Gastrointestinal motor dysfunction, symptoms, and neuropathy in noninsulin-dependent (type 2) diabetes mellitus

Monitoring of gallbladder and gastric coordination by EPI

PURPOSE

To assess for the first time the potential of echo-planar magnetic resonance imaging (EPI) for measuring simultaneously both gallbladder and gastric emptying.

MATERIALS AND METHODS

Eight healthy subjects ingested 500 mL of an acid-stable liquid test meal containing 15% olive oil and flavoring. Every 20 minutes for three hours thereafter, a rapid EPI multislice set was acquired across the whole abdomen, using a dedicated whole-body 0.5-T EPI scanner.

RESULTS

The bile in the gallbladder and the test meal in the stomach appeared bright in the EPI images, aiding localization and region of interest analysis. We measured the gallbladder emptying curve and fitted the data to a simple analytical model. The mean fasted gallbladder volume was 25 +/- 4 mL, comparable to previously published MRI and ultrasound values. Gastric emptying data fitted well to a linear model linear (R2 = 0.99), and we observed an exponential (R2 = 0.98) relationship between gallbladder and gastric volumes for the first 90 minutes.

CONCLUSION

This study shows the potential of EPI to monitor simultaneously and noninvasively the emptying of the gallbladder and of the gastric lumen. No contrast enhancing agents are needed. This method could overcome the limitations of previous gamma scintigraphy and ultrasound techniques.

Laparoscopy-assisted distal gastrectomy for early gastric cancer: is it beneficial for patients of heavier weight?

OBJECTIVE

In this retrospective review, we evaluated the advantages and disadvantages of LADG for patients of heavier weight with early gastric cancer.

SUMMARY BACKGROUND DATA

LADG has been used to treat early gastric cancer. We and others have reported less operative blood loss, less pain, early recovery of bowel activity, early restart of oral intake, and a shorter hospital stay with LADG compared with a conventional open method. There is, however, little information on the advantages of LADG for obese patients with early gastric cancer.

METHODS

Between January 1996 and March 2002, 76 patients with preoperatively diagnosed early gastric carcinoma underwent LADG in our department. We classified these patients into 2 groups on the basis of body mass index (BMI). Nineteen patients had a high-BMI (>/= 24.2 kg/m2), and 57 patients had a normal-BMI (<24.2 kg/m2). We collected data by retrospectively reviewing the medical charts.

RESULTS

Extension of the minilaparotomic incision or conversion to laparotomy was needed in 6 (32%) of the 19 patients in the high-BMI group, whereas only 3 (5%) of 57 patients in the normal-BMI group required either. In the high-BMI group, Roux-en-Y anastomosis rather than Billroth I anastomosis was adopted more often than in the normal-BMI group, due to the difficulty of the reconstruction (58% versus 4%, P = 0.001). Significantly longer operative time (370 +/- 61 minutes versus 317 +/- 58 minutes, P = 0.015) and prolonged recovery of bowel activity (3.5 +/- 1.0 days versus 2.6 +/- 1.0 days, P = 0.007) were observed in the patients in the high-BMI group.

CONCLUSIONS

In the current study, LADG in patients of heavier weight was accompanied by more technical difficulties, and the disadvantages of longer operative time and delayed recovery of bowel activity was observed in patients of heavier weight. Heavier weight appears to be an ominous factor in the successful completion of LADG and should be considered in the decision to use LADG. There are still benefits of a decreased incidence of serious wound and hernia complications in successful cases.

Prevalence of delayed gastric emptying in diabetic patients and relationship to dyspeptic symptoms: a prospective study in unselected diabetic patients

OBJECTIVE

Data on the prevalence of abnormal gastric emptying in diabetic patients are still lacking. The relation between gastric emptying and dyspeptic symptoms assessed during gastric emptying measurement has not yet been investigated. The aim was to investigate the prevalence of delayed gastric emptying in a large cohort of unselected diabetic patients and to investigate the relation between gastric emptying and gastrointestinal sensations experienced in the 2 weeks before and during the test meal, prospectively.

