Gastrointestinal symptoms in diabetes mellitus, and their relation to anxiety and depression

Diabetes distress and depression are independently associated with gastrointestinal symptoms in type 2 diabetes in Bangladesh

BACKGROUND AND AIMS

Gastrointestinal (GI) symptoms, common in type 2 diabetes (T2D), are typically bothersome, socially embarrassing, and impact negatively on quality of life. They may also contribute to diabetes distress (DD), but this has never been formally evaluated. We aimed to investigate the relationships between GI symptoms, DD and depressive symptoms in a large cohort of individuals with T2D in Bangladesh.

MATERIALS AND METHODS

1406 unselected T2D individuals (female 58.8%; mean age 51.0 ± 12.5 years) from four diabetes clinics in Bangladesh completed validated questionnaires evaluating GI symptoms (PAGI-SYM), DD (DDS-17) and depressive symptoms (PHQ-9).

RESULTS

31.1% of participants reported GI symptoms (36.2% females, 23.7% males), while 51.1% had elevated DD and 37.8% depressive symptoms. GI symptoms exhibited independent relationships with both DD and depressive symptoms, and their likelihood was higher among those with DD (OR: 3.6 [2.2-5.6] and with depressive symptoms (OR: 5.9 [3.5-9.9]).

CONCLUSIONS

GI symptoms are independently associated with both DD and depressive symptoms in people with T2D in Bangladesh.

Gastrointestinal adverse effects of old and new antidiabetics: How do we deal with them in real life?

Diabetes is a public health problem with an estimated worldwide prevalence of 10% and a prevalence of 12% in Mexico. The costs resulting from this chronic-degenerative disease are significant. Treatment for diabetes involves different medication groups, some of which can cause significant gastrointestinal adverse effects, such as dyspepsia, nausea, vomiting, bloating, diarrhea, and constipation. The medications most frequently associated with said adverse effects are metformin, acarbose, and GLP-1 agonists. Gastrointestinal adverse effects negatively impact the quality of life and management of patients with diabetes. The factors of visceral neuropathy, acute dysglycemia, dysbiosis, and intestinal bacterial overgrowth contribute to the gastrointestinal symptoms in patients with diabetes, making it necessary to consider multiple etiologic factors in the presence of gastrointestinal symptoms, and not exclusively attribute them to the use of antidiabetics. Personalized treatment, considering gastrointestinal comorbidity and the type of drug utilized, is essential for mitigating the adverse effects and improving the quality of life in patients with diabetes. The aim of the present narrative review was to describe the gastrointestinal adverse effects of the antidiabetic drugs, their pathophysiologic mechanisms, and the corresponding therapeutic measures.

Type II diabetes mellitus increases the risk of inflammatory bowel disease in a prospective cohort study

BACKGROUND

Inflammatory bowel disease is a common digestive disorder and diabetes can lead to intestinal dysfunction. Patients with inflammatory bowel disease in combination with diabetes present a higher rate of hospitalization and consumption of medical resources, yet the association between type 2 diabetes and Inflammatory bowel disease remains unknown.

METHODS

We studied 313,008 participants from the UK Biobank, including 5891 patients with type 2 diabetes at baseline. Multivariate Cox proportional risk models were constructed to examine the risks associated with type 2 diabetes and inflammatory bowel disease and its subtypes (Crohn's disease, ulcerative colitis). Potential confounders including sociodemographic, lifestyle, physical body indicators, psychological state, hypertension, and thyroid-related disorders were adjusted. Propensity score matching was also performed to analyze their sensitivity.

RESULTS

Of a total of 313,008 participants included in the study, 5891 (1.88 %) were diagnosed with type 2 diabetes mellitus at baseline and 1829 (0.58 %) of the entire cohort developed inflammatory bowel disease during follow-up, with a median follow-up time of 13.72 years. Patients with type 2 diabetes had a higher cumulative risk of inflammatory bowel disease compared to the non-type 2 diabetes population (inflammatory bowel disease: 1.24% vs. 0.57%, p < 0.001; Crohn's disease: 0.46% vs. 0.15%, p < 0.001; ulcerative colitis: 0.73% vs. 0.35%, p < 0.001). Multivariate Cox regression analysis showed that type 2 diabetes was independently associated with inflammatory bowel disease (Hazard Ratio: 1.61 [95% Confidence Interval: 1.26-2.06], p < 0.001), Crohn's disease (Hazard Ratio: 2.10 [95% Confidence Interval: 1.39-3.17], p < 0.001) and ulcerative colitis (Hazard Ratio: 1.58 [95% Confidence Interval: 1.15-2.18], p = 0.005). In a propensity-matched analysis, type 2 diabetes still showed its ability to predict the risk of inflammatory bowel disease (Hazard Ratio: 2.09 [95% Confidence Interval: 1.55-2.83], p < 0.001), Crohn's disease (Hazard Ratio: 3.49 [95% Confidence Interval: 2.00 to 6.09], p < 0.001), and ulcerative colitis (Hazard Ratio: 1.76 [95% Confidence Interval: 1.20 to 2.56], p = 0.003) of robustness.

