Functional gastric impairment in carcinoma of the pancreas

Effect of Mirtazapine on Gastric Emptying in Patients with Cancer-associated Anorexia

BACKGROUND/AIMS

The tetracyclic antidepressant mirtazapine is widely used in cancer patients suffering from anorexia. Although it is known to restore appetite, the exact mechanism remains unknown. The aim of the study was to evaluate if mirtazapine has any effect on gastric emptying in patients suffering from cancer-related anorexia.

MATERIALS AND METHODS

Solid-meal gastric-emptying study using radiolabeled meal was performed in 28 patients suffering from cancer anorexia once at baseline and repeated after 15 days of mirtazapine therapy.

RESULTS

At baseline, only 7 (25%) patients had normal gastric motility (emptying >70% at 3 h postingestion) whereas after treatment, 18 (64.2%) patients achieved this limit. Mean % gastric emptying increased from 55.2% ±21.0% to 68.9% ±21.3% (P < 0.001). Mean gastric emptying time (t_1/2) before intervention was 314.7 ± 421.0 min which decreased to 116.0 ± 106.7 min after intervention. Results were further analyzed by dividing the patients into two groups based on baseline gastric-emptying study. Group A (normal gastric emptying) consisted of seven patients, mean % gastric emptying at baseline and postintervention was 75.0% ±5.25% and 87.57% ±5.94%, respectively (P < 0.018). Group B (delayed gastric emptying) consisted of 21 patients, mean % gastric emptying at baseline and postintervention was 48.71% ±18.82% and 62.76% ±16.86%, respectively (P < 0.001).

CONCLUSION

Mirtazapine significantly improves gastric emptying in patients of prostate and breast cancer suffering from cancer-associated anorexia.

Diagnostic and therapeutic approach to pancreatic cancer-associated gastroparesis: literature review and our experience

BACKGROUND

Patients with unresectable pancreatic carcinoma often present with early satiety, nausea, and vomiting without evidence of mechanical obstruction, mucosal disease, or metabolic abnormality. This condition is well described in the literature and is thought to result from pancreatic cancer-associated gastroparesis (PCAG). No clinical guideline is available for diagnosing and managing this rare disease.

OBJECTIVE

To propose an algorithm for diagnosing and managing patients with PCAG based on a literature review and our clinical experience.

METHODS

A comprehensive review was conducted of literature on the subject from 1966 to 2005, and retrospective analysis was performed for patients with PCAG who presented to the University of Iowa Hospitals and Clinics (Iowa City, IA, USA) during the period 1998-2005.

RESULTS

Literature on an optimal diagnostic and therapeutic approach to PCAG is lacking. There are only two small case series and one case report regarding management of PCAG. Extensive chart review only identified two patients who met the diagnostic criteria of PCAG. We propose performing routine upper GI series and esophagogastroduodenoscopy on all patients with pancreatic cancer who present with nausea and vomiting, to rule out obstruction and mucosal disease. If there is no obstruction or mucosal disease, we do not recommend further workup. Prokinetic agents are the first line therapy for PCAG. In refractory cases, percutaneous endoscopic gastrostomy with jejunal extension may be considered in selected patients who respond to nasojejunal decompression.

CONCLUSIONS

We propose a time-effective and useful strategy for diagnosing and managing patients with PCAG. We also define the diagnostic end-point for this difficult to manage condition.

Delayed gastric emptying in patients with caustic ingestion

INTRODUCTION

Patients with caustic ingestion may develop esophageal and/or gastric cicatrization.

OBJECTIVE

Scintigraphic assessment of liquid gastric emptying time in patients with caustic ingestion.

