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Lupoli R, Creanza A, Griffo E, Nardone G, Rocco A, Bozzetto L, Annuzzi G, Riccardi G, Capaldo B. Gastric Emptying Impacts the Timing of Meal Glucose Peak in Subjects With Uncomplicated Type 1 Diabetes. J Clin Endocrinol Metab 2018; 103:2269-2276. [PMID: 29659867 DOI: 10.1210/jc.2017-02811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/06/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT Diabetes mellitus is associated with gastrointestinal (GI) motility dysfunction, ranging from delayed to accelerated gastric emptying (GE). OBJECTIVE To evaluate GE in patients with type 1 diabetes mellitus (T1DM) without chronic complications and to investigate its relation with postprandial glucose and GI hormone responses. DESIGN Cross-sectional study. SETTING/PARTICIPANTS Forty-two patients with T1DM free of chronic complications referred to Federico II University and 31 healthy controls similar for age, sex, and body mass index. INTERVENTIONS/MAIN OUTCOME MEASURES GE was assessed by using the 13C-octanoate breath test with a standardized solid meal. During the meal, plasma glucose, ghrelin, and glucagon-like peptide 1 (GLP-1) responses were assessed, and GI symptoms were evaluated by a specific questionnaire. RESULTS Patients with T1DM showed a significantly slower GE half-emptying time (GE t1/2) (113 ± 34 minutes) than did controls (89 ± 17 minutes; P < 0.001). Thirty-six percent of T1DM showed a delayed GE (t1/2 > 120 minutes), whereas all controls showed a normal GE. When patients with T1DM were stratified according to GE t1/2, postmeal glucose response was significantly different between those with delayed and those with normal GE (P = 0.013). In particular, patients with T1DM and delayed GE showed a significantly longer mean time to peak glucose than did patients with normal GE (P = 0.004). In addition, GE t1/2 was an independent predictor of the time to peak glucose (β = 0.329; P = 0.025). GLP-1 and ghrelin responses to the test meal, as well as the prevalence of GI symptoms, were similar between patients with T1DM and controls and between patients with T1DM with normal GE and those with delayed GE. CONCLUSIONS Delayed GE time is associated with a longer time to peak glucose. GE evaluation could be useful for individualizing the timing of preprandial insulin bolus in patients with T1DM.
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Affiliation(s)
- Roberta Lupoli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Annalisa Creanza
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Ettore Griffo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Gerardo Nardone
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Lutgarda Bozzetto
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Giovanni Annuzzi
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Gabriele Riccardi
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Brunella Capaldo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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2
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Rajeswaran C, Dawson A, Bonney G, Oxynos C, Nicholson VL, Gilbey SG. Intussusception as a gastrointestinal complication of diabetes: case report and literature review. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/14746514040040060801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This is the first reported case of intussusception in a patient with type 1 diabetes mellitus complicated by gastroparesis and autonomic neuropathy. Literature on the reported cases of intussusception in patients with diabetes, its aetiopathology and possible association with gastroparesis has been systematically reviewed following a Medline database search (1951 to June 2003) Intussusception should be considered in the differential diagnosis of gastrointestinal symptoms in diabetic patients presenting with hyperglycaemia.
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Affiliation(s)
| | - Alison Dawson
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Glen Bonney
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Costas Oxynos
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
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3
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Li S, Chen JDZ. Decreased L-type calcium current in antral smooth muscle cells of STZ-induced diabetic rats. Neurogastroenterol Motil 2014; 26:971-9. [PMID: 24758401 DOI: 10.1111/nmo.12351] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 03/28/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Diabetic gastroparesis (delayed gastric emptying) is associated with antral hypomotility. L-type Ca(2+) channels play an important role in generation of action potentials and activation of contractions. This study was designed to investigate if the function of the L-type Ca(2+) channels of antral circular smooth muscle cells (SMCs) is impaired in streptozotocin (STZ)-induced diabetic rats. METHODS Eight weeks after the injection of STZ or vehicle, whole-cell patch clamp was used to record Ca(2+) currents, and isometric tension recording was used to measure Ca(2+) influx-induced contractions in circular muscle strips. Solid gastric emptying was measured in diabetic and control rats. Protein expression of Ca(2+) αlC-subunit in antral smooth muscles was compared between diabetic and control rats. KEY RESULTS (1) Solid gastric emptying, independent of age or bodyweight, was slower in the diabetic rats, even after acute correction of hyperglycemia. (2) Verapamil, a potent calcium channel blocker, dose dependently reduced solid gastric emptying in normal rats. (3) Current density of L-type Ca(2+) channel at 10 mV in antral circular SMCs was significantly decreased in the diabetic rats (-9.8 ± 0.7 pA/pF vs -15.9 ± 1.0 pA/pF in control, p < 0.001). However, protein expression of the Ca(2+) channel in antral muscles did not differ between diabetic and control rats. (4) Contractile responses to 1 and 3 mM [Ca(2+) ] were significantly reduced in the diabetic antral circular muscle strips, indicative of reduced Ca(2+) influx. CONCLUSIONS & INFERENCES These data suggested that the decreased L-type Ca(2+) current in antral SMCs may contribute to antral hypomotility in STZ-induced diabetic rats.
