American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis

Gastroparesis with concomitant gastrointestinal dysmotility is not a contraindication for per-oral pyloromyotomy (POP)

INTRODUCTION

Per-oral pyloromyotomy (POP or G-POEM) provides significant short-term improvements in symptoms and objective emptying for patients with medically refractory gastroparesis, but it is unclear if patients with gastroparesis and co-existing dysmotility (small bowel or colonic delay) also benefit. In this study, we used wireless motility capsule (WMC) data to measure outcomes in patients with isolated gastroparesis (GP) and gastroparesis with co-existing dysmotility (GP + Dys) who underwent POP.

METHODS

We retrospectively analyzed patients who had POP and completed WMC data during their evaluation of intestinal dysmotility. WMC data were reviewed to identify patients who demonstrated isolated GP or GP + Dys. Each patient's pre-op and post-op Gastroparesis Cardinal Symptom Index (GCSI) and 4-h solid-phase scintigraphy gastric emptying studies (GES) scores were compared to evaluate improvement.

RESULTS

Of the entire cohort (n = 73), 89% were female with a mean age of 47.0 ± 15.0 years old. Gastroparesis etiologies were divided among idiopathic (54.8%), diabetic (26%), postsurgical (8.2%), autoimmune (5.5%), and multifactorial (5.5%). Forty-one patients (56%) had GP and 32 patients (44%) had GP + Dys. GCSI improved after POP whether the patient had isolated GP (- 12.31, p < 0.001) or GP + Dys (- 9.58, p < 0.001); however, there was no significant difference in total GCSI improvement between the two groups. A subset of patients had postoperative GES available (n = 47). In the isolated GP and GP + Dys cohorts, 15/28 (54%) and 12/19 (63%) patients had normal post-op 4-h GES, respectively, but no statistical difference between the two groups.

CONCLUSION

Patients with medically refractory gastroparesis with and without concomitant gastrointestinal dysmotility show short-term subjective and objective improvement after POP. Concomitant small bowel or colonic dysmotility should not deter physicians from offering POP in carefully selected patients with gastroparesis.

Gastric half emptying time (T½ ) for 4-h gastric emptying scintigraphy simplifies reporting but reduces detection of gastroparesis

BACKGROUND

Gastric emptying scintigraphy (GES) reports percent retention at 1, 2, and 4 h. Time to empty half the meal (T_½ ) could simplify GE reporting.

AIMS

To compare the performance of GES T_½ to 1-, 2-, and 4-h retention.

METHODS

GES studies were reviewed; results determined according to retention at 1, 2, and 4 h. T_½ was determined using 3 methods: (1) GES curve fitting using 0, 0.5, 1, 2, 3, and 4 h data; (2) linear interpolation using 0, 0.5, 1, 2, 3, and 4 h data; and (3) linear interpolation using only 0, 1, 2, and 4 h data.

RESULTS

Of 495 patients, 265 had normal GE, 4 rapid GE (<30% retention at 1 h), and 226 delayed GE: 17 delayed only at 2 h (>60% ret); 94 delayed only at 4 h (>10% ret); and 115 delayed at both 2 h and 4 h. Strong correlations were seen between each T_½ method and 1, 2, 3, and 4 h %-empty values: curve-fit T_½ (r = -0.851, -0.942, -0.864, -0.744), linear T_½ using all imaging times (r = -0.848, -0.972, -0.878, -0.763), and linear T_½ using standard imaging times (r = -0.853, -0.974, -0.868, -0.760). The 132 min cutoff for delayed GE captures 99.1% to 100% of delayed GE at both 2 h and 4 h, 76.5% to 94.1% delayed at 2 h only, but only 36.7% to 39.4% delayed at 4 h only; 3.5 to 11.3% of patients with normal GE miscategorized as delayed.

CONCLUSIONS

GES T_½ correlates more strongly with retention at 2 h than at 4 h. T_½ alone may misclassify patients, particularly those with late-phase (4 h only) delays, reducing its utility for diagnosing gastroparesis.

Prevalence and clinical correlates of antinuclear antibody in patients with gastroparesis

BACKGROUND

Autoimmunity may play a role in the pathogenesis of gastroparesis in a subset of patients. Antinuclear antibody (ANA) testing is often used to screen for autoimmune disorders.

AIMS

1) Determine prevalence of a positive ANA in patients with gastroparesis; 2) Describe characteristics of idiopathic gastroparesis patients with positive ANA.

METHODS

Patients were assessed with gastric emptying scintigraphy (GES), symptom assessment via Patient Assessment of Upper GI Symptoms [PAGI-SYM], and blood tests-ANA, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP).

RESULTS

Positive ANA was seen in 148 of 893 (17%) patients with gastroparesis, being similar in idiopathic (16% of 536 patients), T1DM (16% of 162), T2DM (18% of 147), and postfundoplication (19% of 48 patients) gastroparesis. Among 536 patients with idiopathic gastroparesis, ANA titer 1:40-1:80 was seen in 33 (6%) patients, 1:160-1:320 in 36 (7%) patients, and ≥1:640 in 17 (3%) patients. Increasing ANA titer was associated with female gender (p = 0.05), Hispanic ethnicity (p = 0.02), comorbid rheumatoid arthritis (p = 0.02), systemic sclerosis (p = 0.004), and elevated ESR (p = 0.007). ANA positivity was associated with lower total GCSI (p = 0.007) and lower nausea/vomiting subscale (p = 0.0005), but not related to gastric emptying.

CONCLUSIONS

The prevalence of a positive ANA in patients with gastroparesis was high at ~17% and did not differ significantly based on etiology. In idiopathic patients, ANA positivity was associated with rheumatoid arthritis, systemic sclerosis, and elevated ESR. ANA-positive gastroparesis represents a subset who often have other autoimmune symptoms or disorders, but less severe nausea and vomiting.

Constipation in Patients With Symptoms of Gastroparesis: Analysis of Symptoms and Gastrointestinal Transit

BACKGROUND & AIMS

Constipation can be an important symptom in some patients with gastroparesis. The aims were to: 1) Determine prevalence of constipation and delayed colonic transit in patients with symptoms of gastroparesis; 2) Correlate severity of constipation to severity of symptoms of gastroparesis; and 3) Relate severity of constipation to GI transit delays assessed by gastric emptying scintigraphy (GES) and wireless motility capsule (WMC).

METHODS

Patients with symptoms of gastroparesis underwent gastric emptying scintigraphy (GES), wireless motility capsule (WMC) assessing gastric emptying, small bowel transit, and colonic transit, and questionnaires assessing symptoms using a modified Patient Assessment of Upper GI Symptoms [PAGI-SYM] and Rome III functional GI disorder questionnaire.

RESULTS

Of 338 patients with symptoms of gastroparesis, 242 (71.5%) had delayed gastric emptying by scintigraphy; 298 (88.2%) also met criteria for functional dyspepsia. Severity of constipation was severe/very severe in 34% patients, moderate in 24%, and none/very mild/mild in 42%. Increasing severity of constipation was associated with increasing symptoms of gastroparesis and presence of irritable bowel syndrome (IBS). Severity of constipation was not associated with gastric retention on GES or WMC. Delayed colonic transit was present in 108 patients (32% of patients). Increasing severity of constipation was associated with increasing small bowel transit time, colonic transit time, and whole gut transit time.