MATERIALS AND METHODS

Consecutive patients with caustic-induced esophageal cicatrization attending the gastroenterology clinic of our institute were studied (patients with age >or=60 years, earlier gastric surgery, vagotomy, peptic ulcer disease, diabetes, systemic sclerosis, and those on gastrointestinal motility-altering drugs were excluded). Gastric emptying time was assessed by radionuclide scintigraphy (ingestion of 200 ml mango juice containing of 18.5 MBq 99mTc sulfur colloid after an overnight fast by static imaging in anterior and posterior projections in supine posture at 10 min intervals each for 1 h). A time-activity curve was generated and gastric half-emptying time (GET 1/2) was calculated. Results were compared with GET 1/2 values estimated for normal individuals in our laboratory (mean+/-2 SD). The emptying study protocol for normal individuals was the same as in patients.

RESULTS

Twenty patients (males 10) median age 32 years, 16 with acid ingestion and four with alkali ingestion, were studied. No patient had symptoms suggestive of gastric outlet obstruction or gastroparesis. Eight patients had evidence of gastric cicatrization in the form of straightening of the lesser curvature and pulling of incisura and duodenal bulb medially and loss of parallelism between the fundus and left dome of diaphragm. Gastric distensibility was however normal in them. As compared with values for normal controls (25+/-9 min), GET 1/2 was significantly prolonged in the study group as a whole (53.2+/-27.77 min, P=0.000). No significant difference was observed between different age groups, sex, or type of caustic agent consumed. GET 1/2 differed in patients (n=10) with stricture involving lower-third of esophagus (72.2+/-27.67 min) when compared with those (n=10) who had a stricture involving upper and/or middle-third of esophagus (34.3+/-8.02 min, P=0.000). In the former, GET 1/2 was maximally prolonged in patients (n=6) with involvement of the lower esophagus and reduced stomach capacity (84.6+/-27.03 min), followed by patients (n=4) with lower esophageal involvement with normal stomach capacity (53.7+/-17.41 min), but the difference did not reach statistical significance (P=0.078). Patients (n=10) without lower esophageal involvement did not have statistically significant altered GET 1/2 compared with normal controls (P>0.05).

CONCLUSION

Our results show that patients with caustic ingestion have prolonged liquid gastric emptying even in the absence of any gastric symptoms.

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

This literature review and the recommendations herein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on May 16, 2004, and by the AGA Governing Board on September 23, 2004.

Signs and symptoms of pancreatic cancer: a population-based case-control study in the San Francisco Bay area

BACKGROUND & AIMS

Pancreatic cancer usually does not cause definitive symptoms until survival is severely compromised. Prevention and early detection are urgently needed. Our aim was to collect and analyze data in a population-based study on signs and symptoms of disease reported by patients with pancreatic cancer and control participants to contribute to earlier detection and better prognosis.

METHODS

A supplemental symptoms questionnaire was administered to 120 consecutive patients with pancreatic cancer who were part of a larger population-based case-control study conducted in the San Francisco Bay Area between 1994 and 2001. One hundred eighty age- and sex-matched population-based control participants also were queried about the same symptoms reported by at least 5% of patients with pancreatic cancer.

RESULTS

Most signs and symptoms occurred within 3 years before diagnosis with pancreatic cancer (cases) and interview (controls). Many signs and symptoms were more likely to have been reported by patients compared with control participants and included appetite loss (odds ratio [OR], 41; 95% confidence interval [CI], 14-120), pale stools (OR, 31; 95% CI, 7.3-134), abdominal pain (OR, 30; 95% CI, 9.1-101), jaundice (OR, 20; 95% CI, 8.0-49), unusual bloating (OR, 20; 95% CI, 5.9-67), unusual belching (OR, 17; 95% CI, 3.9-75), weight loss (OR, 12; 95% CI, 5.2-28), dark urine (OR, 10; 95% CI, 2.9-36), constipation (OR, 7.3; 95% CI, 2.0-26), diarrhea (OR, 5.6; 95% CI, 2.0-16), itching (OR, 5.0; 95% CI, 2.3-11), fatigue (OR, 3.8; 95% CI, 2.0-7.3), altered ability to sleep (OR, 2.9; 95% CI, 1.3-6.3), and unusual heartburn (OR, 2.3; 95% CI, 1.2-4.5).