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Affiliation(s)
- S Li
- Veterans Research and Education Foundation, VA Medical Center, Oklahoma City, OK, USA
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4
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Bilku DK, Dennison AR, Hall TC, Metcalfe MS, Garcea G. Role of preoperative carbohydrate loading: a systematic review. Ann R Coll Surg Engl 2014; 96:15-22. [PMID: 24417824 PMCID: PMC5137663 DOI: 10.1308/003588414x13824511650614] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Surgical stress in the presence of fasting worsens the catabolic state, causes insulin resistance and may delay recovery. Carbohydrate rich drinks given preoperatively may ameliorate these deleterious effects. A systematic review was undertaken to analyse the effect of preoperative carbohydrate loading on insulin resistance, gastric emptying, gastric acidity, patient wellbeing, immunity and nutrition following surgery. METHODS All studies identified through PubMed until September 2011 were included. References were cross-checked to ensure capture of cited pertinent articles. RESULTS Overall, 17 randomised controlled trials with a total of 1,445 patients who met the inclusion criteria were identified. Preoperative carbohydrate drinks significantly improved insulin resistance and indices of patient comfort following surgery, especially hunger, thirst, malaise, anxiety and nausea. No definite conclusions could be made regarding preservation of muscle mass. Following ingestion of carbohydrate drinks, no adverse events such as apparent or proven aspiration during or after surgery were reported. CONCLUSIONS Administration of oral carbohydrate drinks before surgery is probably safe and may have a positive influence on a wide range of perioperative markers of clinical outcome. Further studies are required to determine its cost effectiveness.
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Affiliation(s)
- D K Bilku
- University Hospitals of Leicester NHS Trust, UK.
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5
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Oida T, Mimatsu K, Kano H, Kawasaki A, Kuboi Y, Fukino N, Kida K, Amano S. Delayed gastric emptying after pancreaticoduodenectomy in diabetes mellitus. ANZ J Surg 2012; 83:973-7. [PMID: 22943798 DOI: 10.1111/j.1445-2197.2012.06242.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2012] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) is one of the most troublesome complications of pancreaticoduodenectomy (PD). Diabetes mellitus (DM) is one of the risk factors for pancreatic cancer. Moreover, several studies have shown that diabetic patients tend to have a high incidence of upper gastrointestinal symptoms such as nausea, vomiting and DGE. Here, we compared the influence of DM on the incidence of DGE after PD. METHODS We retrospectively analysed 67 cases of PD with pancreaticogastrostomy. These patients were categorized into the following two groups: the DM group included patients with DM, and the NDM group included patients without DM. The incidence of DGE was determined and compared between the two groups. RESULTS In the DM group, 76.5%, 5.9% and 17.6% of the subjects developed classes A, B and C DGE, respectively; the corresponding values in the NDM group were 58%, 22%, and 20%. The incidence of DGE did not differ between the two groups (P < 0.2771). CONCLUSIONS DM does not accelerate DGE in patients who have undergone PD. Preoperative DM does not appear to play a key role in post-operative DGE after PD.
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Affiliation(s)
- Takatsugu Oida
- Department of Surgery, Social Insurance Yokohama Central Hospital, Naka-ku, Yokohama, Japan
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6
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Abstract
BACKGROUND Previous studies have clearly demonstrated the delayed gastric emptying of solid meals in diabetics, whereas their gastric myoelectrical activity, which primarily determines gastric motility, has not yet been fully confirmed. GOALS This study aimed to clarify the characteristics and potential predictors of gastric myoelectrical activity in type 2 diabetics. STUDY Twenty-eight diabetics and 18 healthy controls participated. Duodenal biopsy sample was used for reverse transcription-polymerase chain reaction to evaluate cholecystokinin and motilin mRNA contents. Electrogastrography was performed before and after the test meal, and was assessed in terms of dominant frequency; dominant frequency instability coefficient; and the percentage of bradygastria, normogastria, and tachygastria. RESULTS Over the entire recording period, dominant frequency was significantly lower, and dominant frequency instability coefficient and the percentage of bradygastria were significantly higher in diabetics than in controls. In diabetics, the multiple regression analysis demonstrated that dominant frequency instability coefficient and the percentage of tachygastria in the fasting period were dependent on fasting plasma glucose level and HbA1c, respectively. Moreover, dominant frequency over the entire period and the postprandial percentage of bradygastria were significantly associated with body mass index; the fasting percentage of bradygastria and postprandial dominant frequency instability coefficient were associated with fasting serum leptin level; the postprandial percentage of bradygastria was also associated with cholecystokinin mRNA content. CONCLUSIONS Gastric myoelectrical activity in type 2 diabetics is impaired on dominant frequency, dominant frequency instability coefficient, and the percentage of bradygastria and predicted by body mass index, fasting serum leptin level, and cholecystokinin mRNA content besides the glycemic status.
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7
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Jung HK, Choung RS, Locke GR, Schleck CD, Zinsmeister AR, Szarka LA, Mullan B, Talley NJ. The incidence, prevalence, and outcomes of patients with gastroparesis in Olmsted County, Minnesota, from 1996 to 2006. Gastroenterology 2009; 136:1225-33. [PMID: 19249393 PMCID: PMC2705939 DOI: 10.1053/j.gastro.2008.12.047] [Citation(s) in RCA: 372] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 12/12/2008] [Accepted: 12/18/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The epidemiology of gastroparesis is unknown. We aimed to determine the incidence, prevalence, and outcome of gastroparesis in the community. METHODS Using the Rochester Epidemiology Project, a medical records linkage system in Olmsted County, Minnesota, we identified county residents with potential gastroparesis. The complete medical records were reviewed by a gastroenterologist. Three diagnostic definitions were used: (1) definite gastroparesis, delayed gastric emptying by standard scintigraphy and typical symptoms for more than 3 months; (2) probable gastroparesis, typical symptoms and food retention on endoscopy or upper gastrointestinal study; (3) possible gastroparesis, typical symptoms alone or delayed gastric emptying by scintigraphy without gastrointestinal symptoms. Poisson regression was used to assess the association of incidence rates with age, sex, and calendar period. RESULTS Among 3604 potential cases of gastroparesis, 83 met diagnostic criteria for definite gastroparesis, 127 definite plus probable gastroparesis, and 222 any of the 3 definitions of gastroparesis. The age-adjusted (to the 2000 US white population) incidence per 100,000 person-years of definite gastroparesis for the years 1996-2006 was 2.4 (95% confidence interval [CI], 1.2-3.8) for men and 9.8 (95% CI, 7.5-12.1) for women. The age-adjusted prevalence of definite gastroparesis per 100,000 persons on January 1, 2007, was 9.6 (95% CI, 1.8-17.4) for men and 37.8 (95% CI, 23.3-52.4) for women. Overall survival was significantly lower than the age- and sex-specific expected survival computed from the Minnesota white population (P<.05). CONCLUSIONS Gastroparesis is an uncommon condition in the community but is associated with a poor outcome.