CONCLUSIONS

Severe/very severe constipation and delayed colon transit occurs in a third of patients with symptoms of gastroparesis. The severity of constipation is associated with severity of gastroparesis symptoms, presence of IBS, small bowel and colon transit delay, but not delay in gastric emptying. ClinicalTrials.gov Identifier: NCT01696747.

Evaluation of the pharmacokinetics of trazpiroben (TAK-906) in the presence and absence of the proton pump inhibitor esomeprazole

Trazpiroben, a dopamine D₂ /D₃ receptor antagonist under development to treat gastroparesis, displays decreasing solubility with increasing pH. This single-sequence, open-label, two-period, crossover study evaluated the effect of esomeprazole, a proton pump inhibitor that raises gastric pH, on the single-dose pharmacokinetics, safety, and tolerability of trazpiroben in healthy adults (NCT03849690). In total, 12 participants were enrolled and entered period 1 (days 1-3), receiving a single oral dose of trazpiroben 25 mg on day 1. After a 4-day washout, participants then entered period 2 (days 8-13) and received esomeprazole 40 mg once daily on days 8-12, with a single oral dose of trazpiroben 25 mg co-administered 1 h post esomeprazole dosing on day 11. Geometric mean area under the curve from time 0 extrapolated to infinity (AUC_∞ ) and maximum plasma concentration (C_max ) values were generally similar when trazpiroben was administered alone versus alongside esomeprazole (AUC_∞ , 44.03 vs. 38.85 ng h/ml; C_max , 19.76 vs. 17.24 ng/ml). Additionally, the associated geometric mean ratio (GMR; co-administration: administration alone) 90% confidence intervals (CIs) suggested no clinically meaningful difference between treatment groups (AUC_∞ , GMR 0.88, 90% CI 0.78-1.00; C_max , 0.87, 90% CI 0.70-1.09). Mean apparent first-order terminal elimination half-life values were similar between treatments, illustrating co-administration with esomeprazole had minimal effect on trazpiroben elimination. Trazpiroben was well-tolerated in healthy adults following administration alone and alongside esomeprazole, with no clinically relevant adverse events reported. The lack of evidence of any clinically meaningful drug-drug interaction supports the co-administration of esomeprazole with trazpiroben.

Cardiac safety and clinical efficacy of high-dose domperidone for long-term treatment of gastroparesis symptoms

Domperidone is an effective antiemetic used worldwide, but there have been reports of possible cardiotoxicity. Our goal was to explore the cardiac safety and clinical efficacy of long-term domperidone, titrated as high as 120 mg/day, in patients not responding or unable to tolerate other therapies for gastroparesis (GP).This retrospective cohort study was conducted at a single tertiary care academic center. We objectively assessed the safety and efficacy of domperidone through questionnaires, clinical follow-up and frequent ECGs as mandated by the Food and Drug Administration. We excluded patients with a history of dangerous arrhythmias, prolonged QTc, clinically significant electrolyte disturbances, gastrointestinal hemorrhage or obstruction, presence of a prolactinoma, pregnant or breastfeeding females, or allergy to domperidone. A total of 21 patients met the inclusion criteria for eligibility in this study (52.4% white, 42.9% Hispanic; mean age 50.1 years; 90.5% female). The mean duration of domperidone therapy was 52.3 (range 16-97) months with a mean highest dose of 80 mg/day (range 40-120 mg). Two patients (9.5%) taking 120 mg/day experienced asymptomatic meaningful QTc prolongation (>450 ms in males, >470 ms in females). One-third of patients had asymptomatic non-meaningful QTc prolongation. Palpitations or chest pain was reported in 19% of patients without ECG abnormalities or adverse cardiac events. The mean severity of vomiting and nausea was improved by 82% and 55%, respectively.Long-term treatment with high doses of domperidone (40-120 mg/day) improved GP symptoms in patients previously refractory to other medical therapies and with a satisfactory cardiovascular risk profile.

Testing the Arabic-Saudi Arabia version of the Rome IV Diagnostic Questionnaire for functional gastrointestinal disorders for Children living in Saudi Arabia

Functional gastrointestinal disorders (FGID) are a worldwide phenomenon described by painful, recurrent or chronic gastrointestinal (GI) symptoms. Variable types of FGID exist in a significant portion of children in Saudi Arabia (SA). While the studies and reports on child FGID are limited, the available ones show a notable significance of FGID in children in SA. The self-report Rome IV Diagnostic Questionnaire (DQ) globally recognizes the selection of symptom criteria and incidence thresholds. Using such a questionnaire would help clinicians provide a provisional diagnosis, serve as a case definition for epidemiological surveys, and identify inclusion criteria for clinical trials. This research aimed to pilot test the collective FGIDs prevalence among preschool children in Jeddah city and its countryside of Saudi Arabia, using Rome IV DQ in Arabic-SA. Of the 59 responses, 11.8% (n = 7), 5% (n = 3), 1 (1.6%), and 1 (1.6%) participants have functional dyspepsia, functional constipation, functional irritable bowel syndrome, and functional aerophagia, respectively according to the Rome IV criteria. The tested translated DQ in this study was the first translated version available in Arabic- SA, which could provide researchers and clinicians in SA with a diagnostic tool for FGIDs. However, because this study is a pilot study in a new field, the conclusions cannot be extrapolated to the demographic of the targeted population of children. The same researchers plan a larger study to use the current results and a larger calculated sample to assess FGIDs prevalence in children 4+ years old in Jeddah and its countryside, Saudi Arabia.

Molecular Mechanisms of Hawthorn Extracts in Multiple Organs Disorders in Underlying of Diabetes: A Review

Diabetes mellitus (DM) is one of the most important metabolic disorders associated with chronic hyperglycemia and occurs when the body cannot manage insulin secretion, insulin action, or both. Autoimmune destruction of pancreatic beta cells and insulin resistance are the major pathophysiological factors of types 1 and 2 of DM, respectively. Prolonged hyperglycemia leads to multiple organs dysfunctions, including nephropathy, neuropathy, cardiomyopathy, gastropathy, and micro- and macrovascular disorders. The basis of the metabolic abnormalities in carbohydrate, fat, and protein in diabetes is insufficient action of insulin on various target tissues. Medicinal plants are rich sources of bioactive chemical compounds with therapeutic effects. The beneficial effects of leaves, fruits, and flowers extracts of Crataegus oxyacantha, commonly called hawthorn, belonging to the Rosaceae family, are widely used as hawthorn-derived medicines. Data in this review have been collected from the scientific articles published in databases such as Science Direct, Scopus, PubMed, Web of Science, and Scientific Information Database from 2000 to 2021. Based on this review, hawthorn extracts appear both therapeutic and protective effects against diabetic-related complications in various organs through molecular mechanisms, such as decreasing triglyceride, cholesterol, very low density lipoprotein and increasing the antioxidant activity of superoxide dismutase, catalase, glutathione peroxidase, total antioxidant capacity, decreasing malondialdehyde level, and attenuating tumor necrosis factor alpha, interleukin 6 and sirtuin 1/AMP-activated protein kinase (AMPK)/nuclear factor kappa B (NF-κB) pathway and increasing the phosphorylation of glucose transporter 4, insulin receptor substrate 1, AKT and phosphoinositide 3-kinases, and attenuating blood sugar and regulation of insulin secretion, insulin resistance, and improvement of histopathological changes in pancreatic beta cells. Collectively, hawthorn can be considered as one new target for the research and development of innovative drugs for the prevention or treatment of DM and related problems.