CONCLUSION

In patients with type 2 diabetes mellitus, the risk of inflammatory bowel disease is higher, and the presence of gastrointestinal symptoms in patients with type 2 diabetes requires vigilance for the possibility of inflammatory bowel disease in clinical practice.

Association of gastrointestinal symptoms and skipping breakfast with anxiety and depressive symptoms in quarantined Chinese college students during the Shanghai 2022 lockdown: a cross sectional survey

BACKGROUND

This study aimed to evaluate the prevalence of anxiety and depressive symptoms among quarantined college students at school in Shanghai 2022 lockdown during the COVID-19 pandemic and investigate the association of gastrointestinal discomfort related-factors and skipping breakfast with anxiety and depressive symptoms.

METHODS

384 quarantined college students in Shanghai China were recruited in this cross-sectional study from April 5th to May 29th, 2022. Generalized Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9) were used to assess anxiety and depressive symptoms, respectively.

RESULTS

The prevalence of anxiety and depressive symptoms were 56.8% and 62.8%, respectively. Longer quarantine duration, higher education level, skipping breakfast, stomachache or abdominal pain, and nausea or dyspepsia were significantly associated with anxiety symptoms. Moreover, longer quarantine duration, being woman, skipping breakfast, stomachache or abdominal pain, and nausea or dyspepsia were markedly related to depressive symptoms. Notably, regularly physical exercising and taking positive attitude towards COVID-19 were negatively correlated with anxiety and depressive symptoms.

CONCLUSIONS

More attention should be paid to anxiety and depressive symptoms of quarantined college students and universities should provide timely psychological monitoring and intervention services to mitigate the impact of negative emotions on students. Effectively relieving gastrointestinal symptoms, insisting on eat breakfast, regularly exercising, and taking a positive attitude towards to COVID-19 might contribute to preventing the anxiety and depressive symptoms for those college students experiencing a long-term quarantine.

Clinical Characteristics of Patients Presenting With Bloating as a Predominant Symptom

BACKGROUND

The estimated prevalence of bloating is 15 to 30% in the adult US population and is even higher in patients with disorders of gut-brain interaction (DGBIs). Despite this frequency, there is little research into patients who endorse bloating as a predominant symptom. The aim of this study was to better characterize these patients.

MATERIALS AND METHODS

New patients with DGBIs were asked to identify their 3 most predominant symptoms over the preceding 3 months; those who reported bloating were classified as "bloating predominant." Rome IV and symptom-specific questionnaires were administered to assess for the frequency of DGBIs and other predominant symptoms in this patient population. Using univariable and multivariable modeling, we analyzed the associations between bloating predominance, DGBI subtype, and clinical characteristics.

RESULTS

Of the 586 patients surveyed, 242 (41%) reported predominant bloating. Bloating-predominant patients were more likely to be female, younger, and meet the criteria for IBS-mixed (IBS-M), functional constipation, and functional dyspepsia compared with nonbloating-predominant patients. Bloating-predominant patients were also more likely to endorse concurrently predominant constipation, incomplete evacuation, abdominal pain, belching, and/or nausea. On multivariable logistic regression, constipation and abdominal pain severity were positively associated, although depression was negatively associated with predominant bloating.

CONCLUSIONS

Patients with predominant bloating are more likely to have constipation-related symptoms than diarrhea-related symptoms. They are also more likely to have more severe abdominal pain than patients without predominant bloating. These findings help characterize patients with bloating as a predominant symptom and suggest that diagnosing and treating constipation should be considered as first-line treatment.

Diabetic Gastroparesis and its Emerging Therapeutic Options: A Narrative Review of the Literature

Diabetic gastroparesis (DG) is one of the many complications of diabetes mellitus (DM). Even though this condition surfaces years after uncontrolled disease, it affects the quality of life in several ways and causes significant morbidity. Common symptoms experienced by the patients include postprandial nausea, vomiting, abdominal fullness, and pain. Strict glycemic control is essential to evade the effects of DG. The purpose of this review article is to briefly study the pathophysiology, clinical features, diagnostic modalities, and the effects of DG on different aspects of life. Furthermore, it also focuses on the emerging treatment modalities for DG. Tradipitant and relamorelin are two such treatment options that are gaining noteworthy recognition and are discussed in detail in this review article. As observed through various clinical trials, these drugs help alleviate symptoms like nausea, vomiting, abdominal pain, and bloating in patients suffering from DG, thereby targeting the most common and bothersome symptoms of the disease. This leads to an improvement in the quality of life, making it a reliable treatment option for this disease. But while pharmacological intervention is vital, psychological support and lifestyle changes are equally important and are the reason why a multidisciplinary approach is required for the treatment of DG.