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Affiliation(s)
- Hye-kyung Jung
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - Rok Seon Choung
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - G. Richard Locke
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Cathy D. Schleck
- Department of Health Sciences Research and Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Alan R. Zinsmeister
- Department of Health Sciences Research and Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Lawrence A. Szarka
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Brian Mullan
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas J. Talley
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA, Department OF Medicine, Mayo Clinic Florida
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Gustafsson UO, Nygren J, Thorell A, Soop M, Hellström PM, Ljungqvist O, Hagström-Toft E. Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol Scand 2008; 52:946-51. [PMID: 18331374 DOI: 10.1111/j.1399-6576.2008.01599.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Post-operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery. Pre-operative oral carbohydrate loading (CHO) reduces post-operative insulin resistance with a reduced risk of hyperglycaemia during post-operative nutrition. Insulin-resistant diabetic patients have not been given CHO because the effects on pre-operative glycaemia and gastric emptying are unknown. METHODS Twenty-five patients (45-73 years) with type 2 diabetes [glycated haemoglobin (HbA1c) 6.2 +/- 0.2%, mean +/- SEM] and 10 healthy control subjects (45-72 years) were studied. A carbohydrate-rich drink (400 ml, 12.5%) was given with paracetamol 1.5 g for determination of gastric emptying. RESULTS Peak glucose was higher in diabetic patients than in healthy subjects (13.4 +/- 0.5 vs. 7.6 +/- 0.5 mM; P<0.01) and occurred later after intake (60 vs. 30 min; P<0.01). Glucose concentrations were back to baseline at 180 vs. 120 min in diabetic patients and healthy subjects, respectively (P<0.01). At 120 min, 10.9 +/- 0.7% and 13.3 +/- 1.2% of paracetamol remained in the stomach in diabetic patients and healthy, subjects respectively. Gastric half-emptying time (T50) occurred at 49.8 +/- 2.2 min in diabetics and at 58.6 +/- 3.7 min in healthy subjects (P<0.05). Neither peak glucose, glucose at 180 min, gastric T50, nor retention at 120 min differed between insulin (HbA1c 6.8 +/- 0.7%)- and non-insulin-treated (HbA1c 5.6 +/- 0.4%) patients. CONCLUSIONS Type 2 diabetic patients showed no signs of delayed gastric emptying, suggesting that a carbohydrate-rich drink may be safely administrated 180 min before anaesthesia without risk of hyperglycaemia or aspiration pre-operatively.
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Affiliation(s)
- U O Gustafsson
- Department of Clinical Science, Intervention and Technology, Centre for Gastrointestinal Disease, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden
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9
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Punkkinen J, Färkkilä M, Mätzke S, Korppi-Tommola T, Sane T, Piirilä P, Koskenpato J. Upper abdominal symptoms in patients with Type 1 diabetes: unrelated to impairment in gastric emptying caused by autonomic neuropathy. Diabet Med 2008; 25:570-7. [PMID: 18445170 DOI: 10.1111/j.1464-5491.2008.02428.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS Diabetic gastroparesis is a common condition occurring in some 30-50% of patients with long-term diabetes. Some studies have found a relationship between autonomic neuropathy and diabetic gastroparesis. In addition to autonomic neuropathy, acute changes in plasma glucose concentration can also affect gastric emptying. The objective was to examine the relationship between autonomic nerve function, glucose concentration, gastric emptying, and upper abdominal symptoms in Type 1 diabetic patients. METHODS Gastric emptying of solids and liquids was measured with scintigraphy in 27 patients with longstanding Type 1 diabetes with upper abdominal symptoms. Autonomic nerve function was examined by standardized cardiovascular tests, and plasma glucose concentrations were measured during scintigraphy. Severity of abdominal symptoms and quality of life were explored by validated questionnaires. RESULTS Seven patients (26%) had delayed gastric emptying of solids and three (11%) of liquids. Mean gastric half-emptying time of solids was 128 +/- 116 min and of liquids 42 +/- 30 min. Of the 26 patients undergoing tests, 16 (62%) had autonomic nerve dysfunction. Autonomic neuropathy score (1.6 +/- 1.7) correlated positively with the gastric emptying rate of solids (P = 0.006), a rate unrelated to symptom scores or plasma glucose concentrations during scintigraphy. Quality of life in patients with abdominal symptoms was lower than in the normal Finnish population. CONCLUSIONS Impaired gastric emptying of solids in patients with Type 1 diabetes is related to autonomic neuropathy, but not to actual glycaemic control. The upper abdominal symptoms observed in these patients cannot be explained, however, by impaired gastric emptying.
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Affiliation(s)
- J Punkkinen
- Department of Gastroenterology, Helsinki University Central Hospital, Helsinki, Finland.
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10
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Abstract
Gastrointestinal (GI) sensory-motor abnormalities are common in patients with diabetes mellitus and may involve any part of the GI tract. Abnormalities are frequently sub-clinical, and fortunately only rarely do severe and life-threatening problems occur. The pathogenesis of abnormal upper GI sensory-motor function in diabetes is incompletely understood and is most likely multi-factorial of origin. Diabetic autonomic neuropathy as well as acute suboptimal control of diabetes has been shown to impair GI motor and sensory function. Morphological and biomechanical remodeling of the GI wall develops during the duration of diabetes, and may contribute to motor and sensory dysfunction. In this review sensory and motility disorders of the upper GI tract in diabetes is discussed; and the morphological changes and biomechanical remodeling related to the sensory-motor dysfunction is also addressed.
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Affiliation(s)
- Jingbo Zhao
- Center of Excellence in Visceral Biomechanics and Pain, the Research Building room 404, Aalborg Hospital, Sdr. Skovvej 15, DK-9000 Aalborg, Denmark.
