency of gastrointestinal motility testing to examine gastric emptying and colonic transit time varied among Asian countries. CONCLUSIONS This survey revealed epidemiology of FGIDs and current status of gastrointestinal motility testing in some East and Southeast Asian countries.
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Affiliation(s)
- Takeshi Kamiya
- Department of Medical Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan,
| | - Satoshi Osaga
- Department of Medical Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Eiji Kubota
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shin Fukudo
- Department of Behavioral Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Motoya
- IBD Center, Sapporo Kosei General Hospital, Sapporo, Japan
| | | | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Akiko Shiotani
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Okayama, Japan
| | - Mitsushige Sugimoto
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital and Hepatology, Tokyo, Japan
| | - Hidekazu Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Satoru Yamaguchi
- First Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Francis K L Chan
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Ki-Baik Hahm
- Digestive Disease Center, CHA University School of Medicine and CHA University Bundang Medical Center, Seoul, Republic of Korea
| | - Kwong Ming Fock
- Department of Gastroenterology, Changi General Hospital, Singapore, Singapore, Singapore
| | - Qi Zhu
- SinoUnited Health, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Hedjoudje A, Huet E, Leroi AM, Desprez C, Melchior C, Gourcerol G. Efficacy of gastric electrical stimulation in intractable nausea and vomiting at 10 years: A retrospective analysis of prospectively collected data. Neurogastroenterol Motil 2020; 32:e13949. [PMID: 33107679 DOI: 10.1111/nmo.13949] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 06/09/2020] [Accepted: 06/23/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastric electrical simulation has been shown to relieve nausea and vomiting in medically refractory patients. Efficacy of gastric electrical stimulation has been reported mostly in short-term studies, but none has evaluated its efficacy beyond 10 years after implantation. METHODS Patients implanted at our center for medically refractory severe and chronic nausea and/or vomiting were evaluated before and over 10 years after implantation using symptomatic scale and quality of life (GIQLI) score. Improvement was defined as a reduction of more than 50% in vomiting frequency. KEY RESULTS A total of 50 patients were implanted from January 1998 to December 2009. Among them, 7 were explanted due to a lack of efficacy and/or side effects, 2 died, and 4 were lost to follow-up. Mean follow-up was 10.5 ± 3.7 years. In intention-to-treat analysis, 27/50 (54%) patients reported an improvement. Beyond 10 years, an improvement in early satiety (3.05 vs 1.76, <0.001), bloating (2.51 vs 1.70, P = .012), nausea (2.46 vs 1.35, P = .001), and vomiting (3.35 vs 1.49 P < .001) scores were observed. Quality of life improved over 10 years (GIQLI score: 69.7 vs. 86.4, P = .005) and body mass index (BMI: 23.4 vs. 26.2 kg/m2 ; P = .048). CONCLUSIONS AND INFERENCES Gastric electrical simulation is effective in the long-term in patients with medically refractory nausea and vomiting, with an efficacy of 54% at 10 years on an intention-to-treat analysis. Other long-term observational studies are warranted to confirm these results.
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Affiliation(s)
- Abdellah Hedjoudje
- Service de Physiologie Digestive, Urinaire et Respiratoire, CHU Charles Nicolle, Rouen, France.,Service d'Endoscopie Digestive, Hôpital Beaujon, Assistance publique des hôpitaux de Paris, Clichy, France
| | - Emmanuel Huet
- Service de Chirurgie Digestive, CHU Charles Nicolle, Rouen, France.,UMR INSERM 1073, Normandy University, Rouen, France
| | - Anne-Marie Leroi
- Service de Physiologie Digestive, Urinaire et Respiratoire, CHU Charles Nicolle, Rouen, France.,Centre d'Investigation Clinique INSERM 1404, CHU Charles Nicolle, Rouen, France
| | - Charlotte Desprez
- Service de Physiologie Digestive, Urinaire et Respiratoire, CHU Charles Nicolle, Rouen, France.,UMR INSERM 1073, Normandy University, Rouen, France
| | - Chloé Melchior
- UMR INSERM 1073, Normandy University, Rouen, France.,Service d'Hépato-Gastro-Entérologie, CHU Charles Nicolle, Rouen, France
| | - Guillaume Gourcerol
- Service de Physiologie Digestive, Urinaire et Respiratoire, CHU Charles Nicolle, Rouen, France.,UMR INSERM 1073, Normandy University, Rouen, France.,Centre d'Investigation Clinique INSERM 1404, CHU Charles Nicolle, Rouen, France
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Gonzalez Z, Loganathan P, Sarosiek I, McCallum RW. Gender-Related Differences in Gastroparesis. Am J Med Sci 2020; 360:474-483. [DOI: 10.1016/j.amjms.2020.04.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 04/01/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW This review assesses the relationship between gastroparesis and functional dyspepsia, in light of recent research assessing cause, pathophysiology and treatment. RECENT FINDINGS The Gastroparesis Cardinal Symptom Index (GCSI) lacks the ability to readily distinguish functional dyspepsia from gastroparesis based on symptoms. Although prior studies found that the extent of delay in gastric emptying did not accurately predict severity of symptoms, when optimally measured, delayed gastric emptying may in fact correlate with gastroparesis symptoms. Enteric dysmotility may be an important risk factor for gastroparesis. Altered central processing may play a role in symptom generation for both gastroparesis and functional dyspepsia based on functional brain MRI. Treatment directed towards reducing low-grade inflammation and improving mucosal barrier function in the duodenum may represent a novel therapeutic target for functional dyspepsia, whereas gastric peroral endoscopy myotomy (G-POEM) remains a promising intervention for refractory gastroparesis. SUMMARY Abnormalities on functional MRI of the brain have been identified in patients with functional dyspepsia and gastroparesis. Small bowel dysmotility and duodenal barrier dysfunction have been implicated in the pathophysiology of gastroparesis and functional dyspepsia, respectively. New treatments for functional dyspepsia may target low-grade duodenal inflammation and barrier dysfunction. The pylorus remains a target in gastroparesis.
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Additional posterior wall isolation is associated with gastric hypomotility in catheter ablation of atrial fibrillation. Int J Cardiol 2020; 326:103-108. [PMID: 33130261 DOI: 10.1016/j.ijcard.2020.10.069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/25/2020] [Accepted: 10/23/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Gastric hypomotility (GH) is a possible complication of catheter ablation (CA) for atrial fibrillation (AF). However, it is unclear which factors are associated with GH. We sought to elucidate the relationship between the CA procedure and GH. METHODS The study population consisted of 254 patients who underwent CA for AF from November 2017 to October 2018. Finally, 119 patients were enrolled and divided into two groups: with or without GH (GH or non-GH groups). To evaluate the association with GH, the clinical backgrounds and procedure characteristics of the radiofrequency CA (RFCA) were compared between the two groups. RESULTS The median age was 69 years old with 34% of female. GH were observed in 27.7% of patients who underwent RFCA, which was significantly higher than that in the cohort of patients who underwent esophago-gastro-duodenoscopy during the same time period (1.9%: 151 in 8063 patients, p < 0.0001). According to the detailed RFCA procedure, additional posterior wall isolation with pulmonary vein isolation (PVI) had a higher prevalence of GH than that with only PVI (54.8% vs. 18.2%; odds ratio 5.46, 95%CI 2.24-13.32, p = 0.0002). After an adjustment using a multivariate logistic analysis, a posterior wall isolation with the PVI was identified as the only independent predictor for GH (odds ratio 5.01, 95%CI 1.94-13.43, p = 0.0009). CONCLUSIONS Additional posterior wall isolation with PVI was associated with gastric hypomotility.
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Factors Associated With Hospital Admissions and Readmissions in Patients With Gastroparesis Using the Nationwide Readmission Database. J Clin Gastroenterol 2020; 54:801-805. [PMID: 31851105 DOI: 10.1097/mcg.0000000000001295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Gastroparesis can be associated with severe symptoms. Health care utilization for gastroparesis has increased in part due to an increase in hospital admissions. GOALS To characterize patients admitted for gastroparesis-related symptoms and determine risk factors associated with 30-day readmissions. STUDY The Nationwide Readmission Database (NRD) for the year 2014 was used to identify patients admitted to hospitals using the International Classification of Diseases (ICD)-9 code for gastroparesis as primary diagnosis or as the secondary diagnosis with first diagnosis code of a gastroparesisrelated symptom. Logistic regression was used to determine risk factors associated with 30-day readmission. RESULTS There were 5268 gastroparesis patients admitted with the average length of stay (LOS) of 5.4±6.6 days. Age averaged 48.9±18.1 years, 73.8% were female individuals, and 31% had diabetes. Inpatient mortality was 0.4%. The overall 30-day readmission rate was 6.2%. Longer LOS [odds ratio (OR)=1.4; 95% confidence interval (CI), 1.0-1.9], younger age, drug abuse (OR=1.6; 95% CI, 1.2-2.2), and marijuana use (OR=1.7; 95% CI, 1.0-2.7) were associated with increased risk of 30-day readmission. Female gender (P=0.083), opioid use (P=0.057), and admission to larger hospital (P=0.070) showed a trend toward higher readmission rates. Older patients, and patients with hypertension and diabetes showed lower rates of readmission. CONCLUSIONS Use of the Nationwide Readmission Database (NRD) allows better understanding of gastroparesis admissions and readmissions. Average hospital stay was 5.4 days with 0.4% mortality rate. Overall 30-day readmission rate was 6.2%. Higher LOS, drug abuse, and marijuana use increased the 30-day readmission rate. Diabetes, hypertension, and older age were associated with lower readmissions.
