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Lee J, Husami A, Arora K, Zhang W, Kadri F, Yarlagadda S, Moon C, Mun KS, Zhang K, Huang Y, Liyanage P, Brewington J, Clancy JP, Shaikhkhalil A, Paul G, Naren AP. A personalized medicine approach to optimize care for a pediatric cystic fibrosis patient with atypical clinical symptoms. Pediatr Pulmonol 2024; 59:229-232. [PMID: 37818777 PMCID: PMC10842517 DOI: 10.1002/ppul.26719] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Jesun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Hospital Medical Center, Los Angeles, California, USA
| | - Ammar Husami
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kavisha Arora
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Hospital Medical Center, Los Angeles, California, USA
| | - Weiqiang Zhang
- USDA-ARS, Pollinator Health in Southern Crop Ecosystem Research Unit, Stoneville, Mississippi, USA
| | - Ferdous Kadri
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Hospital Medical Center, Los Angeles, California, USA
| | - Sunitha Yarlagadda
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Changsuk Moon
- Decibel Therapeutics, Inc