Epidemiology, Etiology, and Treatment of Gastroparesis: Real-World Evidence From a Large US National Claims Database

BACKGROUND & AIMS

Although gastroparesis carries a considerable health care and patient burden, associated epidemiological data are limited. To provide new real-world evidence for gastroparesis, we estimated disease prevalence, and investigated patient demographics and disease etiology in a large US claims database.

METHODS

This retrospective, cross-sectional analysis used de-identified, longitudinal patient-level enrollment and billing data for adults from the Optum Clinformatics Data Mart database, a large US national administrative health insurance claims database. Prevalence was age-, sex-, and geographical region-standardized using the 2018 US census. Descriptive analyses of demographic and clinical variables and underlying disease etiologies were performed.

RESULTS

The overall standardized prevalence of gastroparesis was 267.7 (95% confidence interval [CI] 264.8-270.7) per 100,000 US adults, whereas prevalence of "definite" gastroparesis (individuals diagnosed within 3 months of gastric emptying scintigraphy testing with persistent symptoms for more than 3 months) was 21.5 (95% CI 20.6-22.4) per 100,000 persons. Patients with gastroparesis had an overall Charlson Comorbidity Index score of 4.2, indicating substantial comorbidity burden. The most frequently documented comorbidities were chronic pulmonary disease (46.4%), diabetes with chronic complication (37.3%), and peripheral vascular disease (30.4%). Patients most commonly had a diabetic etiology (57.4%; type 1, 5.7% and type 2, 51.7%), followed by postsurgical (15.0%), drug-induced (11.8%), and idiopathic (11.3%) etiologies.

CONCLUSIONS

New evidence is provided regarding the prevalence, patient demographics, and etiology of gastroparesis in the US general population. Wider availability of reliable objective gastric emptying measures and further education of medical professionals in recognizing and diagnosing gastroparesis would benefit future studies and improve understanding of disease epidemiology.

Evaluating the Safety, Tolerability, and Disposition of Trazpiroben, a D2 /D3 Receptor Antagonist: Phase I Single- and Multiple-Ascending Dose Studies in Healthy Japanese Participants

Trazpiroben (TAK‐906) is a peripherally selective dopamine D₂/D₃ receptor antagonist being developed to treat chronic gastroparesis. This phase I, randomized, double‐blind, placebo‐controlled, single‐ and multiple‐ascending dose, parallel‐group study evaluated the safety, tolerability, pharmacokinetics, and pharmacodynamics of trazpiroben in healthy Japanese men. Findings were compared with those from a prior US trial in healthy individuals. Overall, 24 participants were enrolled into 3 cohorts (each n = 8). Per cohort, 6 participants received trazpiroben (cohort 1, 50 mg; 2, 100 mg; 3, 10 mg) once on day 1 and twice daily on days 3 through 7, and two received placebo. Trazpiroben was well tolerated, with no clinically meaningful adverse events observed. Following single‐ and multiple‐dose administration, trazpiroben was rapidly absorbed and eliminated (mean elimination half‐life, 1.89‐6.45 hours; median time to maximum serum concentration [steady state], 1.00‐1.25 hours). Serum prolactin increased with trazpiroben treatment (mean maximum serum concentration 93.32 ng/mL [10 mg] vs. 10.83 ng/mL [placebo]), illustrating receptor target engagement. Results reflected those from healthy US participants, indicating a lack of differences between these ethnic populations in trazpiroben disposition and safety profile. Trazpiroben may represent a promising therapy for chronic gastroparesis across different populations, with further evaluation ongoing in a phase IIb study (NCT03544229).

[G-POEM - Gastric Peroral Endoscopic Myotomy as a Therapy Option for Chronic Gastric Emptying Disorders]

Many doctors and patients shy away from the surgical intervention of a pyloromyotomy using laparoscopy. The effectiveness of botulinum toxin injections into the pylorus has not been established 1 2. Pharmacological therapeutic approaches are unsatisfactory and show a wide range of side effects 3. G-POEM is a procedure that has proven its feasibility with a low complication rate. A relatively high response could be documented in previous publications 4. The long-term successes are still being discussed controversially 5. After the initial euphoria, the problem of patient selection comes to the fore. The symptoms, as well as the pathophysiology of gastric emptying disorder, are diverse 6. The diagnostic tests available do not reflect the variability of the disease 7 8 9 10. The postoperative gastric emptying disorder seems to be an exception. G-POEM can protect both therapists and patients from another invasive procedure.

Effect of DA-9701 on the Gastrointestinal Motility in the Streptozotocin-Induced Diabetic Mice

Background: Compared to the general population, diabetic patients experience more frequent episodes of gastrointestinal (GI) motility dysfunction, owing to the disruption of functional innervations. DA-9701 is a new prokinetic agent formulated from the extracts of Pharbitidis semen and Corydalis tuber. Aim: To investigate the effect of DA-9701 on GI motility in an animal model of streptozotocin (STZ)-induced diabetes. Methods: Diabetes was induced in mice by intraperitoneal injection of STZ (40 mg/kg of body weight in 0.1 M citrate buffer) for 3 days. Diabetic mice were divided into four groups and administered DA-9701 in different doses (1, 3, and 10 mg/kg) or placebo for 2 weeks. Intestinal transit was assessed using charcoal meal movement. GI isometric contraction was measured by applying an isometric force transducer on a circular muscle strip of the antrum, ileum, and proximal colon of sacrificed mice. Gastric emptying rate was evaluated by measuring the dye percentage remaining in the stomach relative to the total dye amount recovered in a standardization group of mice. Results: Body weight and antral and small intestinal motility were less in diabetic mice than in control mice, and colonic motility was similar in both. DA-9701 showed a dose-dependent increase in the amplitude of spontaneous phasic contractions in the antrum, ileum, and colon in diabetic mice without influencing body weight or blood glucose levels. The degree of improvement was comparable between diabetic and control mice. Intestinal transit was significantly more delayed in diabetic mice than in controls (43 ± 7% vs. 67 ± 8%, p < 0.05); however, DA-9701 restored the delayed intestinal transit more effectively compared to placebo (75% vs. 50%). The gastric emptying rate was significantly more delayed in diabetic mice than in controls (43 ± 10% vs. 62 ± 12%, p < 0.05), and was improved by DA-9701 in a dose-dependent manner (50%, 55%, and 60% in mice treated with 1, 3, and 10 mg/kg of DA-9701, respectively, vs. 43% in placebo-treated and 60% in control mice). Conclusions: DA-9701 improved GI contractility without affecting blood sugar and body weight in diabetic mice. DA-9701 could improve the decreased GI motility and clinical symptoms in progressive diabetic patients.

New device for active gastric mechanical stimulation

BACKGROUND

Gastroparesis is a chronic stomach disorder and effective treatment is the aim of different strategies. Alternative therapies consist of an electrical stimulation of the stomach to evoke a response in the gastric activity. We present the development and in vivo application of an electromagnet system to induce a mechanical stimulus in the stomach aiming for gastric contractile responses.

METHODS

The electromagnet system consisted of an implantable magnet and an external drive coil. We implanted the magnet at the greater curvature of the gastric body in rats. We applied an alternating current to the drive coils, inducing mechanical stimulation of the gastric wall. We measured the gastric contraction activity and gastric electrical activity in response to the stimulus using AC biosusceptometry and electrogastrography. Moreover, we used the phenol red to evaluate the stimulus effects on gastrointestinal transit.

