1
|
Butt MF, Groen J, Jonker CAL, Burton-Murray H, Carrington EV, Chang L, Di Lorenzo C, Ellis J, Escher JC, Gorter RR, Jewell S, Karrento K, Koster EC, Nurko S, Rosen R, van Tilburg MAL, Zarate-Lopez N, Corsetti M, Benninga MA. Pediatric to adult transition care in neurogastroenterology and motility: A position paper from the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility. Neurogastroenterol Motil 2024:e14869. [PMID: 39038114 DOI: 10.1111/nmo.14869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/02/2024] [Indexed: 07/24/2024]
Abstract
Transition services-programs that support adolescents and young adults (AYAs) as they move from a child-centered to a more autonomous, adult-orientated healthcare system-have been associated with improved short- and long-term healthcare outcomes. Unfortunately, there is a paucity of evidence exploring transition services within the neurogastroenterology and motility (NGM) field. The overall aim of this article, endorsed by the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility, is to promote a discussion about the role of transition services for patients with NGM disorders. The AYAs addressed herein are those who have: (a) a ROME positive disorder of gut-brain interaction (DGBI), (b) a primary or secondary motility disorder (including those with motility disorders that have been surgically managed), or (c) an artificial feeding requirement (parenteral or enteral tube feeding) to manage malnutrition secondary to categories (a) or (b). The issues explored in this position paper include the specific physical and psychological healthcare needs of patients with NGM disorders; key healthcare professionals who should form part of a secondary care NGM transition service; the triadic relationship between healthcare professionals, caregivers, and patients; approaches to selecting patients who may benefit most from transition care; methods to assess transition readiness; and strategies with which to facilitate transfer of care between healthcare professionals. Key areas for future research are also addressed, including the construction of NGM-specific transition readiness questionnaires, tools to assess post-transfer healthcare outcomes, and educational programs to train healthcare professionals about transition care in NGM.
Collapse
Affiliation(s)
- Mohsin F Butt
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jip Groen
- Emma Children's Hospital-Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Charlotte A L Jonker
- Emma Children's Hospital-Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Helen Burton-Murray
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Emma V Carrington
- Department of Surgery and Cancer, Imperial College NHS Trust, London, UK
| | - Lin Chang
- G. Oppenheimer Center for Neurobiology of Stress at University of California, Los Angeles, Los Angeles, California, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jacob Ellis
- Department of Child and Adolescent Psychological Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Johanna C Escher
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ramon R Gorter
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Katja Karrento
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Emma C Koster
- Division of Dietetics, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Samuel Nurko
- Division of Gastroenterology, Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Rachel Rosen
- Division of Gastroenterology, Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Miranda A L van Tilburg
- Graduate Medical Education, Cape Fear Valley Health, Fayetteville, North Carolina, USA
- Joan C Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA
- Department of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
- School of Social Work, University of Washington, Seattle, Washington, USA
| | - Natalia Zarate-Lopez
- Department of Gastroenterology and Gastrointestinal Physiology, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Maura Corsetti
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Marc A Benninga
- Emma Children's Hospital-Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Leta V, Klingelhoefer L, Longardner K, Campagnolo M, Levent HÇ, Aureli F, Metta V, Bhidayasiri R, Chung-Faye G, Falup-Pecurariu C, Stocchi F, Jenner P, Warnecke T, Ray Chaudhuri K. Gastrointestinal barriers to levodopa transport and absorption in Parkinson's disease. Eur J Neurol 2023; 30:1465-1480. [PMID: 36757008 DOI: 10.1111/ene.15734] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023]
Abstract
Levodopa is the gold standard for the symptomatic treatment of Parkinson's disease (PD). There are well documented motor and non-motor fluctuations, however, that occur almost inevitably once levodopa is started after a variable period in people with PD. Whilst brain neurodegenerative processes play a part in the pathogenesis of these fluctuations, a range of barriers across the gastrointestinal (GI) tract can alter levodopa pharmacokinetics, ultimately contributing to non-optimal levodopa response and symptoms fluctuations. GI barriers to levodopa transport and absorption include dysphagia, delayed gastric emptying, constipation, Helicobacter pylori infection, small intestinal bacterial overgrowth and gut dysbiosis. In addition, a protein-rich diet and concomitant medication intake can further alter levodopa pharmacokinetics. This can result in unpredictable or sub-optimal levodopa response, 'delayed on' or 'no on' phenomena. In this narrative review, we provided an overview on the plethora of GI obstacles to levodopa transport and absorption in PD and their implications on levodopa pharmacokinetics and development of motor fluctuations. In addition, management strategies to address GI dysfunction in PD are highlighted, including use of non-oral therapies to bypass the GI tract.
Collapse
Affiliation(s)
- Valentina Leta
- Parkinson's Foundation Center of Excellence at King's College Hospital, London, UK.,Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London and National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre, Institute of Psychology, Psychiatry and Neurosciences, King's College London, London, UK
| | | | - Katherine Longardner
- Parkinson and Other Movement Disorders Center, Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Marta Campagnolo
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | - Federico Aureli
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Vinod Metta
- Parkinson's Foundation Center of Excellence at King's College Hospital, London, UK.,Kings College Hospital London, Dubai, United Arab Emirates
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Guy Chung-Faye
- Parkinson's Foundation Center of Excellence at King's College Hospital, London, UK.,Kings College Hospital London, Dubai, United Arab Emirates
| | | | - Fabrizio Stocchi
- Department of Neurology, University San Raffaele Roma and IRCCS San Raffaele Pisana, Rome, Italy
| | - Peter Jenner
- Institute of Pharmaceutical Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Tobias Warnecke
- Department of Neurology and Neurorehabilitation, Klinikum Osnabrueck-Academic Teaching Hospital of the WWU Muenster, Osnabrueck, Germany
| | - K Ray Chaudhuri
- Parkinson's Foundation Center of Excellence at King's College Hospital, London, UK.,Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London and National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre, Institute of Psychology, Psychiatry and Neurosciences, King's College London, London, UK
| | | |
Collapse
|
3
|
Beckers M, Bloem BR, Verbeek MM. Mechanisms of peripheral levodopa resistance in Parkinson's disease. NPJ Parkinsons Dis 2022; 8:56. [PMID: 35546556 PMCID: PMC9095610 DOI: 10.1038/s41531-022-00321-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/08/2022] [Indexed: 02/07/2023] Open
Abstract
Parkinson’s disease (PD) is an increasingly common neurodegenerative condition. The disease has a significant negative impact on quality of life, but a personalized management approach can help reduce disability. Pharmacotherapy with levodopa remains the cornerstone of treatment, and a gratifying and sustained response to this treatment is a supportive criterion that argues in favor of an underlying diagnosis of PD. Yet, in daily practice, it is not uncommon to encounter patients who appear to have true PD, but who nevertheless seem to lose the responsiveness to levodopa (secondary non-responders). Some patients may even fail to respond altogether (primary non-responders). Here, we address how two mechanisms of “peripheral resistance” may underlie this failing response to levodopa in persons with PD. The first explanation relates to impaired bowel motility leading to secondary bacterial overgrowth, and more specifically, to the excessive bacterial production of the enzyme tyrosine decarboxylase (TDC). This enzyme may convert levodopa to dopamine in the gut, thereby hampering entry into the circulation and, subsequently, into the brain. The second explanation relates to the systemic induction of the enzyme aromatic l-amino acid decarboxylase (AADC), leading to premature conversion of levodopa into dopamine, again limiting the bioavailability within the brain. We discuss these two mechanisms and focus on the clinical implications, potential treatments and directions for future research.