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11
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LePard KJ. Choline acetyltransferase and inducible nitric oxide synthase are increased in myenteric plexus of diabetic guinea pig. Auton Neurosci 2005; 118:12-24. [PMID: 15795174 DOI: 10.1016/j.autneu.2004.12.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Revised: 12/08/2004] [Accepted: 12/11/2004] [Indexed: 12/16/2022]
Abstract
Alterations in enzymes in myenteric neurons from ileum were investigated in guinea pigs treated with either the pancreatic beta cell toxin streptozotocin or vehicle. After 5-6 weeks, expressions of choline acetyltransferase, neuronal nitric oxide synthase and inducible nitric oxide synthase were determined in longitudinal and myenteric plexus preparations using indirect immunohistochemistry. In ileum from streptozotocin-treated animals, the density of choline acetyltransferase-immunoreactive nerve fibers within the tertiary plexus and the percent total myenteric neurons expressing inducible nitric oxide synthase were increased, but the percent total myenteric neurons expressing neuronal nitric oxide synthase was not changed. Diabetes resulted in selective alterations in myenteric neurons including an increased density of cholinergic tertiary fibers and percentage of neurons expressing the inducible isoform of nitric oxide synthase. These adaptive changes by myenteric neurons to diabetes may contribute to gastrointestinal dysfunctions associated with diabetes.
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Affiliation(s)
- Kathy J LePard
- Department of Physiology, Chicago College of Osteopathic Medicine, Midwestern University, 555 West 31st Street, Downers Grove, IL 60515, USA.
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12
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Abstract
Diabetic gastroparesis is a common and debilitating condition affecting millions of patients with diabetes mellitus worldwide. Although gastroparesis in diabetes has been known clinically for more than 50 years, treatment options remain very limited. Until recently, the scientific literature has offered few clues regarding the precise aetiology of gastric dysfunction in diabetes.Up to 50% of patients with diabetes may experience postprandial abdominal pain, nausea, vomiting and bloating secondary to gastric dysfunction. There is no clear association between length of disease and the onset of delayed gastric emptying. Gastroparesis affects both type 1 (insulin dependent) and type 2 (non- insulin dependent) forms of diabetes. Diagnosis requires identifying the proper symptom complex, while excluding other entities (peptic ulcer disease, rheumatological diseases, medication effects). The diagnosis of gastroparesis may be confirmed by demonstrating gastric emptying delay during a 4-hour scintigraphic study. Treatment options are limited and rely on dietary modifications, judicious use of available pharmacological agents, and occasionally surgical or endoscopic placement of gastrostomies or jejunostomies. Gastric pacing offers promise for patients with medically refractory gastroparesis but awaits further investigation. Current pharmacological agents for treating gastroparesis include metoclopramide, erythromycin, cisapride (only available via a company-sponsored programme) and domperidone (not US FDA approved). All of these drugs act as promotility agents that increase the number or the intensity of gastric contractions. These medications are not uniformly effective and all have adverse effects that limit their use. Cisapride has been removed from the open market as a result of over 200 reported cases of cardiac toxicity attributed to its use. Unfortunately, there is a paucity of clinical studies that clearly define the efficacy of these agents in diabetic gastroparesis and there are no studies that compare these drugs to each other. The molecular pathophysiology of diabetic gastroparesis is unknown, limiting the development of rational therapies. New studies, primarily in animals, point to a defect in the enteric nervous system as a major molecular cause of abnormal gastric motility in diabetes. This defect is characterised by a loss of nitric oxide signals from nerves to muscles in the gut resulting in delayed gastric emptying. Novel therapies designed to augment nitric oxide signalling are being studied.
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Affiliation(s)
- D Scott Smith
- Department of Medicine, Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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13
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Smith DS, Ferris CD. Current concepts in diabetic gastroparesis. Drugs 2003; 61:281-7. [PMID: 19892019 DOI: 10.1016/j.phrs.2009.10.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Revised: 10/23/2009] [Accepted: 10/23/2009] [Indexed: 12/12/2022]
Abstract
Diabetic gastroparesis is a common and debilitating condition affecting millions of patients with diabetes mellitus worldwide. Although gastroparesis in diabetes has been known clinically for more than 50 years, treatment options remain very limited. Until recently, the scientific literature has offered few clues regarding the precise aetiology of gastric dysfunction in diabetes.Up to 50% of patients with diabetes may experience postprandial abdominal pain, nausea, vomiting and bloating secondary to gastric dysfunction. There is no clear association between length of disease and the onset of delayed gastric emptying. Gastroparesis affects both type 1 (insulin dependent) and type 2 (non- insulin dependent) forms of diabetes. Diagnosis requires identifying the proper symptom complex, while excluding other entities (peptic ulcer disease, rheumatological diseases, medication effects). The diagnosis of gastroparesis may be confirmed by demonstrating gastric emptying delay during a 4-hour scintigraphic study. Treatment options are limited and rely on dietary modifications, judicious use of available pharmacological agents, and occasionally surgical or endoscopic placement of gastrostomies or jejunostomies. Gastric pacing offers promise for patients with medically refractory gastroparesis but awaits further investigation. Current pharmacological agents for treating gastroparesis include metoclopramide, erythromycin, cisapride (only available via a company-sponsored programme) and domperidone (not US FDA approved). All of these drugs act as promotility agents that increase the number or the intensity of gastric contractions. These medications are not uniformly effective and all have adverse effects that limit their use. Cisapride has been removed from the open market as a result of over 200 reported cases of cardiac toxicity attributed to its use. Unfortunately, there is a paucity of clinical studies that clearly define the efficacy of these agents in diabetic gastroparesis and there are no studies that compare these drugs to each other. The molecular pathophysiology of diabetic gastroparesis is unknown, limiting the development of rational therapies. New studies, primarily in animals, point to a defect in the enteric nervous system as a major molecular cause of abnormal gastric motility in diabetes. This defect is characterised by a loss of nitric oxide signals from nerves to muscles in the gut resulting in delayed gastric emptying. Novel therapies designed to augment nitric oxide signalling are being studied.