KEY RESULTS

The stimulus increased the spectral intensity and signal-to-noise ratio significantly of gastric contraction activity and gastric electrical activity. Furthermore, we found a lower phenol red retention in the stomach in rats without stimulus. No significant differences were found in frequency and root mean square amplitude.

CONCLUSIONS & INFERENCES

We developed a new simple electromagnet system that evoked a contraction and gastric electrical response using a mechanical stimulus and decreased gastric emptying time. The system is an accessible tool and may contribute to gastroparesis studies in animals.

A Low Cost, Novel Treatment of Severe Diabetic Gastroparesis Based on Burkitt's Dietary Fiber Hypothesis

We report a seven-year follow-up of a 43-year-old Hispanic female with severe diabetic gastroparesis (GP) and a 42.5 kg weight loss (45% of body mass), who required feeding jejunostomy tube placement. The patient had an excellent response to a treatment regime directed at increasing stool bulk, enhancing gut transit, and mobilizing intestinal gas by using dietary fiber supplements and osmotic laxatives with as needed tap water enemas. Hospital cost savings for this patient exceeded $125,000 annually. This case study suggests that constipation may substantially contribute to GP.

Detection and characteristics of rumination syndrome in patients presenting for gastric symptom evaluation

BACKGROUND

Rumination syndrome involves effortless, repeated regurgitation, and can overlap with other upper gastrointestinal disorders, including gastroparesis. To inform better diagnostic detection of rumination, we aimed to (1) identify frequency and characteristics of rumination in patients presenting for gastric symptom evaluation; and (2) assess demographic and clinical characteristics that could differentiate those with versus those without rumination.

METHODS

Consecutively referred patients to two tertiary academic centers for gastric symptom specialty evaluation were included (N = 242). We obtained demographic information, gastric emptying scintigraphy, upper gastrointestinal symptoms using the Patient Assessment of Upper Gastrointestinal Symptoms (PAGI-SYM), and Rome IV-based rumination questionnaire.

KEY RESULTS

Thirty-one of the 242 (12.8%) patients met criteria for rumination syndrome, of which 48% reported associated psychosocial impairment. Comparing those with rumination and those without, there were no differences in race, gender, frequency of diabetes, or frequency of gastroparesis. The median PAGI-SYM score for rumination patients was higher than for those without (3.03 vs. 2.55; unadjusted p = 0.043, adjusted p = 0.30). This was largely driven by increased heartburn/regurgitation subscale scores (2.71 vs. 1.57, unadjusted p = 0.0067, adjusted p = 0.046), itself influenced by elevated daytime regurgitation/reflux (3.0 vs. 2.0; unadjusted p = 0.007, adjusted p = 0.048). There were no significant differences on the remaining PAGI-SYM subscales.

CONCLUSIONS AND INFERENCES

Rumination syndrome determined by Rome IV criteria was present in 12.8% of patients presenting for gastric symptom evaluation. Higher self-report PAGI-SYM heartburn/regurgitation subscale scores, particularly daytime regurgitation/reflux symptoms, were the only parameters that distinguished rumination. The PAGI-SYM heartburn/regurgitation subscale could be used to screen for rumination, in addition to GERDAQ6.

Factors that contribute to the impairment of quality of life in gastroparesis

BACKGROUND

Understanding factors that impair quality of life (QOL) in gastroparesis is important for clinical management.

AIMS

(a) Determine QOL in patients with gastroparesis; (b) Determine factors that impair QOL.

METHODS

Gastroparetic patientsAQ6 underwent history and questionnaires assessing symptoms (PAGI-SYM and Rome III), QOL (SF-36v2 and PAGI-QOL), depression (Beck Depression Inventory [BDI]), and anxiety (State Trait Anxiety InventoryAQ7).

KEY RESULTS

715 gastroparesis patients (256 diabetic (DG), 459 idiopathic (IG)) were evaluated. SF-36 physical component (PC) score averaged 33.3 ± 10.5; 41% had impaired score <30. SF-36 PC scores were similar between diabetic and idiopathic gastroparesis. Impaired SF-36 PC associated with increased nausea/vomiting and upper abdominal pain subscores, acute onset of symptoms, higher number of comorbidities, use of narcotic pain medications, and irritable bowel syndrome (IBS). SF-36 mental component (MC) score averaged 38.9 ± 13.0; 26% had impaired score <30. Poor SF-36 MC associated with diabetic etiology, higher Beck depression inventory, and state anxiety scores. PAGI-QOL score averaged 2.6 ± 1.1; 50% had a score of <2.6. Low PAGI-QOL associated with higher fullness, bloating, and upper abdominal pain subscores, more depression and Trait anxiety, smoking cigarettes, need for nutritional support, progressively worsening symptoms and periodic exacerbations.

CONCLUSIONS & INFERENCES

Multiple measures show poor QOL present in gastroparesis. Several areas impacted on reduced QOL: (a) Symptoms of nausea, vomiting, and abdominal pain, as well as IBS; (b) Etiology and acute onset and progressively worsening symptoms; (c) Comorbidities and psychological factors such as anxiety and depression; (d) Patient-related factors such as smoking. Targeting the modifiable factors may improve patient outcomes in gastroparesis.

Evaluation of the Pharmacokinetics of Trazpiroben (TAK-906), a Peripherally Selective D2/D3 Dopamine Receptor Antagonist, in the Presence and Absence of Itraconazole, a Potent CYP 3A4 Inhibitor

Purpose

Treatment options for gastroparesis, such as metoclopramide and domperidone, are limited because of safety concerns, which may be exacerbated in the presence of inhibitors of drug metabolism. This study evaluated the effect of itraconazole on the pharmacokinetics, safety, and tolerability of trazpiroben (previously TAK-906), a novel, peripherally selective D₂/D₃ dopamine receptor antagonist.

Methods

This was a phase 1, two-period, crossover trial in healthy participants (NCT03161405). On day 1, period 1 (days 1–3), participants received a single oral dose of trazpiroben 25 mg. During period 2 (days 4–9), participants received oral itraconazole 200 mg once daily (days 1–5) and one oral dose of trazpiroben 25 mg post itraconazole on day 4. Trazpiroben pharmacokinetics were assessed. Safety assessments included triplicate electrocardiograms.

Results

Twelve healthy males (24–45 years old) were studied. Co-administration of itraconazole increased trazpiroben area under the concentration–time curve from time 0 to infinity by 1.28-fold (90% confidence interval: 1.10, 1.49) and maximum plasma concentration (C_max) by 1.98-fold (1.64, 2.39) versus trazpiroben alone. Placebo-corrected, change from baseline in corrected QT interval at the observed geometric mean C_max for trazpiroben alone (9.53 ng/mL) and with itraconazole (18.00 ng/mL) was estimated at 1.31 ms (−0.39, 3.01) and 1.54 ms (−0.15, 3.24), respectively. There were no clinically relevant abnormalities in any safety parameters.

Conclusion

These results indicate that TAK‑906 is relatively insensitive to inhibition of cytochrome P450 3A4, and cardiovascular safety concerns associated with domperidone are unlikely to be elicited by trazpiroben under similar conditions.