Collapse
Affiliation(s)
- Milan Beckers
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands. .,Radboudumc Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands.
| | - Bastiaan R Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| | - Marcel M Verbeek
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
4
|
El-Chammas KI, Santucci NR, Mansi S, Kaul A. Pediatric gastrointestinal neuromodulation: A review. Saudi J Gastroenterol 2022; 28:403-412. [PMID: 35418002 PMCID: PMC9843514 DOI: 10.4103/sjg.sjg_109_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Neuromodulation, also known as bioelectric neuromodulation or neurostimulation, is the therapeutic use of electrical stimulation of nerves or brain centers. Neuromodulation has been trialed in an increasing range of human diseases as well as gastrointestinal disorders. The application of neuromodulation to treat pediatric motility and functional disorders is an exciting recent development. This review aims to briefly discuss the use of neuromodulation for the treatment of pediatric gastroparesis, constipation, and visceral hyperalgesia.
Collapse
Affiliation(s)
- Khalil I. El-Chammas
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA,Address for correspondence: Dr. Khalil I. El-Chammas, 3333 Burnet Ave, Cincinnati, Ohio - 45229, USA. E-mail:
| | - Neha R. Santucci
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Sherief Mansi
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Ajay Kaul
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
5
|
Goyal O, Nohria S, Batta S, Dhaliwal A, Goyal P, Sood A. Low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet versus traditional dietary advice for functional dyspepsia: a randomized controlled trial. J Gastroenterol Hepatol 2022; 37:301-309. [PMID: 34555865 DOI: 10.1111/jgh.15694] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/24/2021] [Accepted: 09/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Prospective trials evaluating efficacy of specific diet restriction in functional dyspepsia (FD) are scarce. We aimed to assess efficacy of low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet in FD, compared with traditional dietary advice (TDA). METHODS In this prospective, single-blind trial, patients with FD (Rome IV) were randomized into low FODMAP diet (LFD) and TDA groups, for 4 weeks (phase I). In phase II (4-12 weeks), LFD group was advised systematic re-introduction of FODMAPs. Symptom severity and quality of life were assessed using "Short-Form Nepean Dyspepsia Index (SF-NDI)." Primary outcome was symptomatic response (symptom score reduction of ≥ 50%), at 4 weeks. Study was registered with CTRI (2019/06/019852). RESULTS Of 184 patients screened, 105 were randomized to LFD (n = 54) and TDA (n = 51) groups. At 4 weeks, both groups showed significant reduction in SF-NDI symptom scores compared with baseline, with no significant difference in inter-group response rates [LFD: 66.7% (36/54); TDA: 56.9% (29/51); P = 0.32]. On sub-group analysis, patients with postprandial distress syndrome or bloating had significantly better symptomatic response with LFD (P = 0.04). SF-NDI quality of life scores improved significantly in both groups. On multivariate analysis, factors predicting response to LFD were bloating and male gender. Incidences of adverse events (minor) were similar in both groups. CONCLUSIONS In patients with FD, LFD and TDA lead to significant symptomatic and quality of life improvement. Patients with postprandial distress syndrome or bloating respond significantly better to LFD. Therefore, dietary advice for FD should be individualized according to FD subtype.
Collapse
Affiliation(s)
- Omesh Goyal
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Sahil Nohria
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Shaveta Batta
- Department of Dietetics, Dayanand Medical College and Hospital, Ludhiana, India
| | - Armaan Dhaliwal
- Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, India
| | - Prerna Goyal
- Department of Medicine, Baba Jaswant Singh Dental College Hospital and Research Institute, Ludhiana, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| |
Collapse
|
6
|
Di Lorenzo C. Functional Nausea Is Real and Makes You Sick. Front Pediatr 2022; 10:848659. [PMID: 35281225 PMCID: PMC8914080 DOI: 10.3389/fped.2022.848659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Functional nausea is a condition that severely impairs the quality of life of affected individuals. Only recently, it has been added to the pediatric list of disorders of gut-brain interaction. In most cases, only minimal testing is needed to diagnose functional nausea. Hypnotherapy has been shown to be a very effective treatment and there are several other medical and non-medical interventions which have the potential to benefit sub-groups of patients with chronic nausea.
Collapse
Affiliation(s)
- Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, United States
| |
Collapse
|
7
|
Radetic M, Kamal A, Rouphael C, Kou L, Lyu R, Cline M. Severe gastroparesis is associated with an increased incidence of slow-transit constipation as measured by wireless motility capsule. Neurogastroenterol Motil 2021; 33:e14045. [PMID: 33231369 DOI: 10.1111/nmo.14045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 10/21/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dysmotility in one region of the gastrointestinal tract has been found to predispose patients to developing motility disorders in other gastrointestinal segments. However, few studies have evaluated the relationship between gastroparesis and constipation. METHODS Retrospective review of 224 patients who completed 4-hour, solid-phase gastric emptying scintigraphy (GES), and wireless motility capsule (WMC) testing to evaluate for gastroparesis and slow-transit constipation, respectively. When available, anorectal manometry data were reviewed to evaluate for dyssynergic defecation. Patients were divided into two groups based on the results of the GES: 101 patients with normal gastric emptying and 123 patients with gastroparesis (stratified by severity). Differences in constipation rates were compared between the groups. KEY RESULTS Slow-transit constipation was more common in the gastroparesis group, but statistical significance was not reached (42.3% vs 34.7%, p = 0.304). Univariate logistical regression analysis found no association between slow-transit constipation and gastroparesis (OR 1.38, 95% CI 0.80-2.38, p = 0.245) nor dyssynergic defecation and gastroparesis (OR 0.88, 95% CI 0.29-2.70, p = 0.822). However, when stratifying gastroparesis based on severity, slow-transit constipation was found to be associated with severe gastroparesis (OR 2.45, 95% CI 1.20-5.00, p = 0.014). This association was strengthened with the exclusion of patients with diabetes mellitus (OR 3.5, 95% CI 1.39-8.83, p = 0.008) - a potential confounder. CONCLUSIONS & INFERENCES Patients with severe gastroparesis (>35% gastric retention at the 4-hour mark on solid-phase GES) have an increased likelihood of having underlying slow-transit constipation. Dyssynergic defecation does not appear to be associated with gastroparesis (of any severity).