Prevalence of Chronic Metabolic Comorbidities in Acute Pancreatitis and Its Impact on Early Gastrointestinal Symptoms during Hospitalization: A Prospective Cohort Study

Background

The prevalence of chronic comorbidities is increasing worldwide, and this has been paralleled by a growing interest in how these comorbidities affect patients with acute pancreatitis. The aim was to investigate the associations between pre-existing diabetes mellitus, obesity, metabolic syndrome, and gastrointestinal symptoms during the early course of acute pancreatitis.

Methods

This was a prospective cohort study of patients with a primary diagnosis of acute pancreatitis. Study groups were formed based on the presence of metabolic comorbidities (pre-existing diabetes mellitus, obesity, and metabolic syndrome). Patient-reported outcomes (nausea, bloating, and abdominal pain) were collected prospectively every 24 h (including weekends and public holidays) over the first 72 h of hospitalization.

Results

A total of 183 consecutive patients were enrolled. Of them, 111 (61%) had at least one major metabolic comorbidity. Patients with pre-existing diabetes mellitus and those with metabolic syndrome had worse nausea at 49-72 h of hospitalization (p = 0.017 and p = 0.012, respectively), but not at other time points. Bloating and abdominal pain did not differ between the study groupings throughout the study period. The studied patient-reported outcomes did not differ significantly between acute pancreatitis patients with and without obesity at any point in time.

Conclusion

More than 3 out of 5 patients hospitalized for acute pancreatitis have at least one major chronic metabolic comorbidity. The presence of metabolic comorbidities does not considerably and consistently affect early gastrointestinal symptoms in patients with acute pancreatitis.

Gastrointestinal transit and contractility in diabetic constipation: A wireless motility capsule study on diabetes patients and healthy controls

BACKGROUND

Diabetic constipation is traditionally attributed to slow colonic transit, despite limited evidence. More than half of patients find treatment unsatisfactory. To improve treatment, there is a need for better diagnostic understanding of the condition.

OBJECTIVE

In this wireless motility capsule study, we aimed to investigate gastrointestinal transit and contractility in diabetes patients with and without constipation, and in healthy controls.

METHODS

We prospectively included type 1 or type 2 diabetes patients with gastrointestinal symptoms. Based on the Gastrointestinal Symptom Rating Scale we distinguished into two groups: with constipation and without constipation. Non-diabetic controls were asymptomatic. All were examined with wireless motility capsule, determining transit times and contractility parameters.

RESULTS

57 patients (42 women, 46 with type 1 diabetes) and 26 healthy controls (14 women) were included. We found no difference in transit times between diabetes patients with and without constipation. Compared to healthy controls (35:55, h:min), whole-gut transit was slower in both diabetes patients with constipation (66:15, p = 0.03) and without constipation (71:16, p < 0.001). Small bowel motility index correlated rs  = -0.32 (p = 0.01) with constipation symptoms.

CONCLUSIONS

Diabetes patients with constipation had similar transit times as those without constipation. Both groups had slower whole-gut transit than healthy controls. Constipation was associated with reduced small bowel, but not colonic contractility. Our results imply that other mechanisms than slow colonic transit may be more important in the pathogenesis of diabetic constipation.

Prediabetes and gastrointestinal (GI) symptoms; a cross-sectional study

AIMS

Prediabetes associate with known micro and macrovascular complications of diabetes. Also gastrointestinal symptoms are present in diabetics higher than general population. The aim of this study was evaluation of gastrointestinal symptoms in subjects with prediabetes.

METHODS

This analytical cross-sectional study was conducted on 130 persons 30-65 years old, 65 pre-diabetic patients and 65 persons without glucose disorders from 2014 to 2015 in YAZD province. FBS and HbA1c used for diagnosis prediabetes. Demographic and medical history were collected. A questionnaire according to Rome III Criteria was used to collect digestive information (diarrhea, abdominal pain, constipation, abdominal bloating, heartburn, increased gas passing, nausea, intermittent diarrhea and constipation in the last 6 months ago). Frequency of GI symptoms in subjects with and without glucose disorders were compared. Data were analyzed by SPSS software Version 20. Data were reported as mean ± standard deviation or frequency and T-test, Chi Square and Spearman correlation coefficient tests were used. P-value less than 0.05 were considered statistically significant.

RESULTS

Higher frequency of bloating, early satiety, nausea, heartburn, gas passing and constipation are seen in the pre-diabetes group than in the control group; (p-value 0.0001, 0.0001, 0.0001, 0.0001, 0.001 and 0.0001 respectively). 96.9% in prediabetics had at least one gastrointestinal symptom, while in the normal groups 50% had at least one GI symptom (p-value: 0.0001).