Preclinical Evaluation of the Effects of Trazpiroben (TAK-906), a Novel, Potent Dopamine D2/D3 Receptor Antagonist for the Management of Gastroparesis

Current therapies for gastroparesis, metoclopramide and domperidone, carry risks of extrapyramidal symptoms and life-threatening cardiac arrhythmias. Trazpiroben, a novel, potent dopamine D₂/D₃ receptor antagonist, has low brain permeation and very low affinity for human ether-à-go-go-related gene (hERG) channel inhibition, potentially improving on safety profiles of existing therapies. Trazpiroben demonstrated the following receptor affinities: high for D₂ and D_3, moderate for D₄ and minimal for D₁ and D₅ It demonstrated moderate affinity for adrenergic alpha 1B (α_1B) and 5-hydroxytryptamine 2A (5HT_2A) receptors and low potential for off-target adverse events (AEs). Trazpiroben potently inhibited dopamine-activated D_2L receptor activation of cognate G-proteins in human embryonic kidney 293 cell membranes and was a neutral D_2L receptor antagonist. In vivo, trazpiroben dose-dependently increased prolactin release in orally dosed rat (0.1-1mg/kg). Additionally, multiple oral doses in the rat (100mg/kg) and dog (50mg/kg) for 3 days produced robust plasma exposures and prolactin increases in both species. Trazpiroben inhibited retching/vomiting in the dog with apomorphine-induced emesis with a potency (0.1-1mg/kg) like that of trazpiroben-mediated prolactin increases in rat. Oral trazpiroben (1, 10, and 30mg/kg) did not affect rat rotarod performance, suggesting low brain penetration. Trazpiroben concentrations were low in cerebrospinal fluid versus plasma following multiple oral doses for 4 days in rat and dog. Trazpiroben weakly inhibited the hERG channel current (concentration causing half-maximal inhibition of control-specific binding of 15.6µM), indicating little potential for disrupting cardiac rhythm. Overall, trazpiroben is a potent D₂/D₃ receptor antagonist designed to avoid serious potential AEs associated with current gastroparesis therapies. Significance Statement Trazpiroben is a novel, potent dopamine D₂/D₃ selective receptor antagonist designed to avoid adverse effects associated with the current pharmacological therapies, metoclopramide and domperidone. Pre-clinical studies have demonstrated low brain penetration and weak affinity for the hERG channel, indicating that trazpiroben is not expected to be associated with central nervous system or cardiovascular safety issues. With these pharmacological properties, trazpiroben may represent a viable new treatment option for gastroparesis due to a potentially improved safety profile relative to existing therapies.

Surgical Treatment for Gastric Cancer

Surgery is an essential component of curative-intent treatment strategies for gastric cancer. However, the care of each patient with gastric cancer must be individualized based on patient and tumor characteristics. It is important that all physicians who will be caring for patient with gastric cancer understand the current best practices of surgical management to provide patients with the highest quality of care. This article aims to provide this information while acknowledging areas of surgical management that are still controversial.

Transcutaneous auricular vagus nerve stimulation influences gastric motility: A randomized, double-blind trial in healthy individuals

BACKGROUND

Transcutaneous auricular vagus nerve stimulation (taVNS) has been investigated regarding its therapeutic properties in several several conditions such as epilepsy, migraine and major depressive disorder and was shown to access similar neural pathways as invasive vagus nerve stimulation. While the vagus nerve's role in gut motility is physiologically established, the effect of taVNS has scarcely been investigated in humans and yielded conflicting results. Real-time gastric magnetic resonance imaging (rtMRI) is an established reproducible method to investigate gastric motility non-invasively.

OBJECTIVE

To investigate the influence of taVNS on gastric motility of healthy participants using rtMRI.

METHODS

We conducted a randomized, double-blind study using high-frequency (HF) stimulation at 25Hz or low-frequency (LF) taVNS at 1Hz after ingestions of a standardized meal in 57 healthy participants. The gastric motility index (GMI) was determined by measuring the amplitude and velocity of the peristaltic waves using rtMRI.

RESULTS

After HF taVNS, GMI was significantly higher than after LF stimulation (p = 0.005), which was mainly attributable to a higher amplitude of the peristaltic waves (p = 0.003).

CONCLUSION

We provide evidence that 4-h of taVNS influences gastric motility in healthy human participants for the first time using rtMRI. HF stimulation is associated with higher amplitudes of peristaltic waves in the gastric antrum compared to LF stimulation. Further studies are needed to investigate the effect of different frequencies of taVNS and its therapeutic properties in conditions with impaired gastric motility.

Gastric emptying in healthy children using the Spirulina breath test: The impact of gender, body size, and pubertal development

BACKGROUND

There are no pediatric norms for gastric emptying (GE) measured by nuclear scintigraphy. The ¹³ C-labeled, stable isotope GE breath test (GEBT) is a non-radioactive alternative. We aimed to determine normative GEBT ranges in a cohort of healthy children and examine the influence of age, gender, puberty, and body surface area (BSA).

METHODS

Healthy children ages 8-18 years completed the [¹³ C]-Spirulina platensis GEBT after an overnight fast. Breath samples were collected at baseline, every 15 min × 1 h, then every 30 min for 4 h total. The ¹³ CO₂ excretion rate was determined by the change in ¹³ CO₂ /¹² CO₂ over time in each breath sample, expressed as kPCD (Percent ¹³ C Dose excreted/min). A mixed model with random time was used for multivariable analysis and outcome fit into a quadratic model.

KEY RESULTS

The 100 subjects completed the test meal within allotted time. Median (IQR) age was 13.5 (11.3-15.5) years; 51% were female. Females had lower ¹³ CO₂ excretion rates (slower GE) than males across time (p < 0.001) while decreased excretion rates correlated with higher BSA (p = 0.015). Gender differences were also noted within pubertal stages with females showing slower GE. Multivariable analysis suggested that pre-pubertal children have faster GE than both peri- and post-pubertal groups (p < 0.0001).

CONCLUSIONS & INFERENCES

Gender, puberty, and BSA influence GE rates in healthy children more than age. Although further data are needed, pubertal stage and hormonal influences may be unique factors to consider when assessing GE in children.

Practical management approach to gastroparesis

Gastroparesis is a syndrome characterised by delayed gastric emptying in the absence of mechanical obstruction. Symptoms can include early satiety, abdominal pain, bloating, vomiting and regurgitation which cause significant morbidity in addition to nutritional deficits. There is a higher prevalence in diabetics and females, but the incidence in the Australian population has not been well studied. Management of gastroparesis involves investigating and correcting nutritional deficits, optimising glycaemic control and improving gastrointestinal motility. Symptom control in gastroparesis can be challenging. Nutritional deficits should be addressed initially through dietary modification. Enteral feeding is a second-line option when oral intake is insufficient. Home parenteral nutrition is rarely used, and only accessible through specialised clinics in the outpatient setting. Prokinetic medication classes that have been used include dopamine receptor antagonists, motilin receptor agonists, 5-HT₄ receptor agonists and ghrelin receptor agonists. Anti-emetic agents are often used for symptom control. Interventional treatments include gastric electrical stimulation, gastric per-oral endoscopic myotomy, feeding jejunostomy and gastrostomy/jejunstomy for gastric venting and enteral feeding. In this article we propose a framework to manage gastroparesis in Australia based on current evidence and available therapies.