CONCLUSIONS

Our results show that signs and symptoms likely to be indicators of pancreatic cancer occur substantially more often among patients with pancreatic cancer than among population-based controls. The large magnitude of the risk estimates indicate that common gastrointestinal symptoms may assist clinicians in earlier diagnosis of pancreatic cancer and perhaps affect survival.

Diagnostic and therapeutic approach to pancreatic cancer

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all GI-related carcinomas. It usually presents late in its course. The clinical features are discussed, with emphasis on those that allow early detection of the disease, as well as a review of diagnostic methods and pre- and perioperative staging, which will allow the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance our therapeutic approach to this aggressive cancer.

Diagnostic approach to pancreatic cancer

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all gastrointestinal-related carcinomas. It usually presents late in its course. In this article, the authors discuss the clinical features of pancreatic cancer, with emphasis on those that allow early detection of the disease. They also review diagnostic methods and preoperative and perioperative staging that allows the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance the therapeutic approach to this aggressive cancer.

Gastroparesis after celiac plexus block

A 36-yr-old woman with metastatic mucinous cystadenocarcinoma of the pancreas underwent neurolytic celiac plexus block with 100% ethanol and 0.5% bupivacaine for intractable back pain. Several hours after the procedure she developed severe nausea and vomiting, which persisted for days despite cessation of opioid analgesics, and administration of intravenous metoclopramide and ondansetron. Both esophagogastroduodenoscopy and barium examination of the stomach and small intestine showed excess gastric fluid but no evidence of mechanical obstruction. A radionuclide study revealed delayed gastric emptying of solids. Treatment with oral cisapride 10 mg p.o. q.i.d. resulted in considerable symptomatic improvement. We document the first reported case of gastroparesis after celiac plexus block and discuss possible etiological mechanisms.

Randomized trial of three types of gastrojejunostomy in unresectable periampullary cancer

BACKGROUND

A gastrojejunostomy with duodenal partition was designed to clarify whether so-called circulus vomiting exists and, if so, its clinical significance, by comparing it with two other types of gastrojejunostomy commonly used for gastric bypass in unresectable periampullary cancer.

METHODS

Forty-five patients with unresectable periampullary cancer complicated by gastric outlet obstruction (GOO) were recruited into this study between May 1992 and November 1995. They were randomized to receive one of the three types of gastrojejunostomy. The anastomosis in type I gastrojejunostomy was performed at the jejunum 20 cm distal to the ligament of Treitz. Type II was similar to type I except that in type II a duodenum partition was done by linear stapler 1 cm beyond the pylorus. Type III gastrojejunostomy was performed at the Roux-limb jejunum 60 cm distal to biliojejunostomy.

RESULTS

"Food reentry" was noted in three (21%) of the type I patients, as determined by upper gastrointestinal (UGI) study. Of the three, one patient had severe circulus vomiting, one had anorexia, and one had no major symptoms. When patients were evaluated immediately after oral diet intake resumed, the incidence (27%) of clinical GOO symptoms and mean value of gastric emptying time (GET1/2, 118.1 +/- 39.2 min) were significantly lower in type II patients than in types I and III patients. When evaluated I month after operation, the incidence (7% and 17%, respectively) of clinical symptoms of GOO and mean value of GET1/2 (42.0 +/- 23.0 and 35.6 +/- 5.4 min, respectively) were significantly lower in both type II and type III patients than in type I patients. The type II patients resumed oral diet after operation 3.5 days earlier than type I patients, p < 0.05.

CONCLUSIONS

Circulus vomiting induced by food reentry does exist if the gastrojejunostomy is performed as the type I gastrojejunostomy in this study. The newly designed type II gastrojejunostomy with duodenal partition is an easy, safe, and effective gastric bypass and avoids the problem of food reentry.