CONCLUSIONS

Gastrointestinal symptoms were seen in prediabetics higher than healthy persons. So, prediabetes can not be considered an entirely benign and asymptomatic condition. Lifestyle interventions maybe necessary at this state.

Gastrointestinal Symptoms in Diabetes: Prevalence, Assessment, Pathogenesis, and Management

If you haven't measured something, you really don't know much about it.-Karl Pearson (attributed)Gastrointestinal (GI) symptoms represent an important and often unappreciated cause of morbidity in diabetes, although the significance of this burden across the spectrum of patients and the underlying pathophysiology, including the relationship of symptoms with glycemic control, remain poorly defined. The relevance of GI symptoms and the necessity for their accurate assessment have increased with the greater focus on the gut as a therapeutic target for glucose lowering. This review addresses the prevalence, assessment, pathogenesis, and management of GI symptoms in diabetes, beginning with broad principles and then focusing on specific segments of the GI tract. We initially performed a literature search of PubMed by using synonyms and combinations of the following search terms: "gastrointestinal symptoms", "diabetes", "prevalence", "pathogenesis", "diagnosis", and "management". We restricted the search results to English only. Review papers and meta-analyses are presented as the highest level of evidence where possible followed by randomized controlled trials, uncontrolled trials, retrospective and observational data, and expert opinion.

A longitudinal study on patients with diabetes and symptoms of gastroparesis - associations with impaired quality of life and increased depressive and anxiety symptoms

AIMS

To examine patient reported outcomes (PRO) in patients previously assessed for diabetic gastroparesis, and to investigate how symptoms of gastroparesis evolve over time. In addition, to further evaluate outcomes in those with versus without diabetic gastroparesis at baseline.

METHODS

Thirty-four patients with diabetes and gastrointestinal (GI) symptoms, diagnosed with or without diabetic gastroparesis in 2011-2013, were included in this follow-up study. PRO were measured with the Patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM), 36-Item Short Form Survey (SF-36), Patient assessment of upper gastrointestinal disorders-quality of life (PAGI-QOL) and Hospital Anxiety and Depression Scale (HADS). Demographic factors and clinical variables were also recorded.

RESULTS

Participants diagnosed with gastroparesis had improved glycemic control (p=0.04) and less GI symptoms (p=0.001), after a follow-up time of 3.2years (mean). Both groups reported severely impaired quality of life (QoL). In total 47% reported symptoms of anxiety, 38% symptoms of depression (scores≥8). GI symptom severity or other PRO could not differentiate between the two groups.

CONCLUSIONS

Patients diagnosed with diabetic gastroparesis, as well as those with gastroparesis symptoms - but normal gastric emptying, suffer from severely impaired QoL and a high burden of anxiety and depressive symptoms.

The Association Between Fasting C-peptide and Gastrointestinal Symptoms of Gastroparesis in Type 2 Diabetic Patients

Background/Aims

The relationship between C-peptide levels and gastrointestinal (GI) symptoms in type 2 diabetic patients is not clear. The purpose of this study is to examine the association between fasting C-peptide and GI symptoms of gastroparesis in type 2 diabetic patients.

Methods

We recruited 333 type 2 diabetic patients into the present study. All patients filled out questionnaires of gastroparesis cardinal symptom index (GCSI) to evaluate GI symptoms. Hospital anxiety and depression scale were adopted to define anxiety and depression. Patients with GCSI scores ≥ 1.9 were regarded as having symptoms of gastroparesis.

Results

In our study, 71 (21.3%) type 2 diabetic patients had GCSI scores ≥ 1.9. In comparison to patients with scores < 1.9, those with scores ≥ 1.9 had significantly lower fasting c-peptide levels (1.49 ng/mL vs 1.94 ng/mL, P < 0.001), higher prevalence of depression (40.9% vs 18.3%, P < 0.001) and anxiety (28.2% vs 13.0%, P = 0.002). Multivariate logistic regression revealed that fasting C-peptide was still significantly associated with symptoms of gastroparesis (odds ratio, 0.67; 95% confidence intervals, 0.48–0.94; P = 0.021), even after adjustments for age, sex, body mass index, HbA1c, current smoking and drinking status, anxiety, and depression. Furthermore, linear regressions showed that fasting C-peptide was independently and negatively related to GCSI scores (standardized regression coefficient, −0.29; P < 0.001) in patients with at least one GI symptom.

Conclusion

GI symptoms of diabetic gastroparesis affect approximately 20% of type 2 diabetes patients and are associated with lower fasting C-peptide levels independent of depression and anxiety status.