An Apriori Algorithm-Based Association Rule Analysis to Identify Acupoint Combinations for Treating Diabetic Gastroparesis

We explored the potential association rules within acupoints in treating diabetic gastroparesis (DGP) using Apriori algorithm complemented with another partition-based algorithm, a frequent pattern growth algorithm. Apriori algorithm is a data mining-based analysis that is widely applied in various fields, such as business and medicine, to mine frequent patterns in datasets. To search for effective acupoint combinations in the treatment of DGP, we implemented Apriori algorithm to investigate the association rules of acupoints among 17 randomized controlled trials (RCTs). The acupoints were extracted from the 17 included RCTs. In total, 29 distinct acupoints were observed in the RCTs. The top 10 frequently selected acupoints were CV12, ST36, PC6, ST25, BL21, BL20, BL23, SP6, BL18, and ST21. The frequency pattern of acupoints achieved by using a frequent pattern growth algorithm also confirms the result. The results showed that the most associated rules were {BL23, BL18} ≥ {SP6}, {BL20, BL18} ≥ {PC6}, {PC6, BL18} ≥ {BL20}, and {SP6, BL18} ≥ {BL23} in the database. Acupoints, including BL23, BL18, SP6, BL20, and PC6, can be deemed as core elements of acupoint combinations for treating DGP.

Epidemiology and outcomes of gastroparesis, as documented in general practice records, in the United Kingdom

OBJECTIVE

To generate real-world evidence for the epidemiology of gastroparesis in the UK, we evaluated the prevalence, incidence, patient characteristics and outcomes of gastroparesis in the Clinical Practice Research Datalink (CPRD) database.

DESIGN

This was a retrospective, cross-sectional study. Prevalence and incidence of gastroparesis were evaluated in the CPRD database, with linkage to Hospital Episodes Statistics Admitted Patient Care and Office for National Statistics mortality data. Prevalence and incidence were age and sex standardised to mid-2017 UK population estimates. Descriptive analyses of demographics, aetiologies, pharmacological therapies and mortality were conducted.

RESULTS

Standardised prevalence of gastroparesis, as documented in general practice records, was 13.8 (95% CI 12.6 to 15.1) per 100 000 persons in 2016, and standardised incidence of gastroparesis rose from 1.5 (95% CI 1.1 to 1.8) per 100 000 person-years in 2004 to 1.9 (95% CI 1.4 to 2.3) per 100 000 person-years in 2016. The most common disease aetiologies were idiopathic (39.4%) and diabetic gastroparesis (37.5%), with a similar distribution of type 1 and type 2 diabetes among the 90% who had type of diabetes documented. Patients with diabetic gastroparesis had a significantly higher risk of mortality than those with idiopathic gastroparesis after diagnosis (adjusted HR 1.9, 95% CI 1.2 to 3.0). Of those with gastroparesis, 31.6% were not offered any recognised pharmacological therapy after diagnosis.

CONCLUSION

This is, to our knowledge, the first population-based study providing data on epidemiology and outcomes of gastroparesis in Europe. Further research is required to fully understand the factors influencing outcomes and survival of patients with gastroparesis.

A link between gastrointestinal disorders and migraine: Insights into the gut-brain connection

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.

Metoclopramide nasal spray for management of symptoms of acute and recurrent diabetic gastroparesis in adults

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 (Gimoti^TM) 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.

Addition of small-bowel transit scintigraphy to gastric emptying for assessment of patients with upper gastrointestinal symptoms

BACKGROUND

Dyspeptic symptoms are not well correlated with gastric emptying (GE) results.

AIMS

To determine (a) prevalence of delayed SB transit (SBT) in patients undergoing GE scintigraphy for symptoms of gastroparesis; (b) symptoms associated with delayed SBT.

METHODS

Patients with symptoms of gastroparesis underwent combined GE and SBT scintigraphy (GES/SBTS). Patients ingested a mixed solid (S)-liquid (L) meal with egg whites labeled with 500 µCi Tc-99 m sulfur colloid and water with 125 µCi In-111 DTPA. Retained S and L gastric activity and percent of L In-111 activity in terminal ileum (TI) and/or cecum/colon at 6 h were determined. Patient Assessment of Gastrointestinal Symptoms (PAGI-SYM) assessed symptoms from 0 (none) to 5 (very severe).

KEY RESULTS

Of 363 patients, 174 (47.9%) had delayed S GE, 141 (38.8%) delayed L GE, and 70 (19.3%) delayed SBT. Delayed SBT was seen in 24 (6.6%) with normal S GE and 46 (12.7%) with delayed S GE. Patients with isolated delayed SBT had highest symptom scores for postprandial fullness (3.5), stomach fullness (3.4), nausea (3.2), bloating (3.2), compared to isolated delayed S GE who had highest symptom scores for postprandial fullness (3.7), nausea (3.6), stomach fullness (3.4), and early satiety (3.3).

CONCLUSIONS & INFERENCES

Delayed SBT occurred in 19.3% of dyspeptic patients using GES/SBTS. While postprandial and stomach fullness were common to both delayed S GE and delayed SBT, early satiety was associated with delayed S GE whereas bloating was associated with delayed SBT. Thus, SBTS can augment GES to help explain some symptoms associated with dyspepsia and suspected gastroparesis.

Body weight in patients with idiopathic gastroparesis

BACKGROUND

The classic clinical picture of gastroparesis is a symptomatic patient losing weight. In addition, a number of patients with delayed gastric emptying are obese and/or gaining weight. Our aim was to investigate the factors impacting body weight in patients with idiopathic gastroparesis.

METHODS

In patients with idiopathic gastroparesis, detailed history and weight were acquired at enrollment and after 48 weeks. Questionnaires assessed symptoms, food intake, physical activity, and quality of life. Patients underwent laboratory testing, gastric emptying scintigraphy, and water load testing.

RESULTS

Of 138 patients with idiopathic gastroparesis, 10% were underweight (BMI < 18.5), 39% were normal weight (BMI 18.5-25), 20% were overweight with BMI 25 to 30 kg/m² , and 29% were obese with BMI > 30 kg/m² . Body weight at enrollment was positively associated with oral caloric consumption (P < .001), following a gastroparesis diet (P = .04), nutrition consultation (P = .001), upper abdominal pain (P = .01); and negatively associated with energy expenditure (P = .05), alcohol use (P = .003) and severity of bloating (P < .001). When followed over 48 weeks, 53% patients stayed stable (within 5% of baseline weight), 30% gained, and 17% lost weight. Weight gain over 48 weeks was positively associated with oral caloric consumption (P = .003) and constipation severity (P = .005) at enrollment, and negatively associated with lower abdominal pain severity (P = .007) at enrollment, and associated with improvement in inability to finish meal score (P < .001) at 48 weeks.

CONCLUSIONS

In this series of patients with idiopathic gastroparesis, 10% were underweight whereas 29% were obese. Over 48 weeks, 30% of patients increased their body weight ≥ 5%. Diet, activity, and symptoms are important factors associated with body weight in patients with idiopathic gastroparesis.

Gastric Electrical Stimulation for Treatment of Refractory Gastroparesis: the Current Approach to Management

Purpose of Review

Gastroparesis is one of the more challenging entities in the landscape of gastroenterology, posing difficulties for both patients and physicians with regard to effective management and therapies. In this article, we reviewed various gastroparesis treatment options, with an emphasis on gastric electrical stimulation (GES).

Recent Findings

GES has demonstrated a significant reduction of cardinal symptoms in refractory gastroparetic patients, particularly nausea and vomiting, across multiple studies. However, GES has not been shown to conclusively decrease gastric emptying time in these patients. Such finding has led the investigators to analyze the impact of combining GES with pyloroplasty. While this treatment pathway is nascent, its results thus far reveal an amplified improvement of gastroparesis symptomatology in addition to significant reduction of gastric transit, compared to GES by itself.

Summary

Limited treatment choices are available for refractory gastroparesis. Combining GES with pyloroplasty holds promise but requires further assessment in large-scale trials to fully evaluate the risks and benefits.