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Affiliation(s)
- D Scott Smith
- Department of Medicine, Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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14
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Abstract
Bloating is a frequently reported symptom in functional bowel disorders. It usually occurs in combination with other symptoms, but may also occur in isolation. The severity of bloating tends to worsen during the course of the day and improves overnight. Although frequently considered to be a subjective phenomenon, recent studies have shown that bloating is associated with a measurable increase in abdominal girth. The pathophysiology of bloating remains elusive, but the evidence supports a sensorimotor dysfunction of the bowel. The possible mechanisms include abnormal gas trapping, fluid retention, food intolerance and altered gut microbial flora. Further studies are needed to define the sensorimotor abnormalities associated with bloating, which might be segmental and transient rather than generalized and persistent. The lack of understanding of this symptom is paralleled by a limited availability of therapeutic options. Conventional medications used in functional bowel disorders are not helpful and may indeed worsen the symptoms. In future, new drugs with activity against serotonin and kappa receptors, or novel approaches such as the use of exclusion diets, probiotics and hypnotherapy, may prove to be useful.
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Affiliation(s)
- S Zar
- OGEM Department, St George's Hospital Medical School, London, UK
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Peters HPF, de Vries WR, Akkermans LMA, van Berge-Henegouwen GP, Koerselman J, Wiersma JWC, Bol E, Mosterd WL. Duodenal motility during a run-bike-run protocol: the effect of a sports drink. Eur J Gastroenterol Hepatol 2002; 14:1125-32. [PMID: 12362104 DOI: 10.1097/00042737-200210000-00014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To examine the effect of a sports drink during strenuous exercise on duodenal motility and gastrointestinal symptoms. METHODS In a cross-over design, seven male triathletes performed two 170-min run-bike-run tests at about 70% peak oxygen uptake (O(2peak)), with either a 7% carbohydrate (CHO) sports drink or tap water. Antroduodenal motility (phase III of the migrating motor complex; MMC) was measured with an ambulant manometry system. The effect of the two exercise trials on the first appearance of the MMC was assessed in the postprandial period. RESULTS Exercise heart rate, percentage O(2peak) and loss of body mass did not differ significantly between the two trials. After the start of the exercise, the expected time before the first phase III occurrence, based on the actual energy intake of the last meal in the morning before exercise (1048 +/- 294 kcal), a fixed gastric emptying rate and a lag phase for solid food, was 183 +/- 113 min (mean +/- standard deviation [SD]). The real time period between the start of the exercise with CHO and the first phase III was 63 +/- 61 min, which was significantly shorter than that observed with tap water (152 +/- 59 min). Both real time periods were shorter than the expected time period of 183 +/- 113 min (P < 0.05). During exercise, the number of subjects with a phase III was higher with CHO than with tap water (n =6 v. n =1; P < 0.05). Also, the median number of phases III per hour with CHO was higher than with tap water (0.4 v. 0.0; P < 0.05). During cycling, significantly more phases III per hour (0.9) were measured than during running (0.2). All subjects reported one or more gastrointestinal symptoms during exercise, however, without a clear association with the mode of exercise or supplementation. CONCLUSIONS Prolonged exercise results in gastrointestinal symptoms and a significant interruption of postprandial motility. Only the latter phenomenon depends on the mode of exercise and supplementation.
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Affiliation(s)
- Harry P F Peters
- Department of Medical Physiology and Sports Medicine, University Medical Centre Utrecht, 3508 AB Utrecht, The Netherlands
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16
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De Block CEM, De Leeuw IH, Pelckmans PA, Callens D, Máday E, Van Gaal LF. Delayed gastric emptying and gastric autoimmunity in type 1 diabetes. Diabetes Care 2002; 25:912-7. [PMID: 11978690 DOI: 10.2337/diacare.25.5.912] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Delayed gastric emptying and/or gastrointestinal symptoms occur in 30-50% of diabetic patients. Known contributing factors are autonomic neuropathy and acute hyperglycemia, but the role of gastric autoimmunity has never been investigated, although 15-20% of type 1 diabetic patients exhibit parietal cell antibodies (PCAs). We studied gastric motility in diabetes in relation to PCA status, autonomic nerve function, HbA(1c), thyroid-stimulating hormone (TSH), Helicobacter pylori (HP), acid production, and gastric histology. RESEARCH DESIGN AND METHODS Gastric emptying of solids and liquids (measured by (13)C-octanoic acid and (13)C-glycine breath tests, respectively) was tested in euglycemic conditions in 42 type 1 diabetic patients (male/female: 29/13; 15 PCA+; mean age 40 +/- 15 years; mean HbA(1c) 7.8 +/- 0.9%). Gastrointestinal symptoms, autonomic nerve function (Ewing tests), PCA status (indirect immunofluorescence), gastric histology, and acid secretion (pentagastrin) were assessed. RESULTS Solid gastric emptying was delayed in 40% and liquid emptying in 36% of patients. Gastric motility did not correlate with symptoms. PCA status, gastric morphology, and acid secretion were similar in those with and without gastroparesis. HbA(1c) level (beta = 1.34, P = 0.011) was the only risk factor for delayed solid emptying in a logistic regression model testing HbA(1c), autonomic nerve function, PCA, HP status, age, sex, diabetes duration, and TSH. Half-emptying time for liquids correlated with TSH level (r = 0.83, P < 0.0001) and autonomic neuropathy score (r = -0.79, P = 0.001). CONCLUSIONS We found that approximately 50% of type 1 diabetic patients studied had delayed gastric emptying that did not correlate with symptoms. Gastric autoimmunity did not contribute to diabetic gastroparesis. Metabolic control was worse in patients with delayed solid emptying.
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Affiliation(s)
- Christophe E M De Block
- Department of Endocrinology-Diabetology, Faculty of Medicine, University of Antwerp, University Hospital Antwerp, Edegem, Belgium.