RESEARCH DESIGN AND METHODS

Gastric emptying was evaluated in 186 patients (106 with type 1 diabetes, mean duration of diabetes 11.6 +/- 11.3 years) using 100 mg (13)C-enriched octanoic acid added to a solid meal.

RESULTS

Gastric emptying was significantly slower in the diabetic subjects than in the healthy volunteers (T(50): 99.5 +/- 35.4 vs. 76.8 +/- 21.4 min, P < 0.003; Ret(120 min): 30.6 +/- 17.2 vs. 20.4 +/- 9.7%, P < 0.006). Delayed gastric emptying was observed in 51 (28%) diabetic subjects. The sensations experienced in the 2 weeks before the test were weakly correlated with the sensation scored during the gastric emptying test. Sensations assessed during the gastric emptying test did predict gastric emptying to some extent (r = 0.46, P < 0.0001), whereas sensations experienced in the previous 2 weeks did not.

CONCLUSIONS

This prospective study shows that delayed gastric emptying can be observed in 28% of unselected patients with diabetes. Upper gastrointestinal sensations scored during the gastric emptying tests do predict the rate of gastric emptying to some extent and sensation experienced during daily life does not.

Nutrition therapy for diabetic gastroparesis

The management of diabetic gastroparesis often represents a significant clinical challenge in which the maintenance of nutrition is pivotal. Gastric emptying is delayed in 30% to 50% of patients with longstanding type 1 or type 2 diabetes and upper gastrointestinal symptoms also occur frequently. However, there is only a weak association between the presence of symptoms and delayed gastric emptying. Acute changes in blood glucose concentrations affect gastric motility in diabetes; hyperglycemia slows gastric emptying whereas hypoglycemia may accelerate it; blood glucose concentrations may also influence symptoms. It is now recognized that gastric emptying is a major determinant of postprandial glycemia and, therefore, there is considerable interest in the concept of modulating gastric emptying, by dietary or pharmacologic means, to optimize glycemic control in diabetes.

Development and validation of the Diabetes Bowel Symptom Questionnaire

BACKGROUND

Although gastrointestinal symptoms occur frequently, there is no validated measure of gastrointestinal symptoms in patients with diabetes mellitus.

AIM

To develop the Diabetes Bowel Symptom Questionnaire.

METHODS

A questionnaire derived from previously validated symptom measures was compiled to assess all relevant gastrointestinal and diabetes items. Face and content validity were ascertained by expert review. One hundred and sixty-eight patients with diabetes mellitus completed the instrument, and reliability was evaluated by a test-re-test procedure 1 week later. Concurrent validity was evaluated by an independent physician interview (n = 33). Measures of glycaemic control (glycated haemoglobin and plasma glucose) were compared with self-reported glycaemic control on a five-point Likert scale in diabetic out-patients (n = 166).

RESULTS

The questionnaire had adequate face and content validity. There was good to excellent test-re-test reliability for the gastrointestinal and diabetes items (median kappa: 0.63 and 0.79, respectively); concurrent validity was good to excellent (median kappa: 0.47 and 0.65, respectively), except for the items assessing the severity of gastrointestinal symptoms. Both glycated haemoglobin (P < 0.0001) and plasma glucose (P = 0.005) correlated significantly with self-reported glycaemic control.

CONCLUSION

The Diabetes Bowel Symptom Questionnaire appears to be a useful measure of gastrointestinal symptoms and glycaemic control in diabetes mellitus, and should have applicability in epidemiological and clinical studies.