Efficacy and Safety of Tradipitant in Patients With Diabetic and Idiopathic Gastroparesis in a Randomized, Placebo-Controlled Trial

BACKGROUND & AIMS

Treatments are needed for gastroparesis; antagonists of tachykinin receptor 1 (TACR1, also called NK1R) can reduce symptoms of nausea and vomiting. We investigated the safety and efficacy of tradipitant, an antagonist of NK1R, in patients with idiopathic or diabetic gastroparesis.

METHODS

We performed a double-blind trial of 152 adults with gastroparesis at 47 sites in the United States from November 2016 through December 2018. Participants were randomly assigned to groups given oral tradipitant 85 mg (n = 77) or placebo (n = 75) twice daily for 4 weeks. Symptoms were assessed by a daily symptom dairy, Gastroparesis Cardinal Symptom Index scores, and other patient-reported questionnaires. The primary outcome from the intent-to-treat analysis was change from baseline to week 4 in average nausea severity, measured by the Gastroparesis Core Symptom Daily Diary.

RESULTS

Patients receiving tradipitant had a significant decrease in nausea score (reduction of 1.2) at week 4 compared with placebo (reduction of 0.7) (P = .0099) and a significant increase in of nausea-free days at week 4 (28.8% increase on tradipitant vs 15.0% on placebo; P = .0160). Patients with nausea and vomiting at baseline (n = 101) had an even greater decrease in nausea in when given tradipitant (reduction of 1.4) compared with those given placebo (reduction of 0.4) (P < .0001), as well as an increase in nausea-free days at week 4 (32.3% improvement on tradipitant vs 7.6% on placebo; P = .0003). The average nausea score was 1 or less at week 4 in 32.9% of patients given tradipitant compared with 11.8% of patients given placebo (P = .0013). A greater than 1-point improvement in Gastroparesis Cardinal Symptom Index score was observed in 46.6% of patients given tradipitant compared with 23.5% of patients given placebo (P = .0053).

CONCLUSIONS

Tradipitant resulted in statistically and clinically meaningful improvements in nausea and reduced vomiting, compared with placebo, in patients with idiopathic or diabetic gastroparesis. ClinicalTrials.gov, Number: NCT02970968.

Dietary modifications achieved successful resolution of symptoms of gastroparesis diagnosed by demonstrating gastric food retention after overnight fasting in diabetic dialysis patients: two case reports with literature review

Background

Gastroparesis is frequently overlooked and difficult to treat. The diagnosis of gastroparesis requires standard upper gastrointestinal endoscopy to exclude gastric outlet obstruction and objective evidence demonstrating delayed gastric emptying. However, none of the internationally recommended methods for measuring gastric emptying including scintigraphy are covered by the Japanese health insurance system. Limitations in the diagnosis might be related to the disease being overlooked in Japan. Meanwhile, presence of retained food in the stomach after overnight fasting without obstruction is classically known to be suggestive of gastroparesis. Some recent reports have considered gastric food retention after an overnight fasting equivalent to delayed gastric emptying.

Case presentation

Two diabetic dialysis patients presented with nausea, vomiting, and oral feeding intolerance in the absence of mechanical obstruction. Abdominal computed tomography, upper gastrointestinal endoscopy, and ultrasonography demonstrated gastric food retention after overnight fasting. The findings led to the diagnosis of gastroparesis. Appropriate dietary modifications alone successfully relieved the symptoms despite persistent delayed gastric emptying.

Conclusions

Demonstrating retained food residue after fasting for sufficient duration might be a diagnostic alternative. Dietary modifications alone provided significant clinical benefits. Possible approaches for the diagnosis and treatment of gastroparesis in Japan should be investigated.

Avoidant/restrictive food intake disorder symptoms are frequent in patients presenting for symptoms of gastroparesis

INTRODUCTION

Patients with symptoms of gastroparesis/dyspepsia often avoid foods or restrict eating for symptom management. There is growing interest in understanding risk for feeding/eating disorders (FEDs) like avoidant/restrictive food intake disorder (ARFID). Among patients presenting with gastroparesis/dyspepsia symptoms, we aimed to determine: (a) FED symptom frequency, and (b) relation of FED symptoms to gastrointestinal symptom severity and gastric retention abnormalities.

METHODS

Adult patients (N = 288; 78% female) referred for gastroparesis/dyspepsia symptoms at two academic medical centers from January 2018-February 2019 completed self-report surveys for gastrointestinal symptom severity and FED symptoms. Gastric retention data were available for 210 patients, using 4-hour EggBeater gastric emptying scintigraphy (GES).

RESULTS

Clinically significant FED symptoms were present in 158 patients (54.9%). Interestingly, 115 patients (39.9%) met conservative self-report cutoff for ARFID symptoms, with 67 (23.3%) patients having documented psychosocial/medical impairment. Of those with survey data for other FEDs (n = 239), only 28 patients (11.7%) had restrictive eating disorders (anorexia nervosa; unspecified FED). Likelihood of having FED symptoms was significantly associated with greater gastroparesis symptom severity (OR = 2.23, P < .001), but not GES. In addition, gastroparesis symptom severity was moderately and significantly associated with greater ARFID symptom severity (b = 0.45, P < .001), but neither GES nor other FED symptoms.

DISCUSSION

In patients presenting with gastroparesis/dyspepsia symptoms, FED symptoms were frequent (55%), particularly ARFID, and were associated with greater gastrointestinal symptom severity, but not gastric retention. Gastroparesis/dyspepsia symptoms may mimic FEDs, particularly ARFID. Clinicians should be cautious about diagnosing ARFID in gastroparesis/dyspepsia patients, and screening for ARFID could assist behavioral treatment referral.

Gastroparesis With the Initiation of Liraglutide: A Case Report

Gastroparesis is a syndrome that is manifested by gastrointestinal symptoms and delayed gastric emptying without evidence of mechanical obstruction. Herein, we present the case of an 18-year-old diabetic female patient who developed clinical features suggestive of gastroparesis after initial doses of liraglutide. Although rare, drug-induced gastroparesis should be contemplated in diabetic patients with a history of recent commencement of liraglutide, particularly at higher doses. Management of drug-induced gastroparesis is largely symptomatic.

Gastroesophageal Reflux Disease and Foregut Dysmotility in Children with Intestinal Failure

Gastrointestinal dysmotility is a common problem in a subgroup of children with intestinal failure (IF), including short bowel syndrome (SBS) and pediatric intestinal pseudo-obstruction (PIPO). It contributes significantly to the increased morbidity and decreased quality of life in this patient population. Impaired gastrointestinal (GI) motility in IF arises from either loss of GI function due to the primary disorder (e.g., neuropathic or myopathic disorder in the PIPO syndrome) and/or a critical reduction in gut mass. Abnormalities of the anatomy, enteric hormone secretion and neural supply in IF can result in rapid transit, ineffective antegrade peristalsis, delayed gastric emptying or gastroesophageal reflux. Understanding the underlying pathophysiologic mechanism(s) of the enteric dysmotility in IF helps us to plan an appropriate diagnostic workup and apply individually tailored nutritional and pharmacological management, which might ultimately lead to an overall improvement in the quality of life and increase in enteral tolerance. In this review, we have focused on the pathogenesis of GI dysmotility in children with IF, as well as the management and treatment options.