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Does etiology of gastroparesis determine clinical outcomes in gastric electrical stimulation treatment of gastroparesis? Surg Endosc 2020; 35:4550-4554. [DOI: 10.1007/s00464-020-07928-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/19/2020] [Indexed: 12/15/2022]
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Tan J, Shrestha SM, Wei M, Wang P, Shi J, Lu Y, Gao Q, Lu T, Zhou J, Shi R. Feasibility, safety, and long-term efficacy of gastric peroral endoscopic myotomy (G-POEM) for postsurgical gastroparesis: a single-center and retrospective study of a prospective database. Surg Endosc 2020; 35:3459-3470. [PMID: 32880749 PMCID: PMC8195960 DOI: 10.1007/s00464-020-07793-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Postsurgical gastroparesis is recognized as a gastrointestinal dysfunction syndrome following foregut surgery. Gastric peroral endoscopic myotomy (G-POEM) is suggested as a minimally invasive therapy for gastroparesis. But the long-term efficacy and safety of G-POEM in treating postsurgical gastroparesis are rarely explored. METHODS The primary outcomes included the symptomatic improvement based on gastroparesis cardinal symptoms index (GCSI) and the improvement of gastric emptying. The secondary outcomes included the improvement of gastroesophageal reflux symptoms and complications of G-POEM. RESULTS The severity of postsurgical gastroparesis was not associated with the onset time and the course of the disease. G-POEM significantly reduced GCSI throughout the follow-up period (p < 0.0001). For different anastomotic site, a significant improvement of GCSI was found at 6 month post-G-POEM (F4,165 = 74.18, p < 0.0001). Subscale analysis of GCSI showed that nausea/vomiting, post-prandial fullness/early satiety, and bloating were improved significantly at 6-month post-G-POEM (p < 0.0001, respectively). Half-emptying and whole-emptying time were significantly shortened in patients with different anastomotic site post-G-POEM (half-emptying time: F3,174 = 65.44, p < 0.0001; whole-emptying time: F3,174 = 54.85, p < 0.0001). The emptying of ioversol was obviously accelerated after G-POEM. GCSI wasn't related to pyloric length, pyloric diameter, and thickness of pyloric wall. GERDQ was also used to evaluate the clinical efficacy of G-POEM. For each time points, GERDQ didn't differ significantly in patients with different anastomotic site (F4,104 = 0.8075, p = 0.5231). For patients with different anastomotic site, GERDQ was improved significantly at different time points (F4,104 = 59.11, p < 0.0001). The higher the esophageal anastomotic site was, the faster G-POEM improved the symptoms of gastroesophageal reflux. No one required re-hospitalization for any complication. CONCLUSION G-POEM is a minimally invasive therapy with long-term effectiveness and safety in treating postsurgical gastroparesis.
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Affiliation(s)
- Jiacheng Tan
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Sachin Mulmi Shrestha
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Ming Wei
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Panpan Wang
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Jinjun Shi
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yanjia Lu
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Qi Gao
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Tong Lu
- Department of Radiology, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Jun Zhou
- Medical Division, Yidu Cloud (Beijing) Technology Co., Ltd, Beijing, 100191, China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China.
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Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat? Gastroenterol Clin North Am 2020; 49:539-556. [PMID: 32718569 PMCID: PMC7391056 DOI: 10.1016/j.gtc.2020.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.
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Chikkamenahalli LL, Pasricha PJ, Farrugia G, Grover M. Gastric Biopsies in Gastroparesis: Insights into Gastric Neuromuscular Disorders to Aid Treatment. Gastroenterol Clin North Am 2020; 49:557-570. [PMID: 32718570 PMCID: PMC7387746 DOI: 10.1016/j.gtc.2020.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The cellular and molecular understanding of human gastroparesis has markedly improved due to studies on full-thickness gastric biopsies. A decrease in the number of interstitial cells of Cajal (ICC) and functional changes in ICC constitutes the hallmark cellular feature of gastroparesis. More recently, in animal models, macrophages have also been identified to play a central role in development of delayed gastric emptying. Activation of macrophages leads to loss of ICC. In human gastroparesis, loss of anti-inflammatory macrophages in gastric muscle has been shown. Deeper molecular characterization using transcriptomics and proteomics has identified macrophage-based immune dysregulation in human gastroparesis.
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Affiliation(s)
- Lakshmikanth L. Chikkamenahalli
- Enteric NeuroScience Program, Mayo clinic, Division of Gastroenterology & Hepatology, Physiology & Biomedical Engineering Mayo Clinic, 200 1 Street SW, Rochester, MN 55905, Tel: +1 507-538-0337
| | - Pankaj J. Pasricha
- Center for Neurogastroenterology, Division of Gastroenterology & Hepatology Johns Hopkins School of Medicine, Ross 958, 720 Rutland Avenue, Baltimore, MD 21205, Tel: +1 443-613-8152
| | - Gianrico Farrugia
- Enteric NeuroScience Program, Division of Gastroenterology & Hepatology, Physiology & Biomedical Engineering Mayo Clinic, 200 1 Street SW, Rochester, MN 55905, Tel: +1 507-284-4695
| | - Madhusudan Grover
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA; Division of Physiology and Biomedical Engineering, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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68
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The Scarcity of Literature on the Psychological, Social, and Emotional Effects of Gastroparesis in Children. CHILDREN-BASEL 2020; 7:children7090115. [PMID: 32877988 PMCID: PMC7552653 DOI: 10.3390/children7090115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/09/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022]
Abstract
Gastroparesis (GP) is a chronic, gastric dysmotility disorder with significant morbidity and mortality. The hallmark of GP is the delayed emptying of the contents of the stomach in the absence of any mechanical obstruction. Patients most commonly report chronic symptoms of nausea, vomiting, feeling full quickly when eating, bloating, and abdominal pain. Treatments are limited with relatively poor efficacy. As such, children with GP are at significant risk for the development of psychological co-morbidities. In this paper, we provide a topical review of the scientific literature on the psychological, social, and emotional impacts of gastroparesis in pediatric patients. We aim to document the current state of research, identify gaps in our knowledge with appropriate recommendations for future research directions, and highlight the unique challenges pediatric patients with GP and their families may face as they manage this disease. Based on the current review, research into the psychosocial impacts in children with GP is essentially non-existent. However, when considering research in children with other chronic digestive diseases, children with GP are likely to face multiple psychosocial challenges, including increased risk for anxiety and depression, stigma, and reduced quality of life. These significant gaps in the current understanding of effects of GP across domains of childhood functioning allow for ample opportunities for future studies to address psychosocial outcomes.
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Comparison of the Status of Interstitial Cells of Cajal in the Smooth Muscle of the Antrum and Pylorus in Diabetic Male and Female Patients with Severe Gastroparesis. GASTROINTESTINAL DISORDERS 2020. [DOI: 10.3390/gidisord2030023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Females dominate in the area of gastroparesis (GP), making up to 70–80% of these patients. One attractive hypothesis is that females have less smooth muscle reserve and thus less resilience to recover from an insult. Our aim was to investigate if there are gender differences in the number of interstitial cells of Cajal (ICC) in the antral and pyloric smooth muscle of diabetic (DM) patients with severe gastroparesis refractory to standard medical management. Full thickness antral and pyloric biopsies were obtained during surgery to implant a gastric electrical stimulation system and perform a pyloroplasty. Thirty-eight DM patients (66% females, n = 25; mean age 44) who failed medical therapies provided antral biopsies. Pyloric tissue samples were also collected from 29 of these patients (65% females, n = 19). Tissues were stained with H&E and c-Kit for the presence of ICC. ICC depletion was defined as less than 10 cells/HPF. In the antrum, 40% of females had significant ICC depletion, similar to 38% in males. In the pylorus, 68% of females had depletion of ICC, compared to 80% depletion in males. When combining both antral and pyloric smooth muscle regions, ICC depletion was similar in males (40%) when compared to females (38%). In diabetic patients with severe GP, females and males showed similar degrees of reduction in antral ICC, while more males had depletion of pyloric smooth muscle ICC compared to their female counterparts. Future larger studies should focus on whether differences in other smooth muscle biomarkers can be identified between males and females.
