Antroduodenal motility and transpyloric fluid movement in patients with diabetes studied using duplex sonography

Diabetic and idiopathic gastroparesis is associated with loss of CD206-positive macrophages in the gastric antrum

BACKGROUND

Animal studies have increasingly highlighted the role of macrophages in the development of delayed gastric emptying. However, their role in the pathophysiology of human gastroparesis is unclear. Our aim was to determine changes in macrophages and other cell types in the gastric antrum muscularis propria of patients with diabetic and idiopathic gastroparesis.

METHODS

Full thickness gastric antrum biopsies were obtained from patients enrolled in the Gastroparesis Clinical Research Consortium (11 diabetic, 6 idiopathic) and 5 controls. Immunolabeling and quantitative assessment was done for interstitial cells of Cajal (ICC) (Kit), enteric nerves protein gene product 9.5, neuronal nitric oxide synthase, vasoactive intestinal peptide, substance P, tyrosine hydroxylase), overall immune cells (CD45) and anti-inflammatory macrophages (CD206). Gastric emptying was assessed using nuclear medicine scintigraphy and symptom severity using the Gastroparesis Cardinal Symptom Index.

RESULTS

Both diabetic and idiopathic gastroparesis patients showed loss of ICC as compared to controls (Mean [standard error of mean]/hpf: diabetic, 2.28 [0.16]; idiopathic, 2.53 [0.47]; controls, 6.05 [0.62]; P=.004). Overall immune cell population (CD45) was unchanged but there was a loss of anti-inflammatory macrophages (CD206) in circular muscle (diabetic, 3.87 [0.32]; idiopathic, 4.16 [0.52]; controls, 6.59 [1.09]; P=.04) and myenteric plexus (diabetic, 3.83 [0.27]; idiopathic, 3.59 [0.68]; controls, 7.46 [0.51]; P=.004). There was correlation between the number of ICC and CD206-positive cells (r=.55, P=.008). Enteric nerves (PGP9.5) were unchanged: diabetic, 33.64 (3.45); idiopathic, 41.26 (6.40); controls, 46.80 (6.04).

CONCLUSION

Loss of antral CD206-positive anti-inflammatory macrophages is a key feature in human gastroparesis and it is associates with ICC loss.

Intussusception as a gastrointestinal complication of diabetes: case report and literature review

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.

Diabetic gastroparesis: diagnosis and management

Gastric emptying is frequently abnormal in patients with long-standing type 1 and type 2 diabetes mellitus. Symptoms commonly associated with disordered gastric emptying include nausea, vomiting, bloating and epigastric pain, while patients are also at risk of malnutrition, weight loss, impaired drug absorption, disordered glycaemic control and poor quality of life. Although often attributed to the presence of irreversible autonomic neuropathy, acute hyperglycaemia represents a potentially reversible cause of gastric dysfunction in diabetes. Scintigraphy represents the gold standard for measuring gastric emptying. The management of diabetic gastroparesis is less than optimal, partly because the pathogenesis has not been clearly defined. Treatment approaches include dietary modification and optimization of glycaemia, and the use of prokinetic drugs, while novel therapies such as gastric electrical stimulation are the subject of ongoing investigation.

Ultrasonographic comparison of gastric motility between diabetic gastroparesis patients with and without metabolic syndrome

BACKGROUND AND AIMS

Diabetic patients with poor glycemic control or long standing disease often have impaired gastric motility. Recently, metabolic factors such as blood glucose have been reported as influencing gastric motility independently of autonomic neuropathy. Many diabetic patients have metabolic syndrome, which is strongly associated with coronary and other diseases. We investigated whether metabolic syndrome influences diabetic gastroparesis patients.

METHODS

We observed gastric motility ultrasonographically in diabetic gastroparesis patients including nine with and nine without metabolic syndrome. Both groups complained of upper abdominal symptoms when hospitalized to improve blood sugar control. All patients underwent upper gastrointestinal endoscopy to rule out gastric and duodenal lesions. All had autonomic neuropathy. Gastric motility was evaluated within 3 days after admission by transabdominal ultrasonography after a test meal.

RESULTS

Gastric emptying was 45.0 +/- 13.7% in patients with and 39.1 +/- 11.9% in patients without metabolic syndrome, which was not statistically significant. Frequency of gastric contractions was 8.33 +/- 2.78 per 3 min in patients with metabolic syndrome and 7.44 +/- 2.13 per 3 min in the others, which was not statistically significant. The motility index, which involves antral contractility, was 3.21 +/- 2.18 in patients with metabolic syndrome and 2.80 +/- 1.87 in the others, which was not statistically significant.