Nutritional approaches for gastroparesis

Patients with gastroparesis often have signs and symptoms including nausea, vomiting, epigastric discomfort, and early satiety, thus leading to inadequate food intake and a high risk of malnutrition. There is a considerable scarcity of data about nutritional strategies for gastroparesis, and current practices rely on extrapolated evidence. Some approaches include the modification of food composition, food consistency, and food volume in the context of delayed gastric emptying. If the patient is unable to consume adequate calories through a solid food diet, stepwise nutritional interventions could include the use of liquid meals, oral nutrition supplements, enteral nutrition, and parenteral nutrition. This Review discusses the role, rationale, and current evidence of diverse nutritional interventions in the management of gastroparesis.

Medical and surgical management of gastroparesis: a systematic review

BACKGROUND

Gastroparesis (GPS) is a rare disease with multiple etiologies that results in delayed gastric emptying. Diagnosis of GPS can be challenging due to its rather complex clinical presentation. Pharmacologic refractory cases require surgical interventions, all of which have yet to be standardized and characterized.

OBJECTIVES

We present a review of the literature and provide an update of current therapies for patients with GPS.

SETTING

Department of General Surgery, Academic Hospital, United States.

METHODS

We conducted a comprehensive search in PubMed, Google Scholar, and Embase of English-written articles published in the last 38 years, with an advance title search of "gastroparesis management." Other keywords included: "surgical management" and "refractory gastroparesis." Further references were obtained through cross-reference.

RESULTS

A total of 12,250 articles were selected after eliminating duplicates. Following thorough screening of selection criteria, 68 full-text articles were included for review.

CONCLUSION

GPS is a challenging disease to manage. Nutritional support must remain the primary approach, followed by either medical or surgical treatment modalities if necessary. In patients with refractory gastroparesis, adjunctive therapies have been proposed as promising long-term options.

Efficacy of gastric electrical stimulation in intractable nausea and vomiting at 10 years: A retrospective analysis of prospectively collected data

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.

Diabetes and Metabolic Disorders and the Peripheral Nervous System

PURPOSE OF REVIEW

This article provides an up-to-date review of the manifestations of neuropathy seen in the setting of diabetes and other metabolic disorders.

RECENT FINDINGS

Although a number of metabolic disorders cause or are associated with peripheral neuropathy, the neuropathies associated with glucose dysregulation make up the vast majority of cases. Recent investigations have determined major differences in the neuropathies associated with type 1 and type 2 diabetes. Neuropathy in type 1 diabetes is closely linked to glycemic control, whereas neuropathy in type 2 diabetes is linked to dyslipidemia, central obesity, hypertension, insulin resistance, and glucose control. Although length-dependent axonal distal symmetric polyneuropathy is the most common clinical presentation, diabetes is also associated with acute, asymmetric, painless, and autonomic neuropathies.

SUMMARY

The prevalence of diabetes and metabolic syndrome is increasing across the globe. The need to recognize and treat the wide array of clinical manifestations of neuropathy detected in individuals with metabolic disorders will continue to grow. As a consequence, an increasing number of well-trained physicians who can manage these patients is needed. At present, treatment is largely focused on prevention and symptomatic management. Investments into funding for both basic and clinical science are necessary to bring novel therapeutic interventions into clinical practice.

Techniques and devices for the endoscopic treatment of gastroparesis (with video)

BACKGROUND AND AIMS

Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Several endoscopic treatment modalities have been described that aim to improve gastric emptying and/or symptoms associated with gastroparesis refractory to dietary and pharmacologic management.

METHODS

In this report we review devices and techniques for endoscopic treatment of gastroparesis, the evidence regarding their efficacy and safety, and the financial considerations for their use.

RESULTS

Endoscopic modalities for treatment of gastroparesis can be broadly categorized into pyloric, nonpyloric, and nutritional therapies. Pyloric therapies such as botulinum toxin injection, stent placement, pyloroplasty, and pyloromyotomy specifically focus on pylorospasm as a therapeutic target. These interventions aim to reduce the pressure gradient across the pyloric sphincter, with a resultant improvement in gastric emptying. Nonpyloric therapies, such as venting gastrostomy and gastric electrical stimulation, are intended to improve symptoms. Nutritional therapies, such as feeding tube placement, aim to provide nutritional support.

CONCLUSIONS

Several endoscopic interventions have shown utility in improving the quality of life and symptoms of select patients with refractory gastroparesis. Methods to identify which patients are best suited for a specific treatment are not well established. Endoscopic pyloromyotomy is a relatively recent development that may prove to be the preferred pyloric-directed intervention, although additional and longer-term outcomes are needed.

State-of-the-art pharmacotherapy for diabetic neuropathy

INTRODUCTION

The global epidemic of diabetes has led to an epidemic of diabetes complications. Diabetic neuropathy is the most common microvascular complication, of which diabetic peripheral neuropathy (DPN) and autonomic neuropathy (AN) are the most prevalent, affecting ~50% of patients. DPN results in pain with a poor quality of life and a loss of sensation with an increased risk of foot ulceration. Autonomic neuropathy can cause significant morbidity in a minority and is associated with increased mortality. The cornerstone of treatment to prevent or limit the progression of DPN/AN is multifactorial risk factor modification including treatment of glycemia, lipids and blood pressure. Whilst, there are no FDA-approved disease-modifying therapies, there are a number of therapies to relieve symptoms in DPN and AN.

AREAS COVERED

The authors discuss current approved therapies for painful diabetic neuropathy and autonomic neuropathy. They also address the potential role of improving risk factors to limit the development and progression of diabetic neuropathy and new pathogenetic and pain-relieving treatments.

EXPERT OPINION

The FDA-approved Pregabalin and Duloxetine over 25 years ago and Tapentadol, 6 years ago for painful diabetic neuropathy. There are currently no FDA-approved disease-modifying treatments for diabetic neuropathy which has been attributed to inappropriate models of the disease with limited translational capacity and major limitations of trial designs and endpoints in clinical trials.

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

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.

Marijuana Use in Patients with Symptoms of Gastroparesis: Prevalence, Patient Characteristics, and Perceived Benefit

BACKGROUND

Marijuana may be used by some patients with gastroparesis (Gp) for its potential antiemetic, orexigenic, and pain-relieving effects.

AIMS

The aim of this study was to describe the use of marijuana by patients for symptoms of Gp, assessing prevalence of use, patient characteristics, and patients' perceived benefit on their symptoms of Gp.

METHODS

Patients with symptoms of Gp underwent history and physical examination, gastric emptying scintigraphy, and questionnaires assessing symptoms. Patients were asked about the current use of medications and alternative medications including marijuana.

RESULTS

Fifty-nine of 506 (11.7%) patients with symptoms of Gp reported current marijuana use, being similar among patients with delayed and normal gastric emptying and similar in idiopathic and diabetic patients. Patients using marijuana were younger, more often current tobacco smokers, less likely to be a college graduate, married or have income > $50,000. Patients using marijuana had higher nausea/vomiting subscore (2.7 vs 2.1; p = 0.002), higher upper abdominal pain subscore (3.5 vs 2.9; p = 0.003), more likely to be using promethazine (37 vs 25%; p = 0.05) and dronabinol (17 vs 3%; p < 0.0001). Of patients using marijuana, 51% had been using it for more than 2 years, 47% were using this once or more per day, and 81% of marijuana users rated their benefit from marijuana as better or much better.

CONCLUSIONS

A subset of patients (12%) with symptoms of Gp use marijuana. Patients with severe nausea and abdominal pain were more likely to use marijuana and perceive it to be beneficial for their symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01696747.