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McDonough W, Aragon IV, Rich J, Murphy JM, Abou Saleh L, Boyd A, Koloteva A, Richter W. PAN-selective inhibition of cAMP-phosphodiesterase 4 (PDE4) induces gastroparesis in mice. FASEB J 2020; 34:12533-12548. [PMID: 32738081 DOI: 10.1096/fj.202001016rr] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
Abstract
Inhibitors of cAMP-phosphodiesterase 4 (PDE4) exert a number of promising therapeutic benefits, but adverse effects, in particular emesis and nausea, have curbed their clinical utility. Here, we show that PAN-selective inhibition of PDE4, but not inhibition of PDE3, causes a time- and dose-dependent accumulation of chow in the stomachs of mice fed ad libitum without changing the animals' food intake or the weight of their intestines, suggesting that PDE4 inhibition impairs gastric emptying. Indeed, PDE4 inhibition induced gastric retention in an acute model of gastric motility that traces the passage of a food bolus through the stomach over a 30 minutes time period. In humans, abnormal gastric retention of food is known as gastroparesis, a syndrome predominated by nausea (>90% of cases) and vomiting (>80% of cases). We thus explored the abnormal gastric retention induced by PDE4 inhibition in mice under the premise that it may represent a useful correlate of emesis and nausea. Delayed gastric emptying was produced by structurally distinct PAN-PDE4 inhibitors including Rolipram, Piclamilast, Roflumilast, and RS25344, suggesting that it is a class effect. PDE4 inhibitors induced gastric retention at similar or below doses commonly used to induce therapeutic benefits (e.g., 0.04 mg/kg Rolipram), thus mirroring the narrow therapeutic window of PDE4 inhibitors in humans. YM976, a PAN-PDE4 inhibitor that does not efficiently cross the blood-brain barrier, induced gastroparesis only at significantly higher doses (≥1 mg/kg). This suggests that PDE4 inhibition may act in part through effects on the autonomic nervous system regulation of gastric emptying and that PDE4 inhibitors that are not brain-penetrant may have an improved safety profile. The PDE4 family comprises four subtypes, PDE4A, B, C, and D. Selective ablation of any of these subtypes in mice did not induce gastroparesis per se, nor did it protect from PAN-PDE4 inhibitor-induced gastroparesis, indicating that gastric retention may result from the concurrent inhibition of multiple PDE4s. Thus, potentially, any of the four PDE4 subtypes may be targeted individually for therapeutic benefits without inducing nausea or emesis. Acute gastric retention induced by PDE4 inhibition is alleviated by treatment with the widely used prokinetic Metoclopramide, suggesting a potential of this drug to alleviate the side effects of PDE4 inhibitors. Finally, given that the cause of gastroparesis remains largely idiopathic, our findings open the possibility that a physiologic or pathophysiologic downregulation of PDE4 activity/expression may be causative in a subset of patients.
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Affiliation(s)
- Will McDonough
- Department of Biochemistry & Molecular Biology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Ileana V Aragon
- Department of Biochemistry & Molecular Biology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Justin Rich
- Department of Biochemistry & Molecular Biology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - James M Murphy
- Department of Biochemistry & Molecular Biology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Lina Abou Saleh
- Department of Biochemistry & Molecular Biology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Abigail Boyd
- Department of Biochemistry & Molecular Biology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Anna Koloteva
- Department of Biochemistry & Molecular Biology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
| | - Wito Richter
- Department of Biochemistry & Molecular Biology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL, USA
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Nguyen L, Wilson LA, Miriel L, Pasricha PJ, Kuo B, Hasler WL, McCallum RW, Sarosiek I, Koch KL, Snape WJ, Farrugia G, Grover M, Clarke J, Parkman HP, Tonascia J, Hamilton F, Abell TL. Autonomic function in gastroparesis and chronic unexplained nausea and vomiting: Relationship with etiology, gastric emptying, and symptom severity. Neurogastroenterol Motil 2020; 32:e13810. [PMID: 32061038 PMCID: PMC7377964 DOI: 10.1111/nmo.13810] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Autonomic dysfunction can be present in patients with idiopathic and diabetic gastroparesis. The role of autonomic dysfunction relating to gastric emptying and upper gastrointestinal symptoms in patients with gastroparesis and chronic unexplained nausea and vomiting (CUNV) remains unclear. The aim of our study is to evaluate autonomic function in patients with gastroparesis and CUNV with respect to etiology, gastric emptying and symptom severity. METHODS We studied 242 patients with chronic gastroparetic symptoms recruited at eight centers. All patients had a gastric emptying scintigraphy within 6 months of the study. Symptom severity was assessed using the gastroparesis cardinal symptom index. Autonomic function testing was performed at baseline enrollment using the ANX 3.0 autonomic monitoring system which measures heart rate variability and respiratory activity measurements. KEY RESULTS Low sympathetic response to challenge (Valsalva or standing) was the most common abnormality seen impacting 89% diabetic and 74% idiopathic patients. Diabetics compared to idiopathics, exhibited greater global hypofunction with sympathetic (OR = 4.7, 95% CI 2.2-10.3; P < .001) and parasympathetic (OR = 7.2, 95% CI 3.4-15.0; P < .001) dysfunction. Patients with delayed gastric emptying were more likely to have paradoxic parasympathetic excessive during sympathetic challenge [(Valsalva or standing) 40% vs. 26%, P = .05]. Patients with more severe symptoms exhibited greater parasympathetic dysfunction compared to those with mild-moderate symptoms: resting sympathovagal balance [LFa/RFa 1.8 (1.0-3.1) vs. 1.2 (0.6-2.3), P = .006)] and standing parasympathetic activity [0.4 (0.1-0.8) vs. 0.6 (0.2-1.7); P = .03]. CONCLUSIONS Autonomic dysfunction was common in patients with gastroparesis and CUNV. Parasympathetic dysfunction was associated with delayed gastric emptying and more severe upper gastrointestinal symptoms. Conversely, sympathetic hypofunction was associated with milder symptoms. INFERENCES Gastroparesis and CUNV may be a manifestation of GI autonomic dysfunction or imbalance, such that sympathetic dysfunction occurs early on in the manifestation of chronic upper GI symptoms, while parasympathetic dysfunction results in more severe symptoms and delayed gastric emptying.
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Affiliation(s)
| | | | | | | | - Braden Kuo
- Harvard University, Boston, Massachusetts
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Usai-Satta P, Bellini M, Morelli O, Geri F, Lai M, Bassotti G. Gastroparesis: New insights into an old disease. World J Gastroenterol 2020. [DOI: 10.3748/wjg.v26.i19.2332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
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Usai-Satta P, Bellini M, Morelli O, Geri F, Lai M, Bassotti G. Gastroparesis: New insights into an old disease. World J Gastroenterol 2020; 26:2333-2348. [PMID: 32476797 PMCID: PMC7243643 DOI: 10.3748/wjg.v26.i19.2333] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/08/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis (Gp) is a chronic disease characterized by a delayed gastric emptying in the absence of mechanical obstruction. Although this condition has been reported in the literature since the mid-1900s, only recently has there been renewed clinical and scientific interest in this disease, which has a potentially great impact on the quality of life. The aim of this review is to explore the pathophysiological, diagnostic and therapeutical aspects of Gp according to the most recent evidence. A comprehensive online search for Gp was carried out using MEDLINE and EMBASE. Gp is the result of neuromuscular abnormalities of the gastric motor function. There is evidence that patients with idiopathic and diabetic Gp may display a reduction in nitrergic inhibitory neurons and in interstitial cells of Cajal and/or telocytes. As regards diagnostic approach, 99-Technetium scintigraphy is currently considered to be the gold standard for Gp. Its limits are a lack of standardization and a mild risk of radiation exposure. The C13 breath testing is a valid and safe alternative method. 13C acid octanoic and the 13C Spirulina platensis recently approved by the Food and Drug Administration are the most commonly used diagnostic kits. The wireless motility capsule is a promising technique, but its use is limited by costs and scarce availability in many countries. Finally, therapeutic strategies are related to the clinical severity of Gp. In mild and moderate Gp, dietary modification and prokinetic agents are generally sufficient. Metoclopramide is the only drug approved by the Food and Drug Administration for Gp. However, other older and new prokinetics and antiemetics can be considered. As a second-line therapy, tricyclic antidepressants and cannabinoids have been proposed. In severe cases the normal nutritional approach can be compromised and artificial nutrition may be needed. In drug-unresponsive Gp patients some alternative strategies (endoscopic, electric stimulation or surgery) are available.
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Affiliation(s)
- Paolo Usai-Satta
- Department of Internal Medicine, Division of Gastroenterology, Brotzu Hospital, Cagliari 09124, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56122, Italy
| | - Olivia Morelli
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia 06123, Italy
| | - Francesca Geri
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56122, Italy
| | - Mariantonia Lai
- Gastroenterology Unit, University of Cagliari, Monserrato 09042, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia 06123, Italy
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Duffey K, Hannon M, Yoo J, Perkons N, Intenzo C, Moleski S, DiMarino AJ. The impact of risk factors on gastroparesis at an urban medical center. Ann Gastroenterol 2020; 33:250-256. [PMID: 32382227 PMCID: PMC7196617 DOI: 10.20524/aog.2020.0475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/29/2020] [Indexed: 12/31/2022] Open
Abstract
Background Gastroparesis is a complex and poorly understood disease. The literature is lacking with respect to the epidemiology of patient comorbidities and their effect on gastric emptying. We aimed to describe the most common comorbid conditions among patients with gastroparesis in an urban population and quantify the effect of these comorbidities on the severity of delayed gastric emptying (DGE). Methods We examined the medical records of all patients diagnosed with gastroparesis at a quaternary care center between 2014 and 2015. The severity of DGE was analyzed after patients were stratified for possible causative etiologies. Likelihood ratio tests were used to assess the significance of demographic and scintigraphic variation in this population. Results Of the 221 patients, 56.1% were Caucasian and 31.7% were African American. Among these patients, 29.4% had evidence of medication-associated gastroparesis, 29.0% had diabetes-associated gastroparesis, and 31.7% had idiopathic disease. African American patients with gastroparesis were more likely to have diabetic gastroparesis than patients of other races (P=0.01). There was a statistically significant relationship between the number of major risk factors and the severity of a patient's DGE (P=0.004). Conclusions Among a diverse urban population, patients with DGE often carry multiple comorbid conditions that serve as risk factors for the development of gastroparesis, including prescriptions for narcotic medications. Greater numbers of these comorbid conditions are associated with more severe disease. Demographics are significantly associated with the etiology and severity of gastroparesis; in particular, African American patients are more likely to have diabetic gastroparesis than patients of other races.