Testing for Chronic Diarrhea

Chronic diarrhea is a frequently encountered symptom in clinical practice. The etiologies for chronic diarrhea are diverse and broad with varying clinical implications. A useful method of categorizing chronic diarrhea to guide a diagnostic work-up is a pathophysiology-based framework. Chronic diarrhea may be categorized as malabsorptive, secretory, osmotic, and inflammatory or motility related. Frequently, overlap between categories may exist for any given diarrhea etiology and diagnostic testing must occur with an understanding of the differential diagnosis. Investigations to achieve a diagnosis for chronic diarrhea range from screening blood and stool tests to more directed testing such as diagnostic imaging, and endoscopic and histological evaluation. The pathophysiology-based framework proposed in this chapter will allow the clinician to select screening tests followed by targeted tests to minimize cost and complications to the patient, while providing a highly effective method to achieve an accurate diagnosis.

The impact of gastroparesis on diabetes control: Patient perceptions

The impact of gastroparesis on diabetes management and control from the patient perspective has not been well characterized. The aim of this study was to identify patient perceptions regarding the impact of gastroparesis on managing their diabetes.

METHODS

Patients with diabetes being referred for gastroparesis were enrolled in this prospective study. Gastroparetic symptom severity was assessed with the Patient Assessment of Upper GI Symptoms (PAGI-SYM). A questionnaire examined the impact of gastroparesis on diabetes related symptoms and control.

RESULTS

54 diabetic gastroparesis patients (36 T1DM, 18 T2DM) participated. Duration of diabetes averaged 17.4±1.4years and gastroparetic symptoms 5.1±1.1years. Patients rated their most severe symptoms as postprandial fullness, early satiety, and nausea. Two thirds of diabetic subjects identified that since their diagnosis of gastroparesis, their diabetes was more difficult to control (44 of 54 patients) and that extra time and effort were required for care of their diabetes (45 of 54). Patients with T1DM, compared to those with T2DM, more often expressed that since developing gastroparesis, their blood sugars have been higher, they have had more frequent episodes of hypoglycemia, and they found that their gastroparetic symptoms worsened if blood sugars were too high.

CONCLUSIONS

Gastroparesis has a significant impact on patients' perceived ability to self-manage and control their diabetes. T1DM patients, in particular, associate their gastroparesis with episodes of hyper- and hypo-glycemia, and find their gastroparetic symptoms worsen with poor control. Future research should focus on strategies to support self-management of patients with diabetic gastroparesis.

Climacteric symptoms in middle-aged women with chronic somatic diseases

OBJECTIVES

Chronic diseases may aggravate or simulate climacteric symptoms. Although acknowledged in clinical practice, there is a lack of research systematically analysing the association between chronic diseases and climacteric symptoms.

STUDY DESIGN AND MAIN OUTCOME MEASURES

Our study was a cross-sectional population-based study, which included 3421 women, aged 41-54 years. Climacteric symptoms were evaluated using the Women's Health Questionnaire (WHQ), of which we included seven symptom domains (vasomotor, sleep, depressive, anxiety/fears, cognitive, sexual, and menstrual) and a question concerning whether the women were worried about growing old. The occurrence of various diseases (cardiovascular, neurological, sensory organ, bronchopulmonary, musculoskeletal, gastrointestinal, urological, dermatological, and thyroid disease, diabetes, and cancer) was recorded. The associations between the diseases and symptoms were defined with multivariable analyses, adjusting for various confounding factors.

RESULTS

The women with the diseases had more symptoms. Vasomotor symptoms and sleep problems were associated only with gastrointestinal diseases, and lower sexual functioning only with diabetes. The remaining symptoms were associated with several diseases, except being worried about growing old, which was not associated with any.

CONCLUSIONS

Many symptoms connected to the climacteric may manifest also due to chronic diseases. Thus, health-care professionals should consider the origin of the symptoms when treating middle-aged women with chronic diseases.

Self-Reported Gastrointestinal Symptoms in Type 2 Diabetes Improve With an Intensive Lifestyle Intervention: Results From the Action for Health in Diabetes (Look AHEAD) Clinical Trial

In Brief This article reports on an investigation of whether an intensive lifestyle intervention (ILI) would reduce gastrointestinal symptoms over 4 years of follow-up for participants in the Action for Health in Diabetes (Look AHEAD) trial compared to a diabetes support and education (DSE) group. Look AHEAD is a randomized, multicenter trial comparing overweight and obese adults with type 2 diabetes treated with ILI versus DSE. ILI, and weight loss in general, had beneficial effects on gastrointestinal (GI) symptoms, with some variability in the strength of the effect depending on the specific symptom and time course. Potential modifiers were analyzed, yet ILI retained an association with improvement in GI symptoms.

Global prevalence of, and risk factors for, uninvestigated dyspepsia: a meta-analysis

OBJECTIVES

Many cross-sectional surveys have reported the prevalence of uninvestigated dyspepsia, but there has been no recent systematic review of data from all studies to determine its global prevalence and risk factors.