Collapse
Affiliation(s)
- Mark Radetic
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City, CA, USA
| | - Carol Rouphael
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Lei Kou
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Michael Cline
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
8
|
Colonic stool burden on computed tomography does not correlate with bowel habit: a cross-sectional study. Abdom Radiol (NY) 2021; 46:506-516. [PMID: 32761405 DOI: 10.1007/s00261-020-02689-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/16/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Stool burden on abdominal radiographs is not reflective of constipation, perhaps because of variable fecal shadowing or limited inter-rater agreement. These limitations are hypothetically mitigated by computed tomography (CT). This research aimed (i) to evaluate whether bowel movement frequency, stool form, or a diagnosis of functional constipation correlate or associate with stool burden identified on CT, and (ii) to investigate whether physicians use CT in their assessment of a patients' bowel function. METHODS Patients attending for non-emergent abdominal CT imaging were invited to participate by completing a bowel questionnaire. Stool burden identified on imaging was determined and inter-rater reliability was evaluated in a subgroup of patients (n = 20). Descriptive and comparative analyses were performed. An online questionnaire evaluated the use of abdominal imaging in assessing patients' bowel function in a cross-section of ordering physicians. RESULTS The patient response rate was 19% (96/516). No clinically useful associations between fecal burden and stool form, bowel motion frequency, gastrointestinal symptoms or a diagnosis of constipation was identified. The physician response rate was 35% (33/94). Opportunistic use of data was more common than deliberate use. However, an abdominal radiograph or CT scan had been requested by 42% and 18% of physicians respectively to assess patient's chronic bowel habit. Approximately 30% of physicians believed evidence supported this practice. CONCLUSIONS Physicians may use abdominal CT in their assessment of patients' chronic bowel habits. However, objective assessment does not support this practice. Colonic stool burden does not correlate with patient-reported symptoms or a criteria-based diagnosis of constipation.
Collapse
|
9
|
Vriesman MH, Noor N, Koppen IJ, Di Lorenzo C, de Jong JR, Benninga MA. Outcomes after enterostomies in children with and without motility disorders: A description and comparison of postoperative complications. J Pediatr Surg 2020; 55:2413-2418. [PMID: 32600839 DOI: 10.1016/j.jpedsurg.2020.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 04/28/2020] [Accepted: 05/15/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To provide an overview of complications after ileostomy or colostomy procedures in children, and to compare outcomes between patients with gastrointestinal motility disorders (i.e. functional constipation, Hirschsprung's disease, pediatric intestinal pseudo-obstruction (PIPO)) and children without motility disorders (including necrotizing enterocolitis, anorectal malformation and inflammatory bowel disease). METHODS We performed a retrospective study of children who underwent an enterostomy procedure at our institution. The number and type of complications and subsequent reoperations after ostomy formation were determined. Complications were scored using the Clavien-Dindo classification. A complication of ≥ grade III-b was considered a high-grade complication. RESULTS 129 children with an ileostomy and 61 children with a colostomy were included. Of these, 62 children (32.6%) had motility disorders; functional constipation (n=40), Hirschsprung's disease (n=18) and PIPO (n=4). The total prevalence of complications was 73.2%. Comparing the perioperative data, children with motility disorders significantly more often underwent a laparoscopic procedure (59.7% vs. 10.9%, p=0.000) and had an end stoma-configuration (37.1% vs. 14.1%, p=0.000) as compared to children without motility disorders. Children with motility problems had a higher complication rate (88.7% vs. 65.5%, OR 4.1, 95% CI 1.7-9.8, p=0.001) compared to children without motility problems, and a larger proportion of complications was classified as high-grade complications (61.8% vs. 31.0% p =0.002). CONCLUSION A high complication rate after enterostomy formation was detected. Children with gastrointestinal motility disorders had more and more severe complications as compared to children without motility disorders. LEVEL OF EVIDENCE Level III TYPE OF STUDY: Retrospective comparative study.
Collapse
Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Najia Noor
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ilan J Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Justin R de Jong
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
10
|
Kovacic K, Elfar W, Rosen JM, Yacob D, Raynor J, Mostamand S, Punati J, Fortunato JE, Saps M. Update on pediatric gastroparesis: A review of the published literature and recommendations for future research. Neurogastroenterol Motil 2020; 32:e13780. [PMID: 31854057 DOI: 10.1111/nmo.13780] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/11/2019] [Accepted: 11/29/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Due to scarcity of scientific literature on pediatric gastroparesis, there is a need to summarize current evidence and identify areas requiring further research. The aim of this study was to provide an evidence-based review of the available literature on the prevalence, pathogenesis, clinical presentation, diagnosis, treatment, and outcomes of pediatric gastroparesis. METHODS A search of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines with the following databases: PubMed, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Web of Science. Two independent reviewers screened abstracts for eligibility. KEY RESULTS Our search yielded 1085 original publications, 135 of which met inclusion criteria. Most articles were of retrospective study design. Only 12 randomized controlled trials were identified, all of which were in infants. The prevalence of pediatric gastroparesis is unknown. Gastroparesis may be suspected based on clinical symptoms although these are often non-specific. The 4-hour nuclear scintigraphy scan remains gold standard for diagnosis despite lack of pediatric normative comparison data. Therapeutic approaches include dietary modifications, prokinetic drugs, and postpyloric enteral tube feeds. For refractory cases, intrapyloric botulinum toxin and surgical interventions such as gastric electrical stimulation may be warranted. Most interventions still lack rigorous supportive data. CONCLUSIONS Diagnosis and treatment of pediatric gastroparesis are challenging due to paucity of published evidence. Larger and more rigorous clinical trials are necessary to improve outcomes.