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Affiliation(s)
- Katherine Duffey
- Department of Medicine, Division of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA (Katherine Duffey, Michelle Hannon)
| | - Michelle Hannon
- Department of Medicine, Division of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA (Katherine Duffey, Michelle Hannon)
| | - Joseph Yoo
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA (Joseph Yoo, Stephanie Moleski, Anthony J. DiMarino)
| | - Nicholas Perkons
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Nicholas Perkons)
| | - Charles Intenzo
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Thomas Jefferson University, Philadelphia, PA (Charles Intenzo), USA
| | - Stephanie Moleski
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA (Joseph Yoo, Stephanie Moleski, Anthony J. DiMarino)
| | - Anthony J DiMarino
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA (Joseph Yoo, Stephanie Moleski, Anthony J. DiMarino)
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Desprez C, Melchior C, Wuestenberghs F, Huet E, Zalar A, Jacques J, Leroi AM, Gourcerol G. Pyloric distensibility measurement after gastric surgery: Which surgeries are associated with pylorospasm? Neurogastroenterol Motil 2020; 32:e13790. [PMID: 31916346 DOI: 10.1111/nmo.13790] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/13/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND STUDY AIMS History of gastric surgery is found in 10% of patients with gastroparesis, and vagal lesion is often suspected to be the cause of pylorospasm. Recently, pyloric distensibility measurement using the EndoFLIP® system showed that pylorospasm was present in 30%-50% of gastroparetic patients. Our objective was to assess whether pylorospasm, diagnosed using EndoFLIP® system was observed in three different types of gastric surgeries: antireflux surgery, sleeve gastrectomy, and esophagectomy. PATIENTS AND METHODS Pyloric distensibility and pressure were measured using the EndoFLIP® system in 43 patients from two centers (18 antireflux surgery, 16 sleeve gastrectomy, and nine esophagectomy) with dyspeptic symptoms after gastric surgery, and in 21 healthy volunteers. Altered pyloric distensibility was defined as distensibility below 10 mm2 /mm Hg as previously reported. RESULTS Compared to healthy volunteers (distensibility: 25.2 ± 2.4 mm2 /mm Hg; pressure: 9.7 ± 4.4 mm Hg), pyloric distensibility was decreased in 61.1% of patients in the antireflux surgery group (14.5 ± 3.4 mm2 /mm Hg; P < .01) and 75.0% of patients in the esophagectomy group (10.8 ± 2.1 mm2 /mm Hg; P < .05), while pyloric pressure was only increased in the antireflux surgery group (18.9 ± 2.2 mm Hg; P < .01). Pyloric distensibility and pressure were similar in healthy volunteers and in sleeve gastrectomy (distensibility: 20.3 ± 3.8 mm2 /mm Hg; pressure: 15.8 ± 1.6 mm Hg) groups, with decreased pyloric distensibility affecting 18.7% of sleeve gastrectomy patients. CONCLUSION Antireflux surgery and esophagectomy were associated with pylorospasm although pylorospasm was not found in all patients. Sleeve gastrectomy was not associated with altered pyloric distensibility nor altered pyloric pressure.
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Affiliation(s)
- Charlotte Desprez
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France
| | - Chloé Melchior
- Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Hepatogastroenterology Department, Rouen University Hospital, Rouen, France
| | - Fabien Wuestenberghs
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France
| | - Emmanuel Huet
- Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Digestive Surgery Department, Rouen University Hospital, Rouen, France
| | - Alberto Zalar
- Hepatogastroenterology Department, Rouen University Hospital, Rouen, France
| | - Jérémie Jacques
- Hepatogastroenterology Department, Limoges University Hospital, Limoges, France
| | - Anne-Marie Leroi
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Clinical Investigation Center, INSERM 0204, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Clinical Investigation Center, INSERM 0204, Rouen University Hospital, Rouen, France
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Abstract
PURPOSE OF REVIEW This review highlights recent work that will lead to near-term advances in the understanding and treatment of gastroparesis (Gp). RECENT FINDINGS Major current advancements in the pathophysiology of Gp, include recognition of the SIP syncytium as the pacemaking unit rather than ICC alone and that Gp may be part of a pan-enteric autoimmune and/or autonomic disorder with macrophage imbalance. The development of newer techniques to assess gastric emptying (gastric emptying breath test and wireless motility capsule) and pyloric distensibility (EndoFLIP®) are allowing clinicians better characterization of their patients. In addition to pharmaceutical compounds in the pipeline, neuromodulation and endosurgical techniques, such as G-POEM, may help address refractory Gp. We expect that the 2020 decade will witness exciting developments. Treatments targeting gastrointestinal motility, immunological dysfunction, and inflammatory mediators will be evaluated. We anticipate future studies will be guided by biomarkers correlated with patient outcomes and therapeutic efficacy to establish new paradigms in the management of Gp.
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77
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Febo‐Rodriguez L, Chumpitazi BP, Shulman RJ. Childhood gastroparesis is a unique entity in need of further investigation. Neurogastroenterol Motil 2020; 32:e13699. [PMID: 31407456 PMCID: PMC7015769 DOI: 10.1111/nmo.13699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite increasing knowledge regarding gastroparesis (GP) in adults, little is known regarding the incidence, prevalence, and natural history of childhood GP. Exacerbating the knowledge gap in pediatric GP is both the lack of normative data for gastric emptying scintigraphy in children and lack of GP-specific pediatric reported outcome measures. PURPOSE The aim of this article was to review the available literature on pediatric GP and identify similarities and differences with studies in adults. We performed a comprehensive search in MEDLINE and Google Scholar from inception to April 2019 for articles published in English using the following combination of keywords: gastroparesis, pediatric gastroparesis, outcomes, metoclopramide, erythromycin, domperidone, cisapride, and gastric neurostimulator. The limited available pediatric data, often retrospective, suggest marked differences between adult and pediatric GP in several aspects including etiology, concomitant co-morbidities (eg, psychiatric disorders), clinical symptom presentation, diagnostic evaluation, response to therapies, and clinical outcome. Further research in pediatric GP is needed and holds the promise to further elucidate the mechanisms of this disorder in children and lead to pediatric-focused therapies.
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Affiliation(s)
- Liz Febo‐Rodriguez
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
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Ward MP, Gupta A, Wo JM, Rajwa B, Furness JB, Powley TL, Nowak TV. An emerging method to noninvasively measure and identify vagal response markers to enable bioelectronic control of gastroparesis symptoms with gastric electrical stimulation. J Neurosci Methods 2020; 336:108631. [PMID: 32087238 DOI: 10.1016/j.jneumeth.2020.108631] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 01/27/2020] [Accepted: 02/07/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Gastric electrical stimulation (GES) can be a life-changing, device-based treatment option for drug-resistant nausea and vomiting associated with diabetic or idiopathic gastroparesis (GP). Despite over two decades of clinical use, the mechanism of action remains unclear. We hypothesize a vagal mechanism. NEW METHOD Here, we describe a noninvasive method to investigate vagal nerve involvement in GES therapy in 66 human subjects through the compound nerve action potential (CNAP). RESULTS Of the 66 subjects, 28 had diabetic GP, 35 had idiopathic GP, and 3 had postsurgical GP. Stimulus charge per pulse did not predict treatment efficacy, but did predict a significant increase in total symptom score in type 1 diabetics as GES stimulus charge per pulse increased (p < 0.01), representing a notable side effect and providing a method to identify it. In contrast, the number of significant left and right vagal fiber responses that were recorded directly related to patient symptom improvement. Increased vagal responses correlated with significant decreases in total symptom score (p < 0.05). COMPARISON WITH EXISTING METHOD(S) We have developed transcutaneous recording of cervical vagal activity that is synchronized with GES in conscious human subjects, along with methods of discriminating the activity of different nerve fiber groups with respect to conduction speed and treatment response. CONCLUSIONS Cutaneous vagal CNAP analysis is a useful technique to unmask relationships among GES parameters, vagal recruitment, efficacy and side-effect management. Our results suggest that CNAP-guided GES optimization will provide the most benefit to patients with idiopathic and type 1 diabetic gastroparesis.
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Affiliation(s)
- Matthew P Ward
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Anita Gupta
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - John M Wo
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bartek Rajwa
- Bindley Bioscience Center, Purdue University, West Lafayette, IN, USA
| | - John B Furness
- Department of Anatomy and Neuroscience, University of Melbourne, Parkville, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, Australia
| | - Terry L Powley
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA; Dept. of Psychological Sciences, Purdue University, West Lafayette, IN, USA
| | - Thomas V Nowak
- Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
GOALS We aimed to establish the epidemiological characteristics and documentation of diagnostic workup for gastroparesis (GP). BACKGROUND No study has used a national database to evaluate the prevalence, demographics, and associated comorbid conditions of GP, and document rates of proper diagnosis. MATERIALS AND METHODS This was a cross-sectional population-based study using the Explorys Platform to determine the prevalence of GP in a large and diverse population highly representative of the US population and to examine the diagnostic approach of GP. Data collected were individual characteristics from electronic medical records (EMRs) included age, ethnicity/race, sex, diagnostic report for esophagogastroduodenoscopy (EGD) and gastric emptying study (GES). RESULTS A total of 43,827,910 medical records were surveyed (1999 to 2014), of which 69,950 had a diagnosis of GP, yielding an overall prevalence of 0.16%. We identified 249,930 EMRs with type 1 diabetes mellitus (T1DM), and 2,940,280 EMR's with type 2 diabetes mellitus (T2DM), of which 11,470 (4.59%) and 38,670 (1.31%) EMR's had concurrent GP, respectively. The remainder 19,810 EMRs with a diagnosis of GP were classified as having idiopathic GP. In all three subgroups, women and Caucasians had the highest prevalence of GP. The diagnosis of GP was confirmed by both GES and EGD in 9,950 of patients (14.22%). For patients with T1DM, T2DM, or idiopathic GP, GP was confirmed by both diagnostic tests in 16.8%, 14.0%, and 13.2%, respectively. CONCLUSIONS Our estimated rates of prevalence of GP in T1DM and T2DM indicate that GP is not a common clinical complication in these populations. Majority of EMRs that indicated a diagnosis of GP did not include any documentation of definitive diagnostic testing (EGD and/or GES).