Aging and intestinal motility: a review of factors that affect intestinal motility in the aged

Normal aging is associated with significant changes in the function of most organs and tissues. In this regard, the gastrointestinal tract is no exception. The purpose of this review is to detail the important age-related changes in motor function of the various parts of the gastrointestinal tract and to highlight some of the important motility changes that may occur, either in relation to common age-related disorders, or as a result of certain drugs commonly prescribed in the aged. A major confounding factor in the interpretation of motor phenomena throughout the gastrointestinal tract in this age group is the frequent coexistence of neurological, endocrinological and other disease states, which may be independently associated with dysmotility. Overall, current data are insufficient to implicate normal aging as a cause of dysmotility in the elderly. Normal aging is associated with various changes in gastrointestinal motility, but the clinical significance of such changes remains unclear. More important is the impact of various age-related diseases on gastrointestinal motility in the elderly: for example, long-standing diabetes mellitus may reduce gastric emptying in up to 50% of patients; depression significantly prolongs whole-gut transit time; hypothyroidism may prolong oro-caecal transit time; and chronic renal failure is associated with impaired gastric emptying. In addition, various, frequently used drugs in the elderly cause disordered gastrointestinal motility. These drugs include anticholinergics, especially antidepressants with an anticholinergic effect, opioid analgesics and calcium antagonists.

Gastric emptying in diabetes: clinical significance and treatment

The outcome of recent studies has led to redefinition of concepts relating to the prevalence, pathogenesis and clinical significance of disordered gastric emptying in patients with diabetes mellitus. The use of scintigraphic techniques has established that gastric emptying is abnormally slow in approx. 30-50% of outpatients with long-standing Type 1 or Type 2 diabetes, although the magnitude of this delay is modest in many cases. Upper gastrointestinal symptoms occur frequently and affect quality of life adversely in patients with diabetes, although the relationship between symptoms and the rate of gastric emptying is weak. Acute changes in blood glucose concentration affect both gastric motor function and upper gastrointestinal symptoms. Gastric emptying is slower during hyperglycaemia when compared with euglycaemia and accelerated during hypoglycaemia. The blood glucose concentration may influence the response to prokinetic drugs. Conversely, the rate of gastric emptying is a major determinant of post-prandial glycaemic excursions in healthy subjects, as well as in Type 1 and Type 2 patients. A number of therapies currently in development are designed to improve post-prandial glycaemic control by modulating the rate of delivery of nutrients to the small intestine.

Physiology and pathology of the oesophagus in the elderly patient

In the 1960s, the term 'presbyoesophagus' was introduced for what were felt to be the characteristics of the oesophagus in old age. Since then a number of sophisticated studies using modern manometric, radiological, pH-metric or endoscopic equipment have been performed to better study this subject. Although results in some aspects are still contradictory, these studies have provided us with some more detailed information on the physiology of the ageing oesophagus. Beginning with an overview of what is currently known and discussed about age-induced physiological changes in oesophageal function, this review will then focus on specific problems of oesophagus-related diseases in the elderly. The main topics discussed will include presentation, diagnosis and treatment of primary and secondary motility disorders, oesophageal manifestations of neuromuscular and neurological disease, gastro-oesophageal reflux disease and oesophageal cancer in the elderly.

Cisapride improves gallbladder emptying in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

Gallbladder motor function is impaired in many patients with diabetes, and may be related to cholinergic nerve damage. Cisapride is a prokinetic drug of the gastrointestinal tract and acts by releasing acetylcholine from cholinergic nerve endings. The aim of this study was to determine the effect of cisapride on gallbladder emptying in patients with type 2 diabetes mellitus (DM).

METHODS

Gallbladder emptying and tests for autonomic neuropathy (AN) were performed in 27 patients with type 2 DM and in 10 healthy subjects. Gallbladder emptying was studied by using real-time ultrasonography after an overnight fast, and after the subjects received a breakfast that contained 2500 J. Gallbladder emptying was repeated after the treatment with cisapride (10 mg t.i.d.) for 1 week in all subjects.