Collapse
Affiliation(s)
- Katja Kovacic
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Walaa Elfar
- Division of Gastroenterology and Nutrition, Department of Pediatrics, The Pennsylvania State Melton S. Hershey Medical Center, Hershey, PA, USA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Mercy Hospital, Kansas City, MO, USA
| | - Desale Yacob
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Jennifer Raynor
- Edward G. Miner Library, University of Rochester Medical Center, Rochester, NY, USA
| | - Shikib Mostamand
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jaya Punati
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John E Fortunato
- Neurointestinal and Motility Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Holtz Children's Hospital, Miller School of Medicine, University of Miami, Miami, FL, USA
| |
Collapse
|
11
|
Hasler WL, Rao SSC, McCallum RW, Krause RA, Nguyen LA, Schulman MI, Lee AA, Moshiree B, Wo JM, Parkman HP, Sarosiek I, Wilding GE, Kuo B. Influence of Gastric Emptying and Gut Transit Testing on Clinical Management Decisions in Suspected Gastroparesis. Clin Transl Gastroenterol 2019; 10:e00084. [PMID: 31663906 PMCID: PMC6919448 DOI: 10.14309/ctg.0000000000000084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 08/16/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Gastric emptying scintigraphy (GES) or wireless motility capsules (WMCs) can evaluate upper gastrointestinal symptoms in suspected gastroparesis; WMC tests can also investigate lower gut symptoms. We aimed to determine whether these tests impact treatment plans and needs for additional diagnostic evaluation. METHODS In a prospective, multicenter study, 150 patients with gastroparesis symptoms simultaneously underwent GES and WMC testing. Based on these results, investigators devised management plans to recommend changes in medications, diet, and surgical therapies and order additional diagnostic tests. RESULTS Treatment changes were recommended more often based on the WMC vs GES results (68% vs 48%) (P < 0.0001). Ordering of additional test(s) was eliminated more often with WMC vs GES (71% vs 31%) (P < 0.0001). Prokinetics (P = 0.0007) and laxatives (P < 0.0001) were recommended more often based on the WMC vs GES results. Recommendations for prokinetics and gastroparesis diets were higher and neuromodulators lower in subjects with delayed emptying on both tests (all P ≤ 0.0006). Laxatives and additional motility tests were ordered more frequently for delayed compared with normal WMC colonic transit (P ≤ 0.02). Multiple motility tests were ordered more often on the basis of GES vs WMC findings (P ≤ 0.004). Antidumping diets and transit slowing medications were more commonly recommended for rapid WMC gastric emptying (P ≤ 0.03). DISCUSSION WMC transit results promote medication changes and eliminate additional diagnostic testing more often than GES because of greater detection of delayed gastric emptying and profiling the entire gastrointestinal tract in patients with gastroparesis symptoms. TRANSLATIONAL IMPACT Gastric scintigraphy and WMCs have differential impact on management decisions in suspected gastroparesis.
Collapse
Affiliation(s)
- William L. Hasler
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Satish S. C. Rao
- Division of Gastroenterology and Hepatology, Medical College of Georgia, Augusta, Georgia, USA
| | | | | | - Linda A. Nguyen
- Division of Gastroenterology, Stanford University, Palo Alto, California, USA
| | | | - Allen A. Lee
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Baharak Moshiree
- Atrium Health Gastroenterology and Hepatology, Carolinas HealthCare System Digestive Health-Morehead Medical Plaza, Charlotte, North Carolina, USA
| | - John M. Wo
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Henry P. Parkman
- Section of Gastroenterology, Temple University, Philadelphia, Pennsylvania, USA
| | - Irene Sarosiek
- Section of Gastroenterology, Texas Tech University, El Paso, Texas, USA
| | - Gregory E. Wilding
- Department of Biostatistics, University of Buffalo, Buffalo, New York, USA
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Adamiak T, Plati KF. Pediatric Esophageal Disorders: Diagnosis and Treatment of Reflux and Eosinophilic Esophagitis. Pediatr Rev 2018; 39:392-402. [PMID: 30068740 DOI: 10.1542/pir.2017-0266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Gastroesophageal reflux (GER) occurs frequently in infants, generally at its worst at 4 months of age, with approximately two-thirds of infants spitting up daily. GER typically improves after 7 months of age, with only ∼5% of infants continuing to have reflux at 1 year of age. The diagnosis can often be made based on clinical symptoms. Upper GI (UGI) study has low sensitivity and specificity and should not be ordered as a diagnostic test for reflux. UGI study is best for evaluating other anatomic causes of vomiting. GER becomes problematic gastroesophageal reflux disease (GERD) when complications are present, including feeding difficulties and poor weight gain. Conservative treatment and thickened formula can be helpful for treating GERD. Proton pump inhibitors (PPIs) are frequently prescribed for treating reflux. However, studies do not show a definite benefit in infants, and there are potential side effects. Older children with GERD may present with regurgitation, heartburn, chest discomfort, dysphagia, abdominal pain, vomiting, poor appetite, or poor weight gain. Upper endoscopy is considered for children with concerning symptoms, persistent symptoms despite treatment, and relapse of symptoms after treatment. Other esophageal disorders can have a similar clinical presentation as GERD, notably eosinophilic esophagitis (EoE). EoE is a chronic immune-mediated disorder of the esophagus, which may present as dysphagia, food impaction, heartburn, vomiting, abdominal pain, feeding difficulties, or failure to thrive. Diagnosis is made histologically by the presence of esophageal eosinophilia on endoscopic biopsies in the correct clinical setting.
Collapse
Affiliation(s)
- Tonya Adamiak
- Department of Pediatrics, Sanford Children's Hospital, Sioux Falls, SD
| | | |
Collapse
|
13
|
Hasler WL, May KP, Wilson LA, Van Natta M, Parkman HP, Pasricha PJ, Koch KL, Abell TL, McCallum RW, Nguyen LA, Snape WJ, Sarosiek I, Clarke JO, Farrugia G, Calles-Escandon J, Grover M, Tonascia J, Lee LA, Miriel L, Hamilton FA. Relating gastric scintigraphy and symptoms to motility capsule transit and pressure findings in suspected gastroparesis. Neurogastroenterol Motil 2018; 30:10.1111/nmo.13196. [PMID: 28872760 PMCID: PMC6004323 DOI: 10.1111/nmo.13196] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/25/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Wireless motility capsule (WMC) findings are incompletely defined in suspected gastroparesis. We aimed to characterize regional WMC transit and contractility in relation to scintigraphy, etiology, and symptoms in patients undergoing gastric emptying testing. METHODS A total of 209 patients with gastroparesis symptoms at NIDDK Gastroparesis Consortium centers underwent gastric scintigraphy and WMCs on separate days to measure regional transit and contractility. Validated questionnaires quantified symptoms. KEY RESULTS Solid scintigraphy and liquid scintigraphy were delayed in 68.8% and 34.8% of patients; WMC gastric emptying times (GET) were delayed in 40.3% and showed 52.8% agreement with scintigraphy; 15.5% and 33.5% had delayed small bowel (SBTT) and colon transit (CTT) times. Transit was delayed in ≥2 regions in 23.3%. Rapid transit was rarely observed. Diabetics had slower GET but more rapid SBTT versus idiopathics (P ≤ .02). GET delays related to greater scintigraphic retention, slower SBTT, and fewer gastric contractions (P ≤ .04). Overall gastroparesis symptoms and nausea/vomiting, early satiety/fullness, bloating/distention, and upper abdominal pain subscores showed no relation to WMC transit. Upper and lower abdominal pain scores (P ≤ .03) were greater with increased colon contractions. Constipation correlated with slower CTT and higher colon contractions (P = .03). Diarrhea scores were higher with delayed SBTT and CTT (P ≤ .04). CONCLUSIONS & INFERENCES Wireless motility capsules define gastric emptying delays similar but not identical to scintigraphy that are more severe in diabetics and relate to reduced gastric contractility. Extragastric transit delays occur in >40% with suspected gastroparesis. Gastroparesis symptoms show little association with WMC profiles, although lower symptoms relate to small bowel or colon abnormalities.