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Sprouse Blum AS, Lavoie B, Haag M, Mawe SM, Tolner EA, van den Maagdenberg AMJM, Chen SP, Eikermann-Haerter K, Ptáček L, Mawe GM, Shapiro RE. No Gastrointestinal Dysmotility in Transgenic Mouse Models of Migraine. Headache 2019; 60:396-404. [PMID: 31876298 DOI: 10.1111/head.13724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether transgenic mouse models of migraine exhibit upper gastrointestinal dysmotility comparable to those observed in migraine patients. BACKGROUND There is considerable evidence supporting the comorbidity of gastrointestinal dysmotility and migraine. Gastrointestinal motility, however, has never been investigated in transgenic mouse models of migraine. METHODS Three transgenic mouse strains that express pathogenic gene mutations linked to monogenic migraine-relevant phenotypes were studied: CADASIL (Notch3-Tg88), FASP (CSNK1D-T44A), and FHM1 (CACNA1A-S218L). Upper gastrointestinal motility was quantified by measuring gastric emptying and small intestinal transit in mutant and control animals. Gastrointestinal motility was measured at baseline and after pretreatment with 10 mg/kg nitroglycerin (NTG). RESULTS No significant differences were observed for gastric emptying or small intestinal transit at baseline for any of the 3 transgenic strains when compared to appropriate controls or after pretreatment with NTG when compared to vehicle. CONCLUSIONS We detected no evidence of upper gastrointestinal dysmotility in mice that express mutations in genes linked to monogenic migraine-relevant phenotypes. Future studies seeking to understand why humans with migraine experience delayed gastric emptying may benefit from pursuing other modifiers of gastrointestinal motility, such as epigenetic or microbiome-related factors.
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Affiliation(s)
- Adam S Sprouse Blum
- Department of Neurological Sciences, The University of Vermont, Burlington, VT, USA
| | - Brigitte Lavoie
- Department of Neurological Sciences, The University of Vermont, Burlington, VT, USA
| | - Melody Haag
- Department of Neurological Sciences, The University of Vermont, Burlington, VT, USA
| | - Seamus M Mawe
- Department of Neurological Sciences, The University of Vermont, Burlington, VT, USA
| | - Else A Tolner
- Departments of Human Genetics & Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Shih-Pin Chen
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | - Louis Ptáček
- Department of Neurology, Weill Neuroscience Institute, and Kavli Institute for Fundamental Neuroscience, University of California San Francisco, San Francisco, CA, USA
| | - Gary M Mawe
- Department of Neurological Sciences, The University of Vermont, Burlington, VT, USA
| | - Robert E Shapiro
- Department of Neurological Sciences, The University of Vermont, Burlington, VT, USA
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81
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Barbash B, Mehta D, Siddiqui MT, Chawla L, Dworkin B. Impact of Cannabinoids on Symptoms of Refractory Gastroparesis: A Single-center Experience. Cureus 2019; 11:e6430. [PMID: 31993268 PMCID: PMC6970440 DOI: 10.7759/cureus.6430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background and aims Cannabinoids are increasingly used for medicinal purposes, including neuropathy. Gastroparesis is a neuromuscular disorder and neuropathy plays a large role in its pathogenesis. It is thus reasonable that cannabinoids can serve a beneficial role in the management of gastroparesis. Our study evaluates the effect of cannabinoids on gastroparesis symptoms. Methods Twenty-four (n=24) patients with gastroparesis and refractory symptoms were selected from a single gastroenterology practice associated with a tertiary care medical center. The ‘Gastroparesis Cardinal Symptom Index' (GCSI) and an analog scale rating abdominal pain were applied to prospectively assess the effect of cannabinoids, in the form of dronabinol and medical cannabis, on refractory gastroparesis symptoms. Patients completed a GCSI form and rated their abdominal pain, before and after treatment. There was a minimum of 60 days of cannabinoid use between reporting intervals. Total composite GCSI symptom scores, GCSI symptom subset scores, and abdominal pain scores were calculated before and after treatment. Results A significant improvement in the GCSI total symptom composite score was seen with either cannabinoid treatment (mean score difference of 12.8, 95% confidence interval 10.4-15.2; p-value < 0. 001). Patients prescribed marijuana experienced a statistically significant improvement in every GCSI symptom subgroup. Significant improvement in abdominal pain score was also seen with either cannabinoid treatment (mean score difference of 1.6; p-value <0.001). Conclusions Cannabinoids dramatically improve the symptoms of gastroparesis. Furthermore, an improvement in abdominal pain with cannabinoids represents a breakthrough for gastroparesis-associated abdominal pain treatment, for which there are currently no validated therapies.
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Affiliation(s)
- Benjamin Barbash
- Department of Gastroenterology, Bridgeport Hospital, Bridgeport, USA
| | - Dhruv Mehta
- Department of Gastroenterology and Hepatology, Westchester Medical Center, Valhalla, USA
| | | | - Lavneet Chawla
- Department of Hospital Medicine, Bridgeport Hospital, Bridgeport, USA
| | - Brad Dworkin
- Division of Gastroenterology and Hepatobiliary Diseases, Westchester Medical Center/New York Medical College, Valhalla, USA
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Grover M, Farrugia G, Stanghellini V. Gastroparesis: a turning point in understanding and treatment. Gut 2019; 68:2238-2250. [PMID: 31563877 PMCID: PMC6874806 DOI: 10.1136/gutjnl-2019-318712] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/29/2019] [Accepted: 08/22/2019] [Indexed: 12/21/2022]
Abstract
Gastroparesis is defined by delayed gastric emptying (GE) and symptoms of nausea, vomiting, bloating, postprandial fullness, early satiety and abdominal pain. Most common aetiologies include diabetes, postsurgical and postinfectious, but in many cases it is idiopathic. Clinical presentation and natural history vary by the aetiology. There is significant morbidity and healthcare utilisation associated with gastroparesis. Mechanistic studies from diabetic animal models of delayed GE as well as human full-thickness biopsies have significantly advanced our understanding of this disorder. An innate immune dysregulation and injury to the interstitial cells of Cajal and other components of the enteric nervous system through paracrine and oxidative stress mediators is likely central to the pathogenesis of gastroparesis. Scintigraphy and 13C breath testing provide the most validated assessment of GE. The stagnant gastroparesis therapeutic landscape is likely to soon see significant changes. Relatively newer treatment strategies include antiemetics (aprepitant), prokinetics (prucalopride, relamorelin) and fundic relaxants (acotiamide, buspirone). Endoscopic pyloromyotomy appears promising over the short term, especially for symptoms of nausea and vomiting. Further controlled trials and identification of the appropriate subgroup with pyloric dysfunction and assessment of long-term outcomes are essential. This review highlights the clinical presentation, diagnosis, mechanisms and treatment advancements for gastroparesis.
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Affiliation(s)
- Madhusudan Grover
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gianrico Farrugia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vincenzo Stanghellini
- Department of Digestive Diseases and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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83
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Doshi S, Patel A, Stocker A, Scoggins C, Agrawal L, Abell T. Gastric Electrical Stimulation Is an Effective Treatment Modality for Refractory Gastroparesis in a Postsurgical Patient with Pancreatic Cancer. Case Rep Gastroenterol 2019; 13:430-437. [PMID: 31762731 PMCID: PMC6873057 DOI: 10.1159/000503275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/06/2019] [Indexed: 12/30/2022] Open
Abstract
Gastroparesis-related hospital visits contribute significantly to healthcare costs. Gastroparesis can lead to chronic symptoms, such as nausea, vomiting, bloating, early satiety, and abdominal pain. It can result in a significant impairment of quality of life. Diabetes and postsurgery are common causes for gastroparesis, but most cases of gastroparesis are idiopathic in presumed etiology. Malignancy-related gastroparesis has also recently been described in the literature, and pancreatic cancer is a malignancy commonly associated with gastroparesis. Whipple surgery for pancreatic cancer is often complicated by gastroparesis during its postoperative course. We report a case where gastric electrical stimulation was an effective treatment option in the treatment of refractory malignancy-related gastroparesis.