CONCLUSIONS

Metabolic syndrome did not appear to contribute to delayed gastric motility in diabetic gastroparesis.

Ultrasonographic assessment of gastric motility in diabetic gastroparesis before and after attaining glycemic control

BACKGROUND

Glycemic control is important for maintaining gastric motility in diabetic patients, but gastric motility has not yet been studied ultrasonographically in relation to glycemic control.

METHODS

We made such observations before and after establishing glycemic control in diabetic patients with gastroparesis. We studied 30 diabetic patients with upper abdominal digestive symptoms who were hospitalized for correction of poor blood sugar control and who underwent upper digestive tract endoscopy to rule out structural causes such as gastric/duodenal lesions. Gastric motility was evaluated by transabdominal ultrasonography, using a test meal, before and after attainment of glycemic control (within 3 days after admission and 3 days before discharge). Also, upper abdominal digestive symptoms present on admission and at discharge were compared.

RESULTS

After glycemic control was established, contractions of the antral region were more frequent than before the attainment of control (8.93 +/- 1.17/3 min vs 7.63 +/- 2.22/3 min, respectively; P < 0.001). Glycemic control also significantly improved gastric emptying (before glycemic control, 49.2 +/- 14.8%; after, 67.1 +/- 11.5%; P < 0.001). This was also true for the motility index, concerning antral gastric contractility (before control, 2.97 +/- 1.57; after, 3.75 +/- 1.09; P < 0.05). Upper abdominal symptom scores were also significantly lower after attainment of control than before (0.47 +/- 0.78 vs 3.17 +/- 2.00, respectively; P < 0.001).

CONCLUSIONS

These findings suggest that attaining glycemic control improves gastric motility and attainments upper abdominal symptoms in diabetic patients with gastroparesis.

A longitudinal study of gastric emptying and upper gastrointestinal symptoms in patients with diabetes mellitus

PURPOSE

To evaluate the natural history of gastric emptying and upper gastrointestinal symptoms in patients with diabetes mellitus.

SUBJECTS AND METHODS

We enrolled 20 patients (6 men, 14 women) with diabetes mellitus (16 with type 1 diabetes, 4 with type 2 diabetes). Each had measurements of gastric emptying of a solid (100 g of ground beef) and liquid (150 mL of 10% dextrose) meal using scintigraphy, glycemic control (glycosylated hemoglobin [HbA(1c)] and mean blood glucose levels), upper gastrointestinal symptoms, and autonomic nerve function at baseline and after a mean (+/- SD) of 12.3 +/- 3.1 years of follow-up.

RESULTS

There were no differences in mean gastric emptying of the solid component (retention at 100 minutes at baseline: 56% +/- 19% vs. follow-up: 51% +/- 21%, P = 0.23) or the liquid component (time for 50% to empty at baseline: 33 +/- 11 minutes vs. follow-up: 31 +/- 12 minutes, P = 0.71) during follow-up. Mean blood glucose (17.0 +/- 5.6 mmol/L vs. 13.8 +/- 4.9 mmol/L, P = 0.007) and HbA(1c) (8.4% +/- 2.3% vs. 7.6% +/- 1.3%, P = 0.03) levels were lower at follow-up. There was no difference in symptom score (baseline: 3.9 +/- 2.7 vs. follow-up: 4.2 +/- 4.0, P = 0.78). There was evidence of autonomic neuropathy in 7 patients (35%) at baseline and 16 (80%) at follow-up.

CONCLUSION

In patients with diabetes mellitus, we did not observe any marked changes in either gastric emptying or upper gastrointestinal symptoms during a 12-year period.

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.

Short air bubble in the gastric fundus during fasting: radiographic sign of gastroparesis after lung transplantation

This study was undertaken to assess whether gastroparesis, as a chronic complication of lung transplantation, correlates with height of the gastric air bubble on chest radiographs of erect fasting subjects. Height of the gastric air bubble and presence or absence of a gastric air-fluid level were assessed on chest radiographic examinations (posteroanterior, lateral, upright position, during fasting, immediately after bronchoscopy, median 148 days after transplantation) obtained on 3 separate days for each of 19 recipients of lung transplantation. Seven of the subjects (five women, two men) had chronic upper gastrointestinal symptoms after transplantation and a confirmed diagnosis of gastroparesis. The gastroparesis was idiopathic in six of the subjects and associated with cytomegalovirus gastritis in one subject. The other 12 subjects, each without upper gastrointestinal symptoms, served as controls. Median height of the gastric air bubble was significantly less in the gastroparetic (2.8 cm; range, 1.0-4.6 cm) than in the control (4.7 cm; range, 1.0-12.4 cm) group (p<0.05). Height of the gastric air bubble was at most 4.6 cm among the seven gastroparetic subjects, whereas it exceeded 5.0 cm on at least one occasion in 8 (67%) of the 12 control subjects (p<0.005). The likelihood of a gastric air-fluid level was 86% for symptomatic subjects and 25% for the control group (p<0.01). When lung transplantation is complicated by chronic gastroparesis, postbronchoscopic chest radiographic examinations of fasting subjects are associated with a gastric air bubble limited to high in the fundus, usually including a fluid level.