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17
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Rayner CK, Samsom M, Jones KL, Horowitz M. Relationships of upper gastrointestinal motor and sensory function with glycemic control. Diabetes Care 2001; 24:371-81. [PMID: 11213895 DOI: 10.2337/diacare.24.2.371] [Citation(s) in RCA: 302] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Acute changes in the blood glucose concentration have a major reversible effect on esophageal, gastric, intestinal, gallbladder, and anorectal motility in both healthy subjects and diabetic patients. For example, gastric emptying is slower during hyperglycemia than euglycemia and accelerated during hypoglycemia. Acute hyperglycemia also affects perceptions arising from the gastrointestinal tract and may accordingly, be important in the etiology of gastrointestinal symptoms in diabetes. Elevations in blood glucose that are within the normal postprandial range also affect gastrointestinal motor and sensory function. Upper gastrointestinal motor function is a critical determinant of postprandial blood glucose concentrations by influencing the absorption of ingested nutrients. Interventions that reduce postprandial hyperglycemia, by modulating the rate of gastric emptying, have the potential to become mainstream therapies in the treatment of diabetes.
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Affiliation(s)
- C K Rayner
- University of Adelaide Department of Medicine, Royal Adelaide Hospital, South Australia, Australia
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18
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Borovicka J, Lehmann R, Kunz P, Fraser R, Kreiss C, Crelier G, Boesiger P, Spinas GA, Fried M, Schwizer W. Evaluation of gastric emptying and motility in diabetic gastroparesis with magnetic resonance imaging: effects of cisapride. Am J Gastroenterol 1999; 94:2866-73. [PMID: 10520835 DOI: 10.1111/j.1572-0241.1999.01392.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The motor mechanisms that underlie both slow gastric emptying in diabetic gastroparesis and its acceleration by cisapride are poorly understood. We have recently shown that magnetic resonance imaging (MRI) allows concurrent evaluation of both gastric emptying and regional gastric motility. METHODS Emptying and motility were measured in eight diabetic patients with previously demonstrated delayed gastric emptying using a rapid MRI technique during oral administration of cisapride and placebo. Studies were performed in a double blind fashion and each patient acted as his own control. Subjects were studied supine for 120 min in a 1.5 Tesla MRI scanner after ingestion of 500 ml of 10% Intralipid. Gastric emptying corrected for the volume of secretions was determined every 15 min using transaxial scans. Each transaxial scan was followed by 120 coronal scans at 1 s intervals. Coronal scans were angled to provide simultaneous imaging of the proximal and distal stomach. MRI studies were also performed in seven diabetic patients with normal emptying who served as disease controls. RESULTS Emptying was slower in the gastroparetic patients (t(1/2): 124 +/- 10 min) compared to patients with normal emptying (81 +/- 9 min, p < 0.05). Cisapride accelerated gastric emptying (74 +/- 5 vs 124 +/- 10 min) in patients with gastroparesis. The contraction amplitudes in the proximal stomach of gastroparetic patients were increased during cisapride treatment (17.2% +/- 1.8% vs 13.2% +/- 0.6%; p < 0.02), whereas antral contraction frequency, amplitude, and velocity were unchanged. CONCLUSIONS We conclude that cisapride-induced acceleration of liquid gastric emptying in diabetic gastroparesis does not appear to result from changes in antral contractility, but may be related to changes in proximal gastric tone or gastric outlet resistance.
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Affiliation(s)
- J Borovicka
- Department of Gastroenterology, University Hospital Zurich, Switzerland
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19
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Abstract
Autonomic neuropathy of the gastrointestinal tract may represent a primary disorder, but much more often it is secondary due to systemic disorders like diabetes mellitus. This review gives an overview about the common clinical manifestations and the principles and limitations in diagnostic work-up of autonomic dysfunction of the gastrointestinal tract. Diagnostic evaluation usually includes a combination of screening tests for autonomic neuropathy and specialized diagnostic procedures for the detection of sequela of autonomic neuropathy in gastrointestinal motility.
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Affiliation(s)
- M Bittinger
- Department of Internal Medicine III, Zentralklinikum Augsburg, Germany
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20
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Samsom M, Smout AJ, Hebbard G, Fraser R, Omari T, Horowitz M, Dent J. A novel portable perfused manometric system for recording of small intestinal motility. Neurogastroenterol Motil 1998; 10:139-48. [PMID: 9614672 DOI: 10.1046/j.1365-2982.1998.00093.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The development of solid-state catheters with miniature pressure transducers and portable dataloggers with a large memory capacity has allowed recording of gastrointestinal motility in ambulant subjects. Developments in silicone rubber extrusion technology made it possible to build a perfused manometric system, using a perfused manometric assembly requiring a low volume of perfusate. In the present study the feasibility of recording and automated analysis of small intestinal motility using a perfused multiple lumen manometric system was evaluated in seven healthy volunteers. Pressures were recorded from 12 sideholes arranged in four clusters spaced at 10-cm intervals from the catheter tip. Each channel was perfused at 0.15 mL min-1 with degassed water by a portable, low-compliance, perfusion pump. The 12 sidehole recording channels were connected to external transducers mounted on a belt. Pressure data were stored in two dataloggers. Motility was recorded in the sitting (30 min), and supine (30 min) position, during walking (30 min) and postprandially (90 min). Using purpose-built software baseline variations were corrected for and manometric variables (number of pressure waves, mean amplitude and motility index) calculated. Bench testing of the manometric assembly showed a median baseline pressure offset of 4.2 kPa (range 3.7-10.1) and upon occlusion a rise rate of 27.8 kPa sec-1 (range 19.7-30.8). Changes in body position affected baseline pressures so that compared to the supine position changes in baseline pressure varied between 1.5 +/- 0.7 kPa and 1.9 +/- 0.6 kPa during sitting (P < 0.02), and between 1.7 +/- 0.7 kPa and 1.5 +/- 0.9 kPa during walking (P < 0.03). Manometric recordings obtained during the fasting period showed an increase in small intestinal motor activity during walking. In the postprandial period no differences in motility variables were observed within one cluster and in time. Recording of small intestinal motility with a multiple-channel silicone rubber manometric assembly with a portable perfusion system is a feasible technique which is relatively inexpensive. Computer-assisted data processing allows for adequate elimination of artefacts and automated numerical analysis.