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Affiliation(s)
- Shreyans Doshi
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, Florida, USA.,North Florida Regional Medical Center, Internal Medicine Residency Program, Gainesville, Florida, USA
| | - Aniruddh Patel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Abigail Stocker
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Laila Agrawal
- Division of Hematology and Oncology, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Thomas Abell
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
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84
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Desprez C, Melchior C, Wuestenberghs F, Zalar A, Jacques J, Leroi AM, Gourcerol G. Pyloric distensibility measurement predicts symptomatic response to intrapyloric botulinum toxin injection. Gastrointest Endosc 2019; 90:754-760.e1. [PMID: 31028783 DOI: 10.1016/j.gie.2019.04.228] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Recent studies have reported that pyloric distensibility was altered in 30% to 50% of patients with gastroparesis, and this was correlated with gastric emptying and symptom severity. The aim of this study was to assess whether pyloric distensibility measurement was predictive of symptomatic response after intrapyloric botulinum toxin (BT) injection. METHODS Pyloric distensibility was measured using the EndoFLIP system (Crospon, Galway, Ireland) before intrapyloric BT injection. Altered pyloric distensibility was defined as distensibility below 10 mm2/mm Hg. Total symptomatic score (TSS), dyspeptic symptoms, Gastrointestinal Quality of Life Index (GIQLI), and gastric emptying were investigated prospectively before and 3 months after BT injection. RESULTS Nineteen of 35 patients had altered pyloric distensibility. In those patients, TSS decreased at 3 months from 13.5 to 10.5 (P < .01), whereas it remained unchanged in patients with normal pyloric distensibility (P = .7). Gastric fullness (from 3.5 to 2.5; P = .03) and bloating (from 3.0 to 2.0; P = .01) were the only symptoms that improved in patients with altered pyloric distensibility, whereas none of them was improved in patients with normal pyloric distensibility. GIQLI score increased from 59.5 to 76.5 in patients with altered pyloric distensibility (P = .02), whereas there was no statistical difference (P = .43) in patients with normal pyloric distensibility. In patients with altered pyloric distensibility, gastric emptying half time was 223 minutes before and 190 minutes 3 months after injection (P = .02), whereas it remained unchanged in patients with normal pyloric distensibility (P = .6). CONCLUSIONS Pyloric distensibility measurement before intrapyloric BT injection predicted symptomatic and quality of life response 3 months after injection in patients with gastroparesis.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Unit, Rouen University Hospital, Rouen, France; Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France
| | - Chloé Melchior
- Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France; Gastroenterology Department, Rouen University Hospital, Rouen, France
| | - Fabien Wuestenberghs
- Digestive Physiology Unit, Rouen University Hospital, Rouen, France; Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France
| | - Alberto Zalar
- Gastroenterology Department, Rouen University Hospital, Rouen, France
| | - Jérémie Jacques
- Gastroenterology Department, Limoges University Hospital, Limoges, France
| | - Anne-Marie Leroi
- Digestive Physiology Unit, Rouen University Hospital, Rouen, France; INSERM CIC 1404, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Digestive Physiology Unit, Rouen University Hospital, Rouen, France; Gastroenterology Department, Rouen University Hospital, Rouen, France; INSERM CIC 1404, Rouen University Hospital, Rouen, France
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A Meta-Analysis of the Efficacy of Prokinetic Agents against Glycemic Control. Gastroenterol Res Pract 2019; 2019:3014973. [PMID: 31582970 PMCID: PMC6754912 DOI: 10.1155/2019/3014973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/02/2019] [Accepted: 08/19/2019] [Indexed: 02/07/2023] Open
Abstract
Background Prokinetic agents are used in diabetic gastroparesis patients to improve gastric emptying and upper gastrointestinal (GI) symptoms. However, the efficacy of prokinetic agents against glycemic control is questionable. Therefore, we conducted a systemic review and meta-analysis to determine the efficacy of prokinetic agents against glycemic control. Methods Randomized controlled trials (RCTs) evaluating the effect of prokinetics were identified by searching PubMed, Embase, and the Cochrane Library databases until April 2018. The primary outcome was changes in the mean value of glycosylated hemoglobin (HbA1c), fasting blood sugar (FBS), and fasting serum insulin (FINS). The pooled standardized mean differences (SMD) with 95% confidence intervals (CIs) were calculated by evaluating the strength of the association. We used the random effect models to analyze these markers. The effects of each component of the prokinetic agents on glycemic control were separately analyzed. Results Five RCTs with 190 patients met the criteria and were included in the meta-analysis. There were statistically significant SMD between prokinetics and placebo-controlled groups with respect to the reduction of HbA1c (-1.141, 95% CI -1.843, -0.438; P < 0.01). No statistically significant differences were noted between the two groups for FBS (-1.270, 95% CI -2.613, -0.074; P = 0.06) and FINS (0.359, 95% CI -1.205~1.923; P = 0.65). Conclusions Prokinetics have a positive effect on glycemic control. Further large-scale prospective studies are needed.
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Abstract
This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yogish C Kudva
- Division of Endocrinology. Mayo Clinic, Rochester, Minnesota
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Abstract
This article reviews the most common gastrointestinal (GI) problems that occur in patients with Parkinson disease, including weight loss, drooling, dysphagia, delayed gastric emptying, constipation, and defecatory dysfunction. Appropriate workup and treatment options are reviewed in detail in order to provide clinicians with a comprehensive and practical guide to managing these problems in Parkinson disease patients. GI adverse effects of commonly used Parkinson disease motor medications are also reviewed.
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Affiliation(s)
- John Legge
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; VCU NOW Center, 11958 West Broad Street, 4th Floor, Box 980220, Henrico, VA 23298-0220, USA
| | - Nicholas Fleming
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; VCU NOW Center, 11958 West Broad Street, 4th Floor, Box 980220, Henrico, VA 23298-0220, USA
| | - Leslie Jameleh Cloud
- VCU NOW Center, 11958 West Broad Street, 4th Floor, Box 980220, Henrico, VA 23298-0220, USA; Parkinson's and Movement Disorders Center, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
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Ogasawara N, Yamaguchi Y, Takahama T, Adachi K, Suzuki M, Izawa S, Ebi M, Funaki Y, Sasaki M, Kasugai K. Radiofrequency catheter ablation-induced gastroparesis successfully treated with administration of mosapride citrate: two case reports. Clin J Gastroenterol 2019; 13:182-185. [PMID: 31456172 DOI: 10.1007/s12328-019-01038-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 08/19/2019] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia, and radiofrequency catheter ablation (RFCA) for pulmonary vein isolation is a well-established therapeutic modality for AF. Transient gastroparesis rarely complicates RFCA. We report two cases of RFCA-induced transient gastroparesis, effectively treated with mosapride citrate administration. Case 1. Computed tomography (CT) performed 4 days after RFCA revealed marked gastric dilatation without any gastric or intestinal obstruction. The patient was fasting and was administered mosapride citrate (5 mg thrice a day). The patient's symptoms improved 6 days later, and CT revealed no gastric dilatation. Esophagogastroduodenoscopy revealed gastric peristalsis without residual food in the stomach. Case 2. CT performed 8 days after RFCA revealed marked gastric dilatation without any gastric or intestinal obstruction. The patient was fasting and was administered pantothenic acid (500 mg/day intravenously for 7 days). However, symptoms persisted, and CT revealed residual food in the stomach. The patient was subsequently administered mosapride citrate (5 mg thrice a day). The patient's symptoms improved 4 days later, and contrast-enhanced gastric X-ray using amidotrizoate meglumine revealed gastric peristalsis, passage of amidotrizoate meglumine into the duodenum, and no gastric dilatation. Mosapride citrate is useful to treat RFCA-induced gastroparesis.
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Affiliation(s)
- Naotaka Ogasawara
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan.
| | - Yoshiharu Yamaguchi
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Takuya Takahama
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Kazunori Adachi
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Manami Suzuki
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Shinya Izawa
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Masahide Ebi
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yasushi Funaki
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Makoto Sasaki
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Kunio Kasugai
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
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Shakhatreh M, Jehangir A, Malik Z, Parkman HP. Metoclopramide for the treatment of diabetic gastroparesis. Expert Rev Gastroenterol Hepatol 2019; 13:711-721. [PMID: 31314613 DOI: 10.1080/17474124.2019.1645594] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction: Gastroparesis is a chronic disorder of the stomach characterized by delayed gastric emptying without mechanical obstruction. Diabetes is the most commonly known cause of gastroparesis. Management of diabetic gastroparesis involves lifestyle modifications, glycemic control, pharmacological drugs, and for refractory cases surgical treatments. Metoclopramide remains the only drug approved by the Food and Drug Administration for diabetic gastroparesis. The aim of this article is to provide a concise review of the pharmacology, clinical efficacy and tolerability of metoclopramide. Areas covered: We searched PubMed using the key words 'metoclopramide', 'diabetic gastroparesis', and 'gastric emptying'. The relevant articles and their bibliography were reviewed. Metoclopramide acts on several different receptors; primarily as a dopamine receptor antagonist, both peripherally improving gastric emptying, and centrally resulting in an anti-emetic effect. Metoclopramide side effects, mostly related to its ability to cross the blood-brain barrier, include drowsiness, restlessness, hyperprolactinemia, and tardive dyskinesia (TD), a movement disorder that may be irreversible. Expert opinion: Metoclopramide carries a black box warning for use >12 weeks due to the risk of TD. However, gastroparesis patients experience chronic symptoms often requiring prolonged treatments. Physicians and patients look forward to FDA approval of new agents for gastroparesis with better efficacy and safety profile.