Gastric emptying in diabetes mellitus: relationship to blood-glucose control

The application of novel investigative techniques has established that disordered gastric motility is a frequent complication of diabetes mellitus. Thus, gastric emptying of solid or nutrient liquid meals is abnormal in 30% to 50% of randomly selected outpatients with long-standing type 1 or type 2 diabetes. Delayed gastric emptying occurs more frequently than rapid emptying. There is increasing evidence that disordered gastric motility has a major impact on the management of patients with diabetes mellitus by leading to gastrointestinal symptoms and poor glycemic control. Although both gastroparesis and upper gastrointestinal symptoms have been attributed to irreversible autonomic damage, it is now clear that acute changes in the blood-glucose concentration have a major effect on both gastrointestinal motor function and the perception of sensations arising in the gut. For example, there is an inverse relationship between the rate of gastric emptying and the blood-glucose concentration, so that gastric emptying is slower during hyperglycemia and accelerated during hypoglycemia. This article reviews some issues in the etiology, diagnosis, and management of problems associated with gastric emptying in elderly persons with diabetes mellitus.

Serum levels of 1,25-dihydroxyvitamin D, 24,25-dihydroxyvitamin D, and 25-hydroxyvitamin D in nondialyzed patients with chronic renal failure

BACKGROUND

In patients with chronic renal failure (CRF), abnormalities in vitamin D metabolism are known to be present, and several factors could contribute to the abnormalities.

METHODS

We measured serum levels of three vitamin D metabolites, 1,25(OH)2D, 24, 25(OH)2D and 25(OH)D, and analyzed factors affecting their levels in 76 nondialyzed patients with CRF (serum creatinine> 1.6 and < 9.0 mg/dl), 37 of whom had diabetes mellitus (DM-CRF) and 39 of whom were nondiabetic (nonDM-CRF).

RESULTS

Serum levels of 1,25(OH)2D were positively correlated with estimated creatinine clearance (CCr; r = 0.429; P < 0.0001), and levels of 24,25(OH)2D were weakly correlated with CCr (r = 0.252, P < 0.05); no correlation was noted for 25(OH)D. Serum levels of all three vitamin D metabolites were significantly and positively correlated with serum albumin. Although there were no significant differences in age, sex, estimated CCr, calcium and phosphate between DM-CRF and nonDM-CRF, all three vitamin D metabolites were significantly lower in DM-CRF than in nonDM-CRF. To analyze factors influencing vitamin D metabolite levels, we performed multiple regression analyses. Serum 25(OH)D levels were significantly and independently associated with serum albumin, presence of DM and serum phosphate (R2 = 0.599; P < 0.0001). 24,25(OH)2D levels were significantly and strongly associated with 25(OH)D (beta = 0.772; R2 = 0.446; P < 0.0001). Serum 1,25(OH)2D levels were significantly associated only with estimated CCr (R2 = 0. 409; P < 0.0001).

CONCLUSIONS

These results suggest that hypoalbuminemia and the presence of DM independently affect serum 25(OH)D levels, probably via diabetic nephropathy and poor nutritional status associated with diabetes, and that 25(OH)D is actively catalyzed to 24,25(OH)2D in CRF, probably largely via extrarenal 24-hydroxylase. Serum levels of 1,25(OH)2D were significantly affected by the degree of renal failure. Thus, this study indicates that patients with CRF, particularly those with DM, should receive supplements containing the active form of vitamin D prior to dialysis.