Collapse
Affiliation(s)
- W L Hasler
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - K P May
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - L A Wilson
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - M Van Natta
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - H P Parkman
- Section of Gastroenterology, Temple University, Philadelphia, PA, USA
| | - P J Pasricha
- Section of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA
| | - K L Koch
- Section on Gastroenterology, Wake Forest University, Winston Salem, NC, USA
| | - T L Abell
- Division of Gastroenterology, University of Louisville, Louisville, KY, USA
| | - R W McCallum
- Section of Gastroenterology, Texas Tech University, El Paso, TX, USA
| | - L A Nguyen
- Division of Gastroenterology, Stanford University, Palo Alto, CA, USA
| | - W J Snape
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA, USA
| | - I Sarosiek
- Section of Gastroenterology, Texas Tech University, El Paso, TX, USA
| | - J O Clarke
- Division of Gastroenterology, Stanford University, Palo Alto, CA, USA
| | - G Farrugia
- Section of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - J Calles-Escandon
- Endocrinology Section, MetroHealth Medical Center, Cleveland, OH, USA
| | - M Grover
- Section of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - J Tonascia
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - L A Lee
- Section of Gastroenterology, Johns Hopkins University Data Coordinating Center, Baltimore, MD, USA
| | - L Miriel
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - F A Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| |
Collapse
|
14
|
Tan VP. The low-FODMAP diet in the management of functional dyspepsia in East and Southeast Asia. J Gastroenterol Hepatol 2017; 32 Suppl 1:46-52. [PMID: 28244670 DOI: 10.1111/jgh.13697] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2016] [Indexed: 01/10/2023]
Abstract
Functional dyspepsia (FD) is a common disorder in East and Southeast Asia where subjects experience post prandial fullness/bloating, early satiety, belching, epigastric pain, and/or burning. A subset of patients with FD experience triggers exclusively related to meals, defined as the post prandial distress syndrome in the Rome IV guidelines. There is significant overlap of symptoms and implicated pathogenic factors with another common functional gastrointestinal disorder, irritable bowel syndrome (IBS) and in fact, a significant proportion of subjects have FD/IBS overlap. The introduction of the low-FODMAP diet has changed the paradigm of treatment for IBS. Like IBS, dietary management appears to be important to patients with FD and clinicians treating the condition. This review aims to examine the current role of diet in the management of FD in East and Southeast Asia, with an exploration of the likely efficacy and mechanisms of action of the low-FODMAP diet in this region.
Collapse
Affiliation(s)
- Victoria P Tan
- Department of Medicine, The University of Hong Kong, Hong Kong SAR
| |
Collapse
|
15
|
Tan VPY, Liu KSH, Lam FYF, Hung IFN, Yuen MF, Leung WK. Randomised clinical trial: rifaximin versus placebo for the treatment of functional dyspepsia. Aliment Pharmacol Ther 2017; 45:767-776. [PMID: 28112426 DOI: 10.1111/apt.13945] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/20/2016] [Accepted: 12/27/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gut dysbiosis may contribute to pain and bloating in patients with functional gastrointestinal disease. AIMS To determine if treatment with rifaximin would improve the symptoms of functional dyspepsia in Chinese patients in a double-blinded, randomised, placebo-controlled trial. METHODS Consecutive subjects with a diagnosis of functional dyspepsia as per the Rome III criteria were randomised to receive rifaximin 400 mg or placebo, all taken three times daily for 2 weeks. The investigators and study subjects were blinded to the treatment allocation. Subjects were followed up for 8 weeks. The primary end point was adequate relief of global dyspeptic symptoms (GDS). Secondary endpoints were relief of individual dyspeptic symptoms. RESULTS Eighty-six subjects were recruited. At week 8, there were significantly more subjects in the rifaximin than in the placebo group who experienced adequate relief of GDS (78% vs. 52%, P = 0.02). A trend favouring rifaximin group was also noted in the preceding 4 weeks. Rifaximin was also superior to placebo in providing adequate relief of belching and post-prandial fullness/bloating (PPF) in subjects at week 4. Subgroup analysis revealed that female subjects had more significant response to rifaximin treatment (adequate relief of GDS at week 4: 76% vs. 42%, P = 0.006; week 8: 79% vs. 47%, P = 0.008), as well as improvements in their belching and PPF at week 4. The incidences of adverse effects were similar in both groups. CONCLUSIONS Treatment with 2 weeks of rifaximin led to adequate relief of global dyspeptic symptoms, belching and post-prandial fullness/bloating in subjects with functional dyspepsia. The difference was more marked in females. (clinicaltrials.org NCT01643083).
Collapse
Affiliation(s)
- V P Y Tan
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - K S H Liu
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - F Y F Lam
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - I F N Hung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - M F Yuen
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - W K Leung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| |
Collapse
|
16
|
Song J, Yin J, Chen JDZ. Inhibitory Effects and Sympathetic Mechanisms of Distension in the Distal Organs on Small Bowel Motility and Slow Waves in Canine. Cell Biochem Biophys 2017; 73:665-72. [PMID: 27259308 DOI: 10.1007/s12013-015-0679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Rectal distension (RD) is known to induce intestinal dysmotility. Few studies were performed to compare effects of RD, colon distension (CD) and duodenal distension (DD) on small bowel motility. This study aimed to investigate effects and underlying mechanisms of distensions in these regions on intestinal motility and slow waves. Eight dogs chronically implanted with a duodenal fistula, a proximal colon fistula, and intestinal serosal electrodes were studied in six sessions: control, RD, CD, DD, RD + guanethidine, and CD + guanethidine. Postprandial intestinal contractions and slow waves were recorded for the assessment of intestinal motility. The electrocardiogram was recorded for the assessment of autonomic functions. (1) Isobaric RD and CD suppressed intestinal contractions (contractile index: 6.0 ± 0.4 with RD vs. 9.9 ± 0.9 at baseline, P = 0.001, 5.3 ± 0.2 with CD vs. 7.7 ± 0.8 at baseline, P = 0.008). Guanethidine at 3 mg/kg iv was able to partially block the effects. (2) RD and CD reduced the percentage of normal intestinal slow waves from 92.1 ± 2.8 to 64.2 ± 3.4 % (P < 0.001) and from 90 ± 2.7 to 69.2 ± 3.7 % (P = 0.01), respectively. Guanethidine could eliminate these inhibitory effects. (3) DD did not induce any changes in small intestinal contractions and slow waves (P > 0.05). (4) The spectral analysis of the heart rate variability showed that both RD and CD increased sympathetic activity (LF) and reduced vagal activity (HF) (P < 0.05). Isobaric RD and CD could inhibit postprandial intestinal motility and impair intestinal slow waves, which were mediated via the sympathetic pathway. However, DD at a site proximal to the measurement site did not seem to impair small intestinal contractions or slow waves.