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Affiliation(s)
- Mohammed Shakhatreh
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Asad Jehangir
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Zubair Malik
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Henry P Parkman
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
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Strijbos D, Keszthelyi D, Smeets FGM, Kruimel J, Gilissen LPL, de Ridder R, Conchillo JM, Masclee AAM. Therapeutic strategies in gastroparesis: Results of stepwise approach with diet and prokinetics, Gastric Rest, and PEG-J: A retrospective analysis. Neurogastroenterol Motil 2019; 31:e13588. [PMID: 30947400 PMCID: PMC6850664 DOI: 10.1111/nmo.13588] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/14/2019] [Accepted: 03/11/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastroparesis is characterized by abnormal gastric motor function with delayed gastric emptying in the absence of mechanical obstruction. In our tertiary referral center, patients are treated with a stepwise approach, starting with dietary advice and prokinetics, followed by three months of nasoduodenal tube feeding with "gastric rest." When not successful, a percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) for long-term enteral feeding is placed. AIM To evaluate the effect of this stepwise approach on weight and symptoms. METHODS Analyses of data of all referred gastroparesis patients between 2008 and 2016. KEY RESULTS A total of 86 patients (71% female, 20-87 years [mean 55.8 years]) were analyzed of whom 50 (58%) had adequate symptom responses to diet and prokinetics. The remaining 36 (decompensated gastroparesis) were treated with three months gastric rest. Symptom response rate was 47% (17/36). Significant weight gain was seen in all patients, independent of symptom response. In the remaining 19 symptom non-responders, the enteral feeding was continued through PEG-J. Treatment was effective (symptoms) in 37%, with significant weight gain in all. In 84% of patients, the PEG-J is still in use (mean duration 962 days). CONCLUSIONS AND INFERENCES Following a stepwise treatment approach in gastroparesis, adequate symptom response was reached in 86% of all patients. Weight gain was achieved in all patients, independent of symptom response. Diet and prokinetics were effective with regard to symptoms in 58%, temporary gastric rest in 47%, and PEG-J as third step in 37% of patients.
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Affiliation(s)
- Denise Strijbos
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands,Department of Gastroenterology and HepatologyCatharina Hospital EindhovenEindhovenThe Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Fabiënne G. M. Smeets
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Joanna Kruimel
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Lennard P. L. Gilissen
- Department of Gastroenterology and HepatologyCatharina Hospital EindhovenEindhovenThe Netherlands
| | - Rogier de Ridder
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - José M. Conchillo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Ad A. M. Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
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91
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Quantitative MRI evaluation of gastric motility in patients with Parkinson's disease: Correlation of dyspeptic symptoms with volumetry and motility indices. PLoS One 2019; 14:e0216396. [PMID: 31050679 PMCID: PMC6499432 DOI: 10.1371/journal.pone.0216396] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 04/20/2019] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate the correlation between dyspeptic symptoms and gastric motility parameters measured by magnetic resonance imaging (MRI) using volumetry and motility indices in patients with Parkinson’s disease (PD). Materials and methods In this IRB-approved study, MRI datasets obtained from August 2014 to May 2016 in 38 PD patients were retrospectively analyzed. Patients underwent a 120-minute-long MRI study using a liquid test meal and 8 sets of scans. Gastric content volume (GCV) and total volume (TGV), gastric half emptying time (T1/2), motility index (GMI), accommodation (GA), and emptying (GE) values were acquired. These measurements were compared between patients according to the presence of gastric symptoms: early satiety (n = 25), epigastric pain (n = 13), and dyspepsia (n = 28). Results Patients with early satiety showed significantly decreased GE of GCV and TGV (p < 0.001 and p = 0.017). Dyspeptic patients had significantly decreased GE of GCV and GMI (p = 0.001 and p = 0.029). GE of GCV at 90 and 120 minutes were significantly lower in patients with early satiety (p = 0.001 and p = 0.002). GE of GCV and GMI at 90 minutes were significantly decreased in patients with dyspepsia (p = 0.004 and p = 0.002). T1/2 of GCV was prolonged in patients with early satiety, epigastric pain, and dyspepsia (p = 0.004, p = 0.041, and p = 0.023). T1/2 of TGV also delayed in patients with early satiety (p = 0.023). GMI at 90 minutes was significantly correlated with dyspepsia on multivariable analysis (p = 0.028). Conclusions Gastric motility can be quantitatively assessed by MRI, showing decreased GMI, delayed GE, and prolonged T1/2 in PD patients with early satiety or dyspepsia.
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92
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Cogliandro RF, Rizzoli G, Bellacosa L, De Giorgio R, Cremon C, Barbara G, Stanghellini V. Is gastroparesis a gastric disease? Neurogastroenterol Motil 2019; 31:e13562. [PMID: 30773743 DOI: 10.1111/nmo.13562] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastroparesis is a digestive syndrome characterized by delayed gastric emptying (GE) and by symptoms that are suggestive of gastroduodenal motor disorders. There are three grades of gastroparesis of increasing severity: (a) mild gastroparesis; (b) compensated gastroparesis; and (c) gastric failure. GE abnormalities are partially related to symptom type and severity, and other mechanisms may be involved. AIM To investigate enteric dysmotility (ED) in patients with suspected gastroparesis. METHODS Patients with symptoms suggestive of gastroparesis were consecutively included in the study and underwent a 13 C-octanoic acid GE breath test and small bowel manometry (SBM). Clinical features were recorded using predefined, validated questionnaires at entry. KEY RESULTS The study enrolled 88 patients (71 women; mean age: 37.8 ± 14.3 years). Gastric emptying was delayed in 25 patients (28.4%), and 70 patients (79.5%) presented small bowel motor abnormalities including bursts, abnormal activity fronts, inability to respond to meal ingestion, and hypocontractility. Gastric emptying was delayed in 24 of the 70 patients with ED (34.3% vs 5.5% of patients with normal SBM). Enteric dysmotility was detected in 24 of 25 patients (96%) with delayed GE. Patients with and without delayed GE showed similar moderate/severe gastroparesis manifestations, but patients with ED significantly more often had moderate/severe gastroparesis manifestations than patients with normal SBM (grade 1:14% vs 39%, grade 2:62% vs 56%, grade 3:24% vs 5%, respectively). CONCLUSIONS AND INFERENCES Enteric dysmotility was more frequent than delayed GE in patients with symptoms suggestive of gastroparesis. Gastroparesis severity was associated with small bowel motor abnormalities but not with delayed GE.
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Affiliation(s)
| | - Giada Rizzoli
- Department of Digestive Diseases, S. Orsola University Hospital, Bologna, Italy
| | - Lara Bellacosa
- Department of Digestive Diseases, S. Orsola University Hospital, Bologna, Italy
| | | | - Cesare Cremon
- Department of Digestive Diseases, S. Orsola University Hospital, Bologna, Italy
| | - Giovanni Barbara
- Department of Digestive Diseases, S. Orsola University Hospital, Bologna, Italy
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93
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Romez C, Zaritzky D, Brown JW. Case Report of gastroparesis healing: 16 years of a chronic syndrome resolved after proximal intercessory prayer. Complement Ther Med 2019; 43:289-294. [PMID: 30935546 DOI: 10.1016/j.ctim.2019.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/06/2019] [Accepted: 03/08/2019] [Indexed: 12/26/2022] Open
Abstract
A male infant at two weeks of age was hospitalized vomiting forcefully. He had a pyloromyotomy. He did not improve with medical therapy. The diagnosis of gastroparesis was made after a nuclear medicine gastric emptying study and intestinal manometry. He required a gastrostomy tube (g-tube) and a jejunostomy tube (j-tube) for feeding. At 11 months of age, the j-tube was converted into a feeding jejunostomy with Roux-en-Y limb. For 16 years he was completely dependent on j-tube feeding. In November 2011, he experienced proximal-intercessory-prayer (PIP) at a church and felt an electric shock starting from his shoulder and going through his stomach. After the prayer experience, he was unexpectedly able to tolerate oral feedings. The g- and j-tube were removed four months later and he did not require any further special treatments for his condition as all symptoms had resolved. Over seven years later, he has been free from symptoms. This article investigates a case of PIP as an alternative intervention for resolving severe idiopathic gastroparesis when maximal medical management is not effective.
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Affiliation(s)
| | | | - Joshua W Brown
- Global Medical Research Institute, United States; Indiana University, Bloomington IN, United States.
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94
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Herring BP, Hoggatt AM, Gupta A, Wo JM. Gastroparesis is associated with decreased FOXF1 and FOXF2 in humans, and loss of FOXF1 and FOXF2 results in gastroparesis in mice. Neurogastroenterol Motil 2019; 31:e13528. [PMID: 30565344 PMCID: PMC6821388 DOI: 10.1111/nmo.13528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/02/2018] [Accepted: 11/12/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS The transcription factors FOXF1 and FOXF2 have been implicated in the development of the gastrointestinal tract but their role in adults or in gastrointestinal diseases is poorly understood. We have recently shown that expression of serum response factor (SRF), a transcription factor whose activity is modulated by FOXF proteins, is decreased in the stomach muscularis of patients with gastroparesis. The aim of the current study was to determine whether FOXF expression is decreased in gastroparesis patients and whether loss of FOXF1 and/or FOXF2 from adult smooth muscle is sufficient to impair gastric emptying in mice. METHODS Full-thickness stomach biopsy samples were collected from control subjects and from patients with gastroparesis. mRNA was isolated from the muscularis externa, and FOXF mRNA expression levels were determined by quantitative reverse transcriptase (RT)-PCR. Foxf1 and Foxf2 were knocked out together and separately from smooth muscle cells in adult mice, and the subsequent effect on liquid gastric emptying and contractile protein expression was determined. KEY RESULTS Expression of FOXF1 and FOXF2 is decreased in smooth muscle tissue from gastroparesis patients. Knockout of Foxf1 and Foxf2 together, but not alone, from mouse smooth muscle resulted in delayed liquid gastric emptying. Foxf1/2 double knockout mice had decreased expression of smooth muscle contractile proteins, SRF, and myocardin in stomach muscularis. CONCLUSIONS AND INFERENCES Our findings suggest that decreased expression of FOXF1 and FOXF2 may be contributing to the impaired gastric emptying seen in gastroparesis patients.