Wide gastric antrum and low vagal tone in patients with diabetes mellitus type 1 compared to patients with functional dyspepsia and healthy individuals

Autonomous neuropathy in patients with diabetes is associated with dysmotility and abdominal discomfort. The disturbances resemble to some extent those seen in patients with functional dyspepsia. To gain further insight into the disorders, we compared patients with long-standing diabetes, patients with functional dyspepsia, and healthy individuals with respect to abdominal symptoms, width of gastric antral area, and autonomic nerve function. We investigated 42 type I diabetic outpatients by structured interview for abdominal discomfort, ultrasonography of the gastric antrum, assessment of vagal and sympathetic nerve function by respiratory sinus arrhythmia and skin conductance, and measurement of blood sugar and HbA1c. Immediately after a standard meal of soup with meat, 21 (50%) of the 42 patients with diabetes complained of abdominal discomfort (pain, bloating, fullness), which was significantly less frequent (95% CI of difference 0.03-0.5) than previously seen in patients with functional dyspepsia (76%), and significantly more frequent (95% CI of difference 0.3-0.6) than that seen in healthy individuals (4%). Bloating was the most marked postprandial complaint. Mean fasting antral area was significantly wider in patients with diabetes (mean 4.9 cm2, SD 1.7) compared to healthy individuals (mean 3.5 cm2, SD 1.2), 95% CI of difference 0.6-2.2 cm2. Mean postprandial antral area was 14.8 cm2 (SD 4.6) in the patients with diabetes, which is insignificantly wider than in patients with functional dyspepsia (mean 13.0 cm2, SD 4.0) but significantly wider (95% CI of difference 1.9-6.5 cm2) than that seen in healthy individuals (mean 10.6 cm2, SD 3.8). The mean respiratory sinus arrhythmia was 0.7 beats/min (SD 0.7) in the patients with diabetes, which was insignificantly lower than that seen in patients with functional dyspepsia (2.1 beats/min, SD 4.5), and significantly lower (99% CI of difference 3.8-7.1 beats/min) compared to healthy individuals (6.2 beats/min, SD 3.8). It is concluded that patients with diabetes have a wider gastric antrum and more discomfort after a meal than healthy individuals. Compared to patients with functional dyspepsia, patients with diabetes have a wider postprandial antrum but fewer symptoms. The very low vagal tone seen in patients with diabetes may play an important role in the pathogenesis of their gastric motility disturbance and postprandial abdominal discomfort.

Ultrasonography of the human stomach

Improved technology and new systems have expanded the possibilities of using ultrasound in clinical gastroenterology.

METHODS

Conventional real-time ultrasound was applied to the stomach in order to study motor activity and accommodation to meals. The antrum was imaged by various modalities of two- and three-dimensional ultrasonography, while duplex sonography was used for studying transpyloric flow. Miniature ultrasound probes and echo-endoscopes were employed for endoscopic ultrasound

RESULTS

The examinations provided new information about contractions, distension, co-ordination of movements, and flow. Patients with functional dyspepsia were characterized by rapid emptying of the proximal stomach, wide gastric antrum, early commencement of transpyloric flow, and epigastric discomfort following ingestion of a meat soup. Endoscopic ultrasonography exposed detailed images of the gastric wall and adjacent structures of great importance in clinical decision-making.

CONCLUSIONS

The new ultrasound methods have improved our diagnostic capabilities and opened new promising possibilities for further research in the field of motility.

Effect of diabetes on relaxations to non-adrenergic, non-cholinergic nerve stimulation in longitudinal muscle of the rat gastric fundus

1. The effect of 8-week streptozotocin-induced diabetes has been examined on relaxations to non-adrenergic, non-cholinergic (NANC) nerve stimulation in longitudinal strips of rat gastric fundus. 2. In the presence of noradrenergic and cholinergic blockade and raised tissue tone, electrical field stimulation (0.5-4 Hz, 30 s trains) induced frequency-dependent relaxations that were significantly smaller in gastric fundus strips from diabetic rats than in strips from control rats. 3. NG-nitro-L-arginine methyl ester (NAME, 100 microM) significantly reduced NANC relaxations in muscle strips from both control and diabetic rats, but the reduction was greater in muscle strips from diabetic rats than in those from control rats at frequencies of 2 and 4 Hz. alpha-Chymotrypsin (1 u ml-1) slightly reduced relaxations to nerve stimulation in muscle strips from both control and diabetic rats. 4. The duration of NANC nerve relaxations (1-4 Hz, 30 s trains) was smaller in muscle strips from diabetic rats than in those from control rats. The duration of NANC relaxations was reduced by alpha-chymotrypsin (1 u ml-1) in muscle strips from control rats but not in muscle strips from diabetic rats. 5. Relaxations to both nitric oxide (NO; 1-30 microM) and vasoactive intestinal polypeptide (VIP; 0.1-30 microM) were concentration-dependent and did not differ between muscle strips from control and diabetic rats. 6. The results suggest that streptozotocin-induced diabetes impairs relaxations to NANC nerve stimulation in the rat gastric fundus, which are largely mediated by NO and to a lesser extent by VIP. The impairment appears to occur at the prejunctional level, as smooth muscle reactivity to NO and VIP is not altered.