Collapse
Affiliation(s)
- Jun Song
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, TX, USA.,Department of Gastroenterology, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Jieyun Yin
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, TX, USA.,Ningbo Pace Translational Medical Research Center, Beilun, Ningbo, People's Republic of China
| | - Jiande D Z Chen
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, TX, USA. .,Ningbo Pace Translational Medical Research Center, Beilun, Ningbo, People's Republic of China. .,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Johns Hopkins University, Baltimore, MD, 21224, USA.
| |
Collapse
|
17
|
Paul SP, Basude D. Non-pharmacological management of abdominal pain-related functional gastrointestinal disorders in children. World J Pediatr 2016; 12:389-398. [PMID: 27363985 DOI: 10.1007/s12519-016-0044-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 04/02/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Abdominal pain-related functional gastrointestinal disorder (AP-FGID) comprises of 4 main conditions: functional dyspepsia, irritable bowel syndrome, abdominal migraine and functional abdominal pain. AP-FGIDs are diagnosed clinically based on the Rome IV criteria for FGIDs of childhood. There is limited evidence for pharmacological therapies. DATA SOURCES This review article discusses nonpharmacological management of AP-FGID based on the current literature including systematic reviews, randomized controlled trials, cohort and case control studies. We aim to provide a comprehensive overview on the available evidence for the pediatricians and pediatric gastroenterologists involved in managing children with AP-FGID. RESULTS Managing AP-FGIDs can be challenging. This should follow a stepwise approach with focused history, identification of "red flag" signs and symptoms, physical examination and investigations done following initial consultation. Family needs explaining that there is nothing seriously wrong with the child's abdomen. This explanation and reassurance can achieve symptom control in large number of cases. Non-pharmacological interventions are delivered through lifestyle and dietary changes and bio-psychosocial therapies. Dietary interventions vary depending on the type of AP-FGID. Bio-psychosocial therapies such as hypnotherapy, cognitive behavioral therapy and yoga aim at stress reduction. CONCLUSION There is increasing evidence for use of non-pharmacological interventions in children with APFGID.
Collapse
Affiliation(s)
- Siba Prosad Paul
- Torbay Hospital, Vowden Hall, Lowes Bridge, Torquay, TQ2 7AA, UK.
| | - Dharamveer Basude
- Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| |
Collapse
|
18
|
Uchida M, Iwamoto C. Effect of colonic distension on gastric adaptive relaxation in rats: barostatic evaluation using an orally introduced gastric balloon. J Smooth Muscle Res 2016; 50:78-84. [PMID: 26081370 PMCID: PMC5137303 DOI: 10.1540/jsmr.50.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
While the gastrocolonic reflex has been known, the cologastric relationship has not been
clarified especially with regard to gastric adaptive relaxation. Therefore, in this study
we have examined the correlation between gastric adaptive relaxation and colonic
distension. Male Sprague-Dawley rats were used after fasting for 18 h. Colonic distension
was performed by injecting 2.2 ml of air into a colonic balloon inserted into the colon
for 5 min in conscious state. After urethane anesthesia, gastric adaptive relaxation was
investigated by using a slightly modified gastric balloon introduced into the stomach
through the mouth. Gastric balloon volumes increased gradually just after an increment in
the gastric balloon pressure (1 to 8 mmHg), and reached a plateau within 1 min. This
increased volume was defined as gastric adaptive relaxation. In control rats, gastric
adaptive relaxation increased with pressure increments in a pressure dependent manner. In
the colon-distended rats, gastric adaptive relaxation increased also in a pressure
dependent manner, but was significantly inhibited as compared with control at 8 mmHg
(P<0.05). These findings show that colonic distension inhibits the
gastric adaptive relaxation and suggests the existence of a cologastric relationship in
rats.
Collapse
Affiliation(s)
- Masayuki Uchida
- Food Science Research Laboratories, Division of Research and Development, Meiji Co. Ltd., Japan
| | | |
Collapse
|
19
|
Mehra R, Sodhi KS, Saxena A, Thapa BR, Khandelwal N. Sonographic evaluation of gallbladder motility in children with chronic functional constipation. Gut Liver 2016; 9:388-94. [PMID: 25167798 PMCID: PMC4413973 DOI: 10.5009/gnl13414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background/Aims Studies in adults suggest that constipation may not be a purely colonic pathology and may be a component of a generalized gastrointestinal (GI) motor disorder in which proximal GI motility can be impaired. Pediatric data are scarce, and the natural history of the disorder remains undefined. We aimed to evaluate gallbladder motility in a subset of Asian children with chronic functional constipation. Methods Abdominal ultrasound was performed on 105 children, including 55 patients (aged 3 to 13 years) with chronic functional constipation who met the inclusion criteria and 50 age- and gender-matched controls. The gallbladder contractility index was calculated based on the preprandial and postprandial gallbladder areas. Preprandial and postprandial values for gallbladder volume and wall thickness were evaluated. Results The mean value of the contractility index for the patients (15.77±24.68) was significantly lower than the mean value for the controls (43.66±11.58) (p=0.001). The mean postprandial gallbladder volumes and areas were larger in children with gallbladder hypomotility (p<0.05). The mean duration of constipation (4.8 months) was significantly higher (p=0.004) in the children with gall-bladder hypomotility. Conclusions Gallbladder motility is significantly impaired in children with chronic functional constipation. This study contributes to the understanding of the underlying pathophysiology, which will enable advancement in and improved management of children with chronic constipation and associated gallbladder hypomotility.
Collapse
Affiliation(s)
- Rakesh Mehra
- Department of Radio Diagnosis, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kushaljit Singh Sodhi
- Department of Radio Diagnosis, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Akshay Saxena
- Department of Postgraduate, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - B R Thapa
- Department of Gastroenterology, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radio Diagnosis, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
20
|
Rosen JM, Cocjin JT, Schurman JV, Colombo JM, Friesen CA. Visceral hypersensitivity and electromechanical dysfunction as therapeutic targets in pediatric functional dyspepsia. World J Gastrointest Pharmacol Ther 2014; 5:122-138. [PMID: 25133041 PMCID: PMC4133438 DOI: 10.4292/wjgpt.v5.i3.122] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/20/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
Functional gastrointestinal disorders (FGID) are common clinical syndromes diagnosed in the absence of biochemical, structural, or metabolic abnormalities. They account for significant morbidity and health care expenditures and are identifiable across variable age, geography, and culture. Etiology of abdominal pain associated FGIDs, including functional dyspepsia (FD), remains incompletely understood, but growing evidence implicates the importance of visceral hypersensitivity and electromechanical dysfunction. This manuscript explores data supporting the role of visceral hypersensitivity and electromechanical dysfunction in FD, with focus on pediatric data when available, and provides a summary of potential therapeutic targets.