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Affiliation(s)
- M Samsom
- Gastrointestinal Motility Unit, University Hospital Utrecht, The Netherlands
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21
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Parkman HP, Miller MA, Trate D, Knight LC, Urbain JL, Maurer AH, Fisher RS. Electrogastrography and gastric emptying scintigraphy are complementary for assessment of dyspepsia. J Clin Gastroenterol 1997; 24:214-9. [PMID: 9252843 DOI: 10.1097/00004836-199706000-00006] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We have tried to correlate abnormalities in electrogastrography (EGG) and gastric emptying (GE) with symptom severity in patients with functional dyspepsia. Seventy-two patients with functional dyspepsia underwent EGG, GE, and symptom severity quantitation. EGGs were assessed for dominant frequency (DF), percentage of time of DF in the 2 to 4 cpm range, and postprandial-fasting DF power ratio. Solid-phase GE scintigraphy was assessed for 2-hour percentage retention. Symptoms of upper abdominal discomfort, early satiety, postprandial abdominal distension, nausea, vomiting, and anorexia were graded as none (0), mild (1), moderate (2), and severe (3); the sum represented a total symptom score. The EGG was abnormal in 11 of 22 (50%) patients with delayed GE compared with 11 of 50 (22%) with normal GE (p < 0.025). The total symptom scores were higher in patients with both delayed GE and abnormal EGG compared with patients with normal GE and EGG, normal GE and abnormal EGG, and delayed GE and normal EGG. We conclude that EGG abnormalities are more common in dyspeptic patients with delayed GE. Patients with both delayed GE and abnormal EGG have more severe symptoms. Our results suggest that EGG and GE complement each other in correlating symptoms to gastric dysmotility.
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Affiliation(s)
- H P Parkman
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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22
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Contreras R, Fuentes O, Mann GE, Sobrevia L. Diabetes and insulin-induced stimulation of L-arginine transport and nitric oxide synthesis in rabbit isolated gastric glands. J Physiol 1997; 498 ( Pt 3):787-96. [PMID: 9051589 PMCID: PMC1159194 DOI: 10.1113/jphysiol.1997.sp021902] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
1. The properties of L-arginine transport have been characterized and correlated with cGMP production (index of nitric oxide (NO)) in whole gastric glands isolated from non-diabetic and alloxan-diabetic rabbits. 2. In non-diabetic and diabetic glands, transport of L-arginine was stereoselective, Na+ and pH independent and inhibited by other cationic amino acids. L-Arginine transport was slightly inhibited by L-leucine and L-phenylalanine, but unaffected by other neutral amino acids. 3. Diabetes enhanced the Vmax for saturable L-arginine transport from 10.7 +/- 1.0 to 17.7 +/- 0.5 pmol (mg protein)-1 s-1, with negligible changes in K(m). 4. Accumulation of the membrane potential-sensitive probe tetra[3H]phenylphosphonium (TPP+) was increased 2-fold in diabetic compared with non-diabetic gastric glands, suggesting a membrane hyperpolarization. 5. Basal intracellular cGMP levels were elevated 2-fold in diabetic gastric glands, and in non-diabetic glands histamine, vasoactive intestinal peptide, and bradykinin increased cGMP levels. The NO synthase inhibitor NG-nitro-L-arginine methyl ester (100 microM) abolished basal cGMP accumulation. 6. Addition of extracellular L-arginine induced a concentration-dependent increase in cGMP levels in gastric glands isolated from non-diabetic rabbits, but had no effect on elevated cGMP levels in diabetic glands. 7. Insulin induced a rapid (5 min) concentration-dependent increase in cGMP levels in non-diabetic gastric glands, but reduced elevated cGMP levels in diabetic gastric glands. 8. The present study has identified a specific transport system for L-arginine in gastric glands which resembles the classical system y+. Our findings also provide the first direct evidence that diabetes increases the basal activity of system y+ and NO synthase in gastric glands. The differential modulation of L-arginine transport by insulin and L-arginine identified in non-diabetic and diabetic glands, may be of importance in protecting the gastric mucosa from injuries associated with diabetes.
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Affiliation(s)
- R Contreras
- Department of Physiology, Faculty of Biological Sciences, University of Concepción, Chile
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23
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Tomomasa T, DiLorenzo C, Morikawa A, Uc A, Hyman PE. Analysis of fasting antroduodenal manometry in children. Dig Dis Sci 1996; 41:2195-203. [PMID: 8943972 DOI: 10.1007/bf02071400] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Antroduodenal manometry has been used to determine the pathophysiology associated with signs and symptoms of gastrointestinal motility disorders. The diagnostic value of antroduodenal manomentry has been limited by the paucity of data from normal children. In this study, we compared antroduodenal manometry findings from 95 patients with symptoms suggesting a gastrointestinal motility disorder to 20 control children. Phase III of the migrating motor complex (MMC) was less frequent in patients (P < 0.05), especially in those who required total parenteral nutrition (P < 0.001), than in controls. Abnormal migration of phase III and short intervals between phase IIIs were more frequent in patients than in controls (P < 0.01 and P < 0.05, respectively). During phase II, persistent low-amplitude contractions and sustained tonic-phasic contraction were found only in parenteral-nutrition-dependent children. Short or prolonged duration of phase III, absence of phase I following phase III, tonic contractions during phase III, low amplitude of phase III contractions in a single recording site and clusters of contractions or prolonged propagating contractions during phase II were not more frequent in patients than in controls. We conclude that there are five manometric features having a clear association with pediatric gastrointestinal motility disorders: (1) absence of phase III of the MMC, (2) abnormal migration of phase III, (3) short intervals between phase III episodes, (4) persistent low-amplitude contractions, and (5) sustained tonic-phasic contractions.