RESULTS

Abnormal gallbladder emptying was present in 14 (51.9%) patients. The residual gallbladder volume (mean +/- SEM) was higher (9.3 +/- 1.0 vs 4.6 +/- 0.6; P = 0.002), and ejection fraction was lower (57.4 +/- 4.0 vs 74.2 +/- 2.4; P = 0.015) in diabetic patients than it was in healthy subjects. Cisapride produced a reduction in fasting and residual volumes (24.6 +/- 2.4 vs 20.0 +/- 1.4; P = 0.034 and 9.3 +/- 1.0 vs 5.9 +/- 1.1; P = 0.00003, respectively), and an improvement in ejection fraction (57.4 +/- 4.0 vs 72.6 +/- 3.8; P = 0.000007). The improvement in gallbladder emptying after cisapride therapy was confined to the patients with AN (n = 13) (57.3 +/- 5.4 vs 80.4 +/- 2.9; P = 0.0017), suggesting denervation supersensitivity with an upregulation of cholinergic receptors. There was no significant change in the ejection fraction in patients without AN (57.5 +/- 6.1 vs 65.4 +/- 6.5; P = NS). Sex, duration of diabetes, peripheral neuropathy, diabetic retinopathy and serum cholesterol level did not influence gallbladder emptying.

CONCLUSION

Impaired gallbladder emptying is common in patients with type 2 DM. Cisapride significantly improves gallbladder emptying in patients with autonomic neuropathy.

Predictors of delayed gastric emptying in diabetes

OBJECTIVE

To define the predictors of the rate of gastric emptying in patients with diabetes.

RESEARCH DESIGN AND METHODS

A total of 101 outpatients with diabetes (79 type 1 and 22 type 2) underwent measurements of gastric emptying of a solid/liquid meal (scintigraphy), upper gastrointestinal symptoms (questionnaire), glycemic control (blood glucose concentrations during gastric emptying measurement), and autonomic nerve function (cardiovascular reflexes).

RESULTS

The gastric emptying of solid and/or liquid was delayed in 66 (65%) patients. Solid (retention at 100 min 64 +/- 3.2 vs. 50.2 +/- 3.6%, P < 0.005) and liquid (retention at 100 min 22.7 +/- 1.7 vs. 16.0 +/- 1.8%, P < 0.001) gastric emptying was slower in women than in men. Of all upper gastrointestinal symptoms (including nausea and vomiting), only abdominal bloating/fullness was associated with slower gastric emptying (P < 0.005). A multiple regression analysis demonstrated that both abdominal bloating/fullness and female sex were predictors of slower gastric emptying of both solids and liquids.

CONCLUSIONS

We conclude that the presence of abdominal bloating/fullness but not any other upper gastrointestinal symptom is associated with diabetic gastroparesis and that gastric emptying is slower in diabetic women than in diabetic men.

Relationship between esophageal dysfunction and neuropathy in diabetic patients

OBJECTIVE

Few studies have compared esophageal dysfunction with diabetic neuropathy, and their relationship is not yet clear. The aim of this study was to investigate the relationship between esophageal function and diabetic neuropathy.

METHODS

A total of 59 patients with type 2 diabetes were studied. Long-term ambulatory esophageal pH and motility monitoring were performed. The motor nerve conduction velocity (MCV) and coefficient of variation of R-R intervals (CVRR) were also examined.

RESULTS

The 59 patients were classified into four groups: group 1 consisted of patients with both diabetic autonomic neuropathy (DAN) and diabetic motor neuropathy (DMN), group 2 had DMN alone, group 3 had DAN alone, and group 4 had neither DAN nor DMN. In pH monitoring, differences were observed among the four groups in DeMeester score, total number of acid reflux episodes, and % time pH < 4 (p < 0.05). A correlation was observed between % time pH < 4 and MCV; however, no correlation with CVRR was observed. In motility monitoring, differences were observed among the four groups in amplitude of peristaltic waves (p < 0.001), rising velocity of peristaltic waves (p < 0.01), and percentage of effective peristalsis (p < 0.01). A correlation was observed between esophageal motility and MCV; however, no correlation with CVRR was observed.

CONCLUSIONS

Esophageal motility disorder and abnormal acid reflux were related to DMN in diabetic patients. A significant correlation was found between esophageal dysfunction and MCV. However, no significant correlation was found between esophageal dysfunction and CVRR.