Collapse
|
21
|
Abstract
Testing to define delayed gastric emptying is required to diagnose gastroparesis; rapid emptying is found in other patients. Commonly performed methods of gastric emptying testing include scintigraphy and breath testing. The SmartPill wireless motility capsule (WMC) system is US FDA-approved for evaluating suspected delayed emptying in gastroparesis and functional dyspepsia. The device measures transit in the stomach, small intestine, and colon by detecting characteristic pH transitions; and quantifies pressure waves in each gut region. WMC gastric emptying times correlate with scintigraphic measures. Incremental benefits of WMC testing in patients with suspected gastroparesis include delineation of pressure abnormalities and small intestinal and colonic transit delays. Acceptance of trial data confirming usefulness of WMC testing in suspected gastric motor disorders has been hampered by small sample sizes and design limitations. Ongoing multicenter studies will validate the utility of WMC methods in patients with suspected gastroparesis and other upper gastrointestinal motor disorders.
Collapse
Affiliation(s)
- William L Hasler
- Division of Gastroenterology, University of Michigan Health System, 3912 Taubman Center, SPC 5362, Ann Arbor, MI 48109, USA
| |
Collapse
|
22
|
Occult constipation: faecal retention as a cause of recurrent abdominal pain in children. Eur J Pediatr 2014; 173:781-5. [PMID: 24384798 DOI: 10.1007/s00431-013-2257-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 12/17/2013] [Indexed: 02/07/2023]
Abstract
UNLABELLED Recurrent abdominal pain (RAP) in children is generally believed to be functional. In practice, many children with RAP become pain-free with laxative therapy. The aims of the study were to establish the role of (occult) constipation in RAP and to investigate whether patients diagnosed with (occult) constipation could be identified by history and physical examination. During 2 years, all patients (age 4-16 years, secondary referral) fulfilling Apley criteria of RAP were included. After exclusion of gastrointestinal infections and food intolerance, laxatives were advised when pain persisted. (Occult) constipation was defined as 'abdominal pain disappearing with laxative treatment and not reappearing within a 6 month follow up period'; 'occult constipation' was diagnosed in patients who did not fulfil the Rome criteria of constipation. Two hundred children (87 M; median age 8.8 years) were evaluated. (Occult) constipation was found in 92 patients (46 %). Of these, 18 had considerable relief of pain when treated for a somatic cause but experienced complete relief only after laxative measures; they were considered to have two diagnoses. Using multivariate analysis, a simple model was developed with cystitis in past history, early satiety and flatulence as predictors for (occult) constipation. The risk of (occult) constipation ranged from 18/58 if no predictor was present to 4/4 if all three were present. CONCLUSION Laxatives played a pivotal role in the recovery of patients with RAP. We developed a simple model to identify patients at risk of having (occult) constipation.
Collapse
|
23
|
Kolar GJ, Camilleri M, Burton D, Nadeau A, Zinsmeister AR. Prevalence of colonic motor or evacuation disorders in patients presenting with chronic nausea and vomiting evaluated by a single gastroenterologist in a tertiary referral practice. Neurogastroenterol Motil 2014; 26:131-8. [PMID: 24118658 PMCID: PMC3865078 DOI: 10.1111/nmo.12242] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 09/12/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Nausea and vomiting are thought to result from upper gastrointestinal dysfunctions. Our clinical observations led to the hypothesis that colonic motor dysfunction is associated with nausea and vomiting. METHODS We reviewed electronic medical records (EMR) of 149 patients presenting with complaints of nausea and/or vomiting in a tertiary gastroenterology practice to investigate the association with disorders of colonic motor or evacuation disorders. We extracted demographics, gastric emptying (GE in 149) and colonic transit (CT in 138) of solids, ascending colon emptying half-time (AC t1/2 ), rectal evacuation by anorectal manometry (ARM) in 91 and balloon expulsion test (BE) in 55 patients. We estimated the proportions with delayed GE or CT, based on the 5th percentile of GE (in 319) and CT in 220 healthy volunteers using same method. KEY RESULTS Among 11 patients with nausea and/or vomiting with only GE measured, five had delayed and six normal GE. Among the 149 patients, 77 (52%) patients had evacuation disorders, confirmed by objective tests in 68 patients, and clinical examination in nine patients. In the 138 patients with both GE and CT measured, 106 (76%) had both normal GE and CT, 11 (8%) only delayed GE, 16 (11%) normal GE with delayed CT, and five (3%) delayed GE and CT. Among 21 patients (15%) with delayed CT, nine had slow AC t1/2 and 12 evacuation disorder. CONCLUSIONS & INFERENCES In patients with chronic nausea and/or vomiting in gastroenterology practice, evaluation of colonic motility and rectal evacuation should be considered, since about half the patients have abnormal functions that conceivably contribute to the presenting nausea and/or vomiting.
Collapse
Affiliation(s)
- G. J. Kolar
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER); Mayo Clinic; Rochester MN USA
| | - M. Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER); Mayo Clinic; Rochester MN USA
| | - D. Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER); Mayo Clinic; Rochester MN USA
| | - A. Nadeau
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER); Mayo Clinic; Rochester MN USA
| | - A. R. Zinsmeister
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER); Mayo Clinic; Rochester MN USA
| |
Collapse
|
24
|
Fernandes VPI, Lima MCL, Camargo EE, Collares EF, Bustorff-Silva JM, Lomazi EA. Gastric emptying of water in children with severe functional fecal retention. Braz J Med Biol Res 2013; 46:293-8. [PMID: 23532267 PMCID: PMC3854375 DOI: 10.1590/1414-431x20132448] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 01/14/2013] [Indexed: 01/18/2023] Open
Abstract
The objective of this study was to evaluate gastric emptying (GE) in pediatric
patients with functional constipation. GE delay has been reported in adults with
functional constipation. Gastric emptying studies were performed in 22 children
with chronic constipation, fecal retention and fecal incontinence, while
presenting fecal retention and after resuming regular bowel movements. Patients
(18 boys, median age: 10 years; range: 7.2 to 12.7 years) were evaluated in a
tertiary pediatric gastroenterology clinic. Gastric half-emptying time of water
(reference range: 12 ± 3 min) was measured using a radionuclide technique
immediately after first patient evaluation, when they presented fecal impaction
(GE1), and when they achieved regular bowel movements
(GE2), 12 ± 5 weeks after GE1. At study admission, 21
patients had reported dyspeptic symptoms, which were completely relieved after
resuming regular bowel movements. Medians (and interquartile ranges) for
GE1 and GE2 were not significantly different [27.0
(16) and 27.5 (21) min, respectively (P = 0.10)]. Delayed GE seems to be a
common feature among children with chronic constipation and fecal retention.
Resuming satisfactory bowel function and improvement in dyspeptic symptoms did
not result in normalization of GE data.