DESIGN

MEDLINE, EMBASE and EMBASE Classic were searched (until January 2014) to identify population-based studies that reported the prevalence of uninvestigated dyspepsia in adults (≥ 15 years old); dyspepsia was defined using symptom-based criteria or questionnaires. The prevalence of dyspepsia was extracted for all studies and according to the criteria used to define it. Pooled prevalence, according to study location and certain other characteristics, ORs and 95% CIs were calculated.

RESULTS

Of the 306 citations evaluated, 103 reported the prevalence of uninvestigated dyspepsia in 100 separate study populations, containing 312,415 subjects. Overall pooled prevalence in all studies was 20.8% (95% CI 17.8% to 23.9%). The prevalence varied according to country (from 1.8% to 57.0%) and criteria used to define dyspepsia. The greatest prevalence values were found when a broad definition of dyspepsia (29.5%; 95% CI 25.3% to 33.8%) or upper abdominal or epigastric pain or discomfort (20.4%; 95% CI 16.3% to 24.8%) were used. The prevalence was higher in women (OR 1.24; 95% CI 1.13 to 1.36), smokers (OR 1.25; 95% CI 1.12 to 1.40), non-steroidal anti-inflammatory drug (NSAID) users (OR 1.59; 95% CI 1.27 to 1.99) and Helicobacter pylori-positive individuals (OR 1.18; 95% CI 1.04 to 1.33).

CONCLUSIONS

The overall pooled prevalence of uninvestigated dyspepsia was 21%, but varied among countries and according to the criteria used to define its presence. Prevalence is significantly higher in women, smokers, NSAID users and H. pylori-positive individuals, although these associations were modest.

Expression of FGF-2 and IGF-1 in diabetic rats with fracture

OBJECTIVE

To observe the change of fibroblast growth factor-2 (FGF-2), insulin-like growth factor-1 (IGF-1) in serum and bone callus after fracture in diabetic rats, and to explore molecular biological mechanism of healing of diabetic fracture.

METHODS

Thirty male SD rats were designed into normal (n=15) and control (n=15) groups randomly. Venous blood was extracted on the lst, 2nd, 4th, 6th, 8th week after surgery. It was certificated and the serum was obtained. Left lower extremity was observed by X- ray. Bone callus at broken ends was observed under light microscope. Expressions of FGF-2 and IGF-1 in tissue were detected by immunohistochemistry method, and ELISA was used to detect expression of FGF-2 and IGF-1 in serum.

RESULTS

The results showed a significant increase in the density and area of newly formed bone in the distraction gaps of normal rats compared to control rats. Increased cell proliferation was also found in the distraction gaps of normal rats versus control rats. There was significant difference in serum levels of FGF-2 and IGF-1 between two groups.

CONCLUSIONS

The decrease of FGF-2 and IGF-1 both in the serum and in the fracture region is one of the reasons for bad bone healing or delayed union in rats' fracture with diabetes. There are some synergistic effects possibly between FGF-2 and IGF-1.

Electroacupuncture at ST36 increases contraction of the gastric antrum and improves the SCF/c-kit pathway in diabetic rats

Electroacupuncture (EA) at ST36 is effective for improving gastric motility. However, the underlying mechanism remains poorly understood. The aim of this study was to investigate the effects of EA on gastric contraction and to determine whether interstitial cells of Cajal (ICCs) are involved. Rats were randomized into control, diabetic (DM), diabetic with sham EA (DM + SEA), diabetic with low frequency EA (DM + LEA) and diabetic with high frequency EA (DM + HEA) groups. EA was performed everyday for four and eight weeks. Contractions in antrum strips were explored using the organ bath technique. Western blotting was employed to determine c-kit and transmembrane stem cell factor (M-SCF) expression in the gastric antrum, and levels of soluble stem cell factor (S-SCF) in serum were determined by enzyme-linked immunosorbent assay (ELISA). The distribution of ICCs was further assessed by immunohistochemistry. The results were as follows: (1) Contractions in the DM group were attenuated at four and eight weeks, but LEA and HEA restored the attenuated contraction. (2) ICCs were significantly decreased at eight weeks without alteration at four weeks in DM group, but were rescued in the LEA and HEA groups. (3) Whereas M-SCF and S-SCF in the DM group were slightly decreased at four weeks and were dramatically reduced at eight weeks, LEA and HEA markedly enhanced SCF at eight weeks. Collectively, the data suggest that in diabetic rats, LEA and HEA at ST36 could facilitate contraction of the gastric antrum, possibly by involving the SCF/c-kit pathway.

Association between visceral, cardiac and sensorimotor polyneuropathies in diabetes mellitus

AIMS

Gastrointestinal complaints are common in diabetes mellitus. However, its association to peripheral sensorimotor and autonomic neuropathies is not well investigated. The aim was to assess skin, muscle, bone and visceral sensitivity in diabetes patients with sensorimotor neuropathy, and correlate these with gastrointestinal symptoms and degree of cardiac autonomic neuropathy.