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Affiliation(s)
- B. Paul Herring
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202.,Correspondence: Paul Herring, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, 635 Barnhill Drive, Indianapolis IN, 46202, Phone: (317) 278-1785, FAX: (317) 274-3318,
| | - April M. Hoggatt
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Anita Gupta
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202
| | - John M. Wo
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202
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95
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Hirsch W, Nee J, Ballou S, Petersen T, Friedlander D, Lee HN, Cheng V, Lembo A. Emergency Department Burden of Gastroparesis in the United States, 2006 to 2013. J Clin Gastroenterol 2019; 53:109-113. [PMID: 29256990 PMCID: PMC6005709 DOI: 10.1097/mcg.0000000000000972] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Gastroparesis, a chronic gastrointestinal disorder defined by delayed stomach emptying in the absence of obstruction, is often associated with frequent and costly visits to the emergency department (ED). The aim of this study was to analyze trends in gastroparesis-related ED visits from 2006 to 2013. MATERIALS AND METHODS Patients with a primary diagnosis of gastroparesis were identified from the Nationwide Emergency Department Sample (NEDS), the largest publicly available ED all-payer representative database in the United States. ED visits, admission rates, duration of hospitalizations, and charges were compiled. Patients with a secondary diagnosis of diabetes mellitus were analyzed as a subgroup. RESULTS The number of ED visits for gastroparesis as a primary diagnosis in the United States increased from 15,459 in 2006 to 36,820 in 2013, an increase from 12.9 to 27.3 per 100,000 ED visits. The total charges associated with these ED visits and subsequent admissions increased from $286 million to $592 million. In contrast, admission rates through the ED decreased by 22%, procedure rates decreased by 6.2%, and the mean length of stay was shortened by 0.6 days. ED visits for patients with diabetic gastroparesis increased from 5696 to 14,114, an increase from 4.7 to 10.5 per 100,000 ED visits, with an increase in total associated charges for ED visits and subsequent admissions from $84 million to $182 million. CONCLUSIONS The number of ED visits and associated charges for a primary diagnosis of gastroparesis with or without a secondary diagnosis of diabetes mellitus rose significantly from 2006 to 2013.
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Affiliation(s)
- William Hirsch
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Nee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Ballou
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Travis Petersen
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Friedlander
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Ha-Neul Lee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian Cheng
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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96
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Navas CM, Crowell MD, Lacy BE. The willingness of patients with gastroparesis to take risks with medications. Aliment Pharmacol Ther 2019; 49:429-436. [PMID: 30628106 DOI: 10.1111/apt.15112] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/02/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastroparesis has a significant negative impact on patients' quality of life. Only one medication is approved for gastroparesis and it is associated with a significant risk of side effects. AIM To assess the willingness of patients to take risks associated with medications to treat gastroparesis symptoms. METHODS We developed a questionnaire to assess medication risk-taking behaviour in patients identified as having documented gastroparesis (consistent symptoms, normal upper endoscopy, delayed gastric emptying). The survey assessed demographics, symptoms, medication use, anxiety, depression and impulsivity. A standard reference gamble evaluated respondents' willingness to take medication risks. RESULTS Two hundred seven questionnaires were mailed to patients, 103 questionnaires were completed. Seventy-six percent were female; the mean age was 48 years; average duration of gastroparesis symptoms was 10 years. Self-reported symptom severity was severe in 52% and moderate in 32%. Gastroparesis patients reported that they would accept a median 13.4% risk of sudden death to cure their symptoms using a hypothetical medication. Self-reported gastroparesis symptom severity and Gastroparesis Cardinal Symptom Index scores correlated significantly with increased willingness to take risks associated with medications to treat gastroparesis, while anxiety was negatively associated. CONCLUSIONS Gastroparesis patients are willing to accept markedly high risks with a hypothetical medication to cure their symptoms. Patients with severe gastroparesis symptoms and higher Gastroparesis Cardinal Symptom Index scores were more willing to take these risks. This study, the first to quantify gastroparesis patients' willingness to accept medication associated risks, should help clinicians through the complex maze of gastroparesis therapies and their associated risks and benefits.
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Affiliation(s)
- Christopher M Navas
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Brian E Lacy
- Section of Gastroenterology, Mayo Clinic, Jacksonville, Florida
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97
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Loganathan P, Gajendran M, McCallum RW. Clinical Manifestation and Natural History of Gastroparesis. Gastrointest Endosc Clin N Am 2019; 29:27-38. [PMID: 30396526 DOI: 10.1016/j.giec.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although gastroparesis was described more than 60 years ago, the natural history and the long-term outcome are still being clarified. The patients with more severe gastroparesis often seek health care treatment in university medical centers specializing in gastrointestinal motility disorders and hence reports in the literature tend to be based on this population and may not be representative of the entire spectrum. The clinical manifestations of gastroparesis are heterogeneous but a significant proportion of patients end up with substantially poorer quality of life. In this article, the focus is on the clinical presentation and natural history of gastroparesis.
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Affiliation(s)
- Priyadarshini Loganathan
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Richard W McCallum
- Division of Gastroenterology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX 79905, USA.
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98
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Abstract
Gastroparesis is a chronic and debilitating neuromuscular disorder of the upper gastrointestinal tract. Symptoms of gastroparesis include nausea, vomiting, epigastric pain, early satiety, and weight loss. Treating gastroparesis can be difficult. Dietary changes may improve symptoms in patients with mild disease. A variety of medications can be used to treat symptoms of nausea and vomiting, although most have not been subjected to randomized controlled trials and only one is approved by the Food and Drug Administration (metoclopramide). Pain management is essential, as nearly 90% of patients report symptoms of epigastric pain. This article reviews treatment options for symptoms of gastroparesis.
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Affiliation(s)
- Christopher M Navas
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Nihal K Patel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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99
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Bekkelund M, Sangnes DA, Gunnar Hatlebakk J, Aabakken L. Pathophysiology of idiopathic gastroparesis and implications for therapy. Scand J Gastroenterol 2019; 54:8-17. [PMID: 30638082 DOI: 10.1080/00365521.2018.1558280] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Idiopathic gastroparesis is a gastric motility disorder characterized by chronic upper gastrointestinal symptoms and delayed gastric emptying without an identifiable underlying condition. This review summarizes recent understanding of the pathophysiology and treatment of idiopathic gastroparesis. MATERIALS AND METHODS Structured literature search in the PubMed, Embase and ClinicalTrials.gov databases. RESULTS Idiopathic gastroparesis involves several alterations in gastric motility and sensation, including delayed gastric emptying, altered myoelectrical activity, impaired fundic accommodation, visceral hypersensitivity and disturbances in antropyloroduodenal motility and coordination. Multiple cellular changes have been identified, including depletion of interstitial cells of Cajal (ICC) and enteric nerves, as well as stromal fibrosis. The underlying cause of these changes is not fully understood but may be an immune imbalance, including loss of anti-inflammatory heme-oxygenase-1 positive (HO-1) macrophages. There is currently no causal therapy for idiopathic gastroparesis. The treatment ladder consists of dietary measures, prokinetic and antiemetic medications, and varying surgical or endoscopic interventions, including promising pyloric therapies. There are ongoing trials with several novel medications, raising hopes for future treatment. CONCLUSIONS Patients with idiopathic gastroparesis present several pathophysiological alterations in the stomach, where depletion of ICC is of special importance. Treatment is currently focused on alleviating symptoms through dietary adjustments, medication or surgical or endoscopic interventions.
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Affiliation(s)
- Mattis Bekkelund
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway
| | - Dag A Sangnes
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Jan Gunnar Hatlebakk
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Lars Aabakken
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,e Department of Transplantation Medicine , Section for Gastroenterology, Oslo University Hospital , Oslo , Norway
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100
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Abstract
Gastroparesis is an increasing concern and options remain limited. Diagnosis hinges on recognition of delayed gastric emptying in the absence of mechanical obstruction. Nontransit studies evaluating gastric motility serve a complementary role and may help guide therapy. Treatment consists of a combination of lifestyle and dietary medication, medications (antiemetics, prokinetics, neuromodulators, and accommodation-enhancers), alternative and complementary therapy, endoscopic therapy (pyloric-directed therapy, temporary stimulation, jejunostomy, or venting gastrostomy) and surgical therapy (pyloroplasty, gastric electrical stimulation, gastrectomy). Treatment can be tailored to the individual needs and symptoms of the affected patient.
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Affiliation(s)
- Frances U Onyimba
- Department of Medicine, Division of Gastroenterology, University of California San Diego, 9500 Gillman Drive, #0956, La Jolla, CA 92093, USA
| | - John O Clarke
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, 300 Pasteur Drive, MC 5244, Stanford, CA 94305, USA.
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