Collapse
Affiliation(s)
- V P I Fernandes
- Gastroenterologia Pediátrica, Departamento de Pediatria, Universidade Estadual de Campinas, Campinas, SP, Brasil.
| | | | | | | | | | | |
Collapse
|
25
|
Gijsbers CFM, Kneepkens CMF, Schweizer JJ, Benninga MA, Büller HA. Recurrent abdominal pain in 200 children: somatic causes and diagnostic criteria. Acta Paediatr 2011; 100:e208-14. [PMID: 21575052 DOI: 10.1111/j.1651-2227.2011.02351.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM To establish to what extent somatic causes can be found in children referred to secondary care with recurrent abdominal pain. METHODS For 2 years, all consecutive patients (age 4-16 years) fulfilling Apley criteria, referred to secondary care, were included. After a diagnostic work-up, stepwise therapeutic interventions were performed. A diagnosis was considered to be the cause of the pain when the patient became pain free following therapeutic intervention and remained so for at least 6 months. RESULTS Two hundred and twenty children (128 F, 92 M; mean age 8.8 years) were enrolled, of which 20 were lost to follow-up. Spontaneous recovery was seen in 54 patients, (occult) constipation in 92 patients (of whom 18 also had a somatic cause), gastrointestinal infections in 40, food allergy in five, miscellaneous disorders in seven and uncertain diagnosis in 13. In five patients, stress most likely caused the pain. A total of 198 patients became pain free and remained so during follow-up (mean 18, range 6-60 months). CONCLUSION In 200 children with recurrent abdominal pain, somatic causes were found in 26%. Laxative therapy was successful in 46%, resulting in nearly all patients with functional abdominal pain to become pain free. Eventually, 99% became pain free using a therapeutic intervention protocol.
Collapse
Affiliation(s)
- C F M Gijsbers
- Department of Paediatric Gastroenterology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands.
| | | | | | | | | |
Collapse
|
26
|
Abstract
PURPOSE OF REVIEW Disorders of colonic motor and sensory function are common among children and adults and pose significant diagnostic and therapeutic challenges; the purpose of this review, therefore, was to critically assess the recent literature on this topic. RECENT FINDINGS Considerable progress has been made at the ultrastructural, molecular and electrophysiological level in understanding the normal functions of the muscles, nerves and interstitial cells that generate and control colonic motility. Furthermore, abnormalities in these cell types and in the interstitial cells of Cajal, in particular, have been identified in a number of disease states. Testing of colonic motor and sensory function in clinical practice continues to be a challenge due, in part, not only to the technical issues presented by accessing the organ but also to the intrinsic variability of its physiology. These have not been auspicious times for advances in the therapy of disturbed colonic motility; new agents or new applications for 'old' agents continue to be explored as are more innovative approaches such as those based on neural stimulation and cell therapy. SUMMARY Considerable progress has been made in understanding the basic pathophysiology of colonic dysmotility; clinical diagnostics and therapeutics continue to lag behind.
Collapse
|
27
|
Abstract
PURPOSE OF REVIEW Abnormalities of gastric sensory and motor function are considered key players in the pathogenesis of upper gastrointestinal symptoms in functional dyspepsia and in gastroparesis. This review summarizes recent progress in our understanding of gastric sensory and motor function in health and in disease. RECENT FINDINGS Although assessment of gastric emptying rate is often used in the clinical work-up of patients with functional dyspepsia or gastroparesis, the correlation with symptoms is generally poor. Central processing, related to psychosocial dysfunction, is increasingly implicated in the pathogensis of gastric hypersensitivity. Meal challenge test and in fact even simple ingestion of a meal induce increased symptom occurrence in functional dyspepsia. Impaired motor function in critically ill patients is increasingly being studied and recognized as a prognostically relevant factor. Studies have reported on pharmacological approaches as well as electrical stimulation in the treatment of gastric sensorimotor dysfunction. SUMMARY Progress in our understanding of the normal and abnormal gastric sensory and motor function may lead to new or improved treatment modalities. Areas of recent advances are the role of the central nervous system in visceral hypersensitivity, motor abnormalities of the stomach in critically ill patients and the exploration of novel pharmacotherapeutic approaches.
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW Chronic constipation remains one of the most frequent complaints in primary and subspecialty pediatric clinics. It is associated with significant emotional and economic burden for both the children and the caregivers. Recently, advances have expanded our understanding of the pathophysiology and treatment options for children with chronic constipation. Here, we review current strategies addressing the cause, diagnostic technologies and treatments of chronic constipation. RECENT FINDINGS There is some new information presented here on techniques for diagnosis and long-term complications associated with chronic childhood constipation. Comparative data on current laxatives and the development of medications with novel mechanisms of action are reviewed for a glimpse into the horizon of possible new treatments for children with chronic constipation. Studies on effects of growth, quality of life, dietary fiber and symptoms, which may coexist with constipation, are discussed. SUMMARY The recent literature on chronic constipation has provided some new knowledge providing a more evidence-based approach to treating these patients. We review the scope of this problem and the estimated cost of treating constipation. The availability of long-term outcome data enhances our understanding of the natural history of this problem. Newer pharmacological approaches provide optimism for treatment for this common problem.
Collapse
|
29
|
Waseem S, Moshiree B, Draganov PV. Gastroparesis: Current diagnostic challenges and management considerations. World J Gastroenterol 2009; 15:25-37. [PMID: 19115465 PMCID: PMC2653292 DOI: 10.3748/wjg.15.25] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis refers to abnormal gastric motility characterized by delayed gastric emptying in the absence of mechanical obstruction. The most common etiologies include diabetes, post-surgical and idiopathic. The most common symptoms are nausea, vomiting and epigastric pain. Gastroparesis is estimated to affect 4% of the population and symptomatology may range from little effect on daily activity to severe disability and frequent hospitalizations. The gold standard of diagnosis is solid meal gastric scintigraphy. Treatment is multimodal and includes dietary modification, prokinetic and anti-emetic medications, and surgical interventions. New advances in drug therapy, and gastric electrical stimulation techniques have been introduced and might provide new hope to patients with refractory gastroparesis. In this comprehensive review, we discuss gastroparesis with emphasis on the latest developments; from the perspective of the practicing clinician.
Collapse
|
30
|
Abstract
Fecal impactions occur in both sexes at any age but are particularly concentrated in children, in the institutionalized or impaired elderly, and in patients with certain psychiatric disorders or medical conditions that predispose to obstipation. The clinical consequences may be disabling and occasionally life threatening. Clinical manifestations include fecal incontinence, abdominal distention and pain, anorexia, weight loss, intestinal obstruction, and stercoral ulceration with bleeding or colonic perforation. Diagnosis begins with recognition of possible fecal impaction and confirmation by digital examination or abdominal radiography. Management consists of disimpaction, colon evacuation, and a maintenance bowel program to prevent recurrent impactions.
Collapse
|