METHODS

Twenty patients with sensorimotor neuropathy (65% type 2 diabetes, aged 58.3±12.0 years, diabetes duration 15.8±10.0 years) and 16 healthy controls were recruited. Cutaneous sensitivity to von Frey filaments, mechanical allodynia, muscle/bone/rectosigmoid sensitivities, and heart rate variability were examined. Gastrointestinal symptom scores (PAGI-SYM) and health-related quality of life (SF-36) were also recorded.

RESULTS

Patients displayed hypesthesia to von Frey filaments (p=0.028), but no difference to muscle and bone pain sensitivities. Also, patients were hyposensitive to multimodal rectal stimulations (all p<0.05), although they suffered more gastrointestinal complaints. Heart rate variability was reduced in the patient cohort. Rectal mechanical and cutaneous sensitivities correlated (p<0.001), and both were associated with heart rate variability as well as PAGI-SYM and SF-36 scores (p<0.01).

CONCLUSIONS

In diabetic sensorimotor neuropathy there is substantial evidence of concomitant cutaneous, cardiac and visceral autonomic neuropathies. The neuropathy may reduce quality of life and explain the higher prevalence of gastrointestinal complaints.

Rectal sensitivity in diabetes patients with symptoms of gastroparesis

In a clinical setting, diabetic autonomic complications (cardiac, gastrointestinal, urogenital, etc.) are often handled as separate entities. We investigated rectal sensitivity to heat, mechanical distension, and electrical stimulations in 20 patients with diabetes and symptoms of gastroparesis, to evaluate the extent of visceral neuronal damage. Furthermore, to evaluate the relation between the nervous structures we examined gastric emptying and cardiac autonomic function with the hypothesis being an association between these. We found that 60% of patients had delayed gastric empting. Rectal hyposensitivity was a general finding as they tolerated 67% higher thermal, 42% more mechanical, and 33% higher electrical current intensity compared to healthy controls. In patients, most heart rate variability parameters were reduced; they reported significantly more gastrointestinal symptoms and a reduced quality of life in all SF-36 domains. Shortened RR interval correlated with reduced rectal temperature sensitivity, and gastric retention rate was negatively associated with symptoms of nausea and vomiting. To conclude, in these patients with signs and symptoms of diabetic gastroparesis, rectal sensitivity was reduced, and heart rate variability was impaired. Thus, we suggest regarding diabetic autonomic neuropathy as a diffuse disorder. Symptoms of widespread autonomic dysfunction and sensory disorders should be expected and treated in these patients.

Gastro 2013 APDW/WCOG Shanghai working party report: chronic diarrhea: definition, classification, diagnosis

Diarrhea is best defined as passage of loose stools often with more frequent bowel movements. For clinical purposes, the Bristol Stool Form Scale works well to distinguish stool form and to identify loose stools. Laboratory testing of stool consistency has lagged behind. Acute diarrhea is likely to be due to infection and to be self-limited. As diarrhea becomes chronic, it is less likely to be due to infection; duration of 1 month seems to work well as a cut-off for chronic diarrhea, but detailed scientific knowledge is missing about the utility of this definition. In addition to duration of diarrhea, classifications by presenting scenario, by pathophysiology, and by stool characteristics (e.g. watery, fatty, or inflammatory) may help the canny clinician refine the differential diagnosis of chronic diarrhea. In this regard, a careful history remains the essential part of the evaluation of a patient with diarrhea. Imaging the intestine with endoscopy and radiographic techniques is useful, and biopsy of the small intestine and colon for histological assessment provides key diagnostic information. Endomicroscopy and molecular pathology are only now being explored for the diagnosis of chronic diarrhea. Interest in the microbiome of the gut is increasing; aside from a handful of well-described infections because of pathogens, little is known about alterations in the microbiome in chronic diarrhea. Serological tests have well-defined roles in the diagnosis of celiac disease but have less clearly defined application in autoimmune enteropathies and inflammatory bowel disease. Measurement of peptide hormones is of value in the diagnosis and management of endocrine tumors causing diarrhea, but these are so rare that these tests are of little value in screening because there will be many more false-positives than true-positive results. Chemical analysis of stools is of use in classifying chronic diarrhea and may limit the differential diagnosis that must be considered, but interpretation of the results is still evolving. Breath tests for assessment of carbohydrate malabsorption, small bowel bacterial overgrowth, and intestinal transit are fraught with technical limitations that decrease sensitivity and specificity. Likewise, tests of bile acid malabsorption have had limited utility beyond empirical trials of bile acid sequestrants.

Measurement of gastric emptying by radiopaque markers in patients with diabetes: correlation with scintigraphy and upper gastrointestinal symptoms

BACKGROUND

Scintigraphy, the gold standard to measure gastric emptying, is expensive and not widely available. Therefore, we compared emptying of radiopaque markers (ROM) from the stomach, by use of fluoroscopy, with scintigraphy in patients with insulin-treated diabetes.