Psychological distress is linked to gastrointestinal symptoms in diabetes mellitus

OBJECTIVE

Gastrointestinal (GI) symptoms are common in patients with long-standing diabetes mellitus, but the pathogenesis is controversial. We aimed to determine if GI symptoms are linked to psychological distress in diabetes.

METHODS

A consecutive sample of outpatients with diabetes mellitus (n = 209) and a random sample of community diabetics (n = 892) completed a validated questionnaire measuring GI symptoms, the Hospital Anxiety and Depression (HAD) Scale for anxiety and depression, and the Eysenck short neuroticism scale.

RESULTS

Overall, 42% reported one or more GI symptoms: bloating, abdominal pain, loose stools, and urgency were most common. The mean HAD and neuroticism scores were significantly higher for most GI symptoms (11 of 14, all p < 0.05), and a dose-response relationship was observed. GI symptoms were, in general, approximately twice as frequent in cases with anxiety or depression (HAD > or = 11). Anxiety, depression, and neuroticism were each independently associated with the number of GI symptoms, adjusting for age, gender, duration and type of diabetes, and self-reported glycemic control.

CONCLUSIONS

Increased levels of state anxiety and depression and neuroticism are associated with upper and lower GI symptoms in diabetes mellitus. It is uncertain whether psychological distress is causally linked to symptoms, or whether GI symptoms per se increase levels of anxiety and depression.

Helicobacter pylori infection is not associated with diabetes mellitus, nor with upper gastrointestinal symptoms in diabetes mellitus

OBJECTIVE

The association between Helicobacter pylori (H. pylori) infection and diabetes mellitus is controversial. We aimed to determine the prevalence of H. pylori infection in patients with diabetes and nondiabetic controls, and assess whether H. pylori infection was associated with upper gastrointestinal (GI) symptoms in diabetes mellitus.

METHODS

A total of 429 patients with type 1 (n = 49) or type 2 (n = 380) diabetes mellitus (48.6% women, mean age 60.7 yr) and 170 nondiabetic controls (34.7% women, mean age 60.4 yr) were evaluated. All subjects completed a validated questionnaire (the Diabetes Bowel Symptom Questionnaire) to determine upper GI symptoms, and a blood sample was tested for H. pylori infection using a validated ELISA kit (sensitivity 96%, specificity 94%).

RESULTS

Seroprevalence of H. pylori was 33% and 32%, respectively, in patients with diabetes and controls (NS). In both groups, the seroprevalence was significantly higher in men than in women; 39% vs 25% (p = 0.002) in diabetic patients, and 40% vs 20% (p = 0.01) in controls. Patients with diabetes had a significantly higher prevalence of early satiety (OR = 2.30), fullness (OR = 3.15), and bloating (OR = 1.50) compared with controls. Upper GI symptoms were present in 49% of H. pylori-positive and 53% of H. pylori-negative patients with diabetes (OR = 0.87, 95% CI 0.58-1.31, p = 0.56). H. pylori infection was also not associated with any of the individual upper GI symptoms before or after adjustment for potential confounding factors. However, patient age and female gender were identified as independent risk factors for upper GI symptoms. Smoking was a risk factor for bloating and early satiety.

CONCLUSIONS

H. pylori infection appears not to be associated with diabetes mellitus or upper GI symptoms in diabetes mellitus.

Esophageal motor disorders

Motor dysfunction is responsible for symptomatic illnesses both in the proximal skeletal muscle region and in the distal smooth muscle esophagus. Practical methods for diagnosing and treating oropharyngeal dysphagia continue to reach consensus. Achalasia, the most significant of the distal motor disorders, is of investigative interest because of the expanded armamentarium of treatment options. Minimally invasive surgical methods have taken an important foothold as a primary treatment of this disorder. Appreciation is growing for sensory dysfunction that accompanies distal motor disorders. Such dysfunction may help explain the observed discrepancies between symptoms and measurable motility abnormality.