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Affiliation(s)
- T Tomomasa
- Department of Pediatrics, Gunma University School of Medicine, Japan
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24
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Ziegler D, Schadewaldt P, Pour Mirza A, Piolot R, Schommartz B, Reinhardt M, Vosberg H, Brösicke H, Gries FA. [13C]octanoic acid breath test for non-invasive assessment of gastric emptying in diabetic patients: validation and relationship to gastric symptoms and cardiovascular autonomic function. Diabetologia 1996; 39:823-30. [PMID: 8817107 DOI: 10.1007/s001250050516] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Since there is a need for a widely applicable non-invasive test to assess gastric emptying in diabetic patients, we evaluated the sensitivity, specificity, and reproducibility of the [13C]octanoic acid breath test as compared with scintigraphy. Moreover, we examined the relationship between the breath test indices and gastric symptoms, cardiovascular autonomic function, and metabolic parameters. Forty healthy control subjects and 34 diabetic patients were studied. Three indices of gastric emptying, assessed by the breath test, were computed: half-emptying time (t1/2breath), gastric emptying coefficient (GEC), and lag phase. Furthermore, the half-emptying time, measured by scintigraphy (t1/2scint), was calculated and gastric symptoms and cardiovascular autonomic neuropathy (CAN) were scored. The coefficients of variation of day-to-day reproducibility in 10 healthy subjects were 29.6% for t1/2breath, 7.4% for GEC, and 46.5% for lag phase. An abnormal delay for t1/2scint (> 100 min) or t1/2breath (> 200 min) was noted in 12 patients. Based on the results for t1/2scint, the sensitivity of t1/2breath and GEC was 75% and the specificity was 86%. Both t1/2breath (rs = 0.523; p < 0.05) and GEC (r2 = -0.594; p < 0.05) were significantly associated with the gastric symptom score. A significant relationship to the CAN score was demonstrated for t1/2breath (rs = 0.448; p < 0.05), GEC (rs = -0.467; p < 0.05), and t1/2scint (rs = 0.602; p < 0.05). There were no significant associations of the breath test indices with the blood glucose levels during the test, HbA1c, age, and duration of diabetes. In patients with abnormal t1/2scint (n = 12) not only was t1/2breath significantly prolonged and GEC reduced, but also the scores of CAN and gastric symptoms were significantly increased as compared with those who had a normal t1/2scint (n = 22). We conclude that the [13C]octanoic acid breath test represents a suitable measure of delayed gastric emptying in diabetic patients which is associated with the severity of gastric symptoms and CAN but not affected by the blood glucose level.
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Affiliation(s)
- D Ziegler
- Diabetes Research Institute, Heinrich Heine University, Düsseldorf, Germany
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25
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Samsom M, Salet GA, Roelofs JM, Akkermans LM, Vanberge-Henegouwen GP, Smout AJ. Compliance of the proximal stomach and dyspeptic symptoms in patients with type I diabetes mellitus. Dig Dis Sci 1995; 40:2037-42. [PMID: 7555462 DOI: 10.1007/bf02208676] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED In the present study the function of the proximal stomach and its role in eliciting dyspeptic symptoms were evaluated in patients with diabetes mellitus. Eight type I diabetics with cardiovascular autonomic neuropathy and dyspeptic symptoms, and 10 healthy volunteers were studied using an electronic barostat device connected to a intragastric bag. The intragastric bag was inflated and deflated by stepwise pressure increments, creating pressure-volume curves. During the experiment the blood glucose concentrations were maintained within the euglycemic range in the diabetics. The volume-pressure curves showed a larger volume during the pressure increase in the diabetics than in the controls (P < 0.01). This resulted in a significant difference in compliance (dV/dP), 57.2 +/- 4.2 ml/mm Hg in diabetics and 43.7 +/- 3.5 ml/MM Hg in controls (P < 0.014). The volume-pressure curves during deflation of the intragastric balloon were different from the curves during inflation, creating a hysteresis loop. The area between the inflation and deflation curves was 827 ml/mm Hg in diabetics and 627 ml/mm Hg in the controls (P = 0.21). Gastric distension induced more upper gastrointestinal sensations in the patients than in the volunteers: nausea (P < 0.002), bloating (P < 0.003), upper abdominal pain (P < 0.001). IN CONCLUSION this study showed that the compliance of the proximal stomach is increased in diabetic patients with autonomic neuropathy and gastrointestinal symptoms. This abnormality, probably due to autonomic neuropathy, is associated with increased symptom generation during gastric distension.
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Affiliation(s)
- M Samsom
- Department of Gastroenterology, University Hospital Itrecht, The Netherlands
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26
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Abstract
Disturbed gastric and small intestinal motility is an often overlooked clinical problem. Delayed gastric emptying of liquid and/or solid food in patients with type 1 and type 2 diabetes (gastroparesis diabeticorum) occurs in approximately 50% of the patients. Also, the interdigestive gastric and small intestinal motility is often affected. There is only a weak correlation between symptoms and objectively measurable motor disturbances. Patients with severe upper gastrointestinal symptoms usually have disturbed motility, but most patients with impaired motility are asymptomatic. Recent studies have clearly shown that, in addition to autonomic neuropathy, acute metabolic derangements are likely to contribute to disturbed motility. Elevated glucose levels impair gastric and small intestinal motility during fasting and after food intake. Hyperinsulinemia per se has effects similar to hyperglycaemia on the stomach and small bowel, and may be a mediator of the effects of hyperglycaemia in healthy subjects. The impact of insulin on motility in diabetic patients is still unclear. Treatment of the gastric motility disorder should include a stabilization of gastric emptying. Different therapeutic modes may be useful, e.g. application of prokinetic drugs and optimizing the metabolic situation.
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Affiliation(s)
- H Abrahamsson
- Department of Internal Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
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