METHODS

On the same day we measured gastric emptying of 20 ROM using fluoroscopy and scintigraphic emptying of a standard solid meal. The subjects also completed a validated gastrointestinal (GI) symptom questionnaire.

KEY RESULTS

We included 115 patients with insulin-treated diabetes (median age 53, range 21-69 years; 59 women). A moderately strong correlation was demonstrated between scintigraphic (% retained at 2 h) and ROM emptying (markers retained at 6 h) (r = 0.47; P < 0.0001). Eighty-three patients had delayed gastric emptying with scintigraphy, whereas only 29 patients had delayed emptying of ROM. Of the 29 patients with delayed emptying of ROM, 28 also had delayed scintigraphic emptying. The sensitivity and specificity of the ROM test was 34% and 97%, respectively. Significant correlations were only noted between scintigraphic gastric emptying and GI symptom severity, with the strongest correlations for fullness/early satiety (r = 0.34; P < 0.001) and nausea/vomiting (r = 0.30; P < 0.001).

CONCLUSIONS & INFERENCES

A gastric emptying test with ROM is a widely available screening method to detect delayed gastric emptying in patients with diabetes, where a positive result seems reliable. However, a normal ROM test does not exclude delayed gastric emptying, and if the clinical suspicion of gastroparesis remains, scintigraphy should be performed. Results from scintigraphy also correlate with GI symptom severity, which ROM test did not.

Association of diabetes with anxiety: a systematic review and meta-analysis

OBJECTIVES

Anxiety has been shown to be associated with poor outcomes in people with diabetes. However, there has been little research which has specifically examined whether diabetes mellitus is associated with an increased likelihood of co-morbid anxiety. The aim of this systematic review and meta-analysis was to determine whether people with diabetes are more likely to have anxiety disorders or elevated anxiety symptoms than people who do not have diabetes.

METHODS

A systematic review was performed by three independent reviewers who searched for articles that examined the association between anxiety and diabetes in adults 16 or older. Those studies that met eligibility criteria were put forward for meta-analysis using a random-effects model.

RESULTS

A total of twelve studies with data for 12,626 people with diabetes were eligible for inclusion in the systematic review and meta-analysis. Significant and positive associations were found for diabetes with both anxiety disorders, 1.20 (1.10-1.31), and elevated anxiety symptoms, 1.48 (1.02-1.93). The pooled OR for all studies that assessed anxiety was 1.25 (1.10-1.39).

CONCLUSIONS

Results from this meta-analysis provide support that diabetes is associated with an increased likelihood of having anxiety disorders and elevated anxiety symptoms.

Association between psychological distress and gastrointestinal symptoms in diabetes mellitus

AIM: To examine the possible association between gastrointestinal symptoms and anxiety and depression in type 2 diabetes mellitus (T2DM).

METHODS: The study was a matched case-control study based on a face to face interview with designed diagnostic screening questionnaires for gastrointestinal (GI) symptoms and T2DM, Patient Health Questionnaire (PHQ-9) for depression and General Anxiety Disorders (GAD-7) for anxiety. The questionnaire consisted of questions about symptoms and signs of anxiety and depression disorders. Also, socio-demographic characteristics, life style habits and the family history of patients were collected. It was carried out from June 2010 to May 2011 among Qatari and other Arab nationals over 20 years of age at Primary Health Care Centers of the Supreme Council of Health, Qatar, including patients with diabetes mellitus and healthy subjects over 20 years of age.

RESULTS: In the studied sample, most of the studied T2DM patients with GI symptoms (39.3%) and healthy subjects (33.3%) were in the age group 45-54 years (P < 0.001). The prevalence of severe depression (9.5% vs 4.4%, P < 0.001) and anxiety (26.3% vs 13.7%, P < 0.001) was significantly higher in T2DM patients with GI symptoms than in general population. Obesity (35.7% vs 31.2%) and being overweight (47.9% vs 42.8%) were significantly higher in T2DM patients with GI symptoms than in healthy subjects (P = 0.001). Mental health severity score was higher in T2DM patients with GI symptoms than in healthy subjects; depression (8.2 ± 3.7 vs 6.0 ± 3.6) and anxiety (7.6 ± 3.3 vs 6.0 ± 3.7). The most significant GI symptom which was considerably different from controls was early satiety [odds ratio (OR) = 10.8, P = 0.009] in depressed T2DM patients and loose/watery stools (OR = 2.79, P = 0.029) for severe anxiety. Anxiety was observed more than depression in T2DM patients with GI symptoms.

CONCLUSION: Gastrointestinal symptoms were significantly associated with depression and anxiety in T2DM patients, especially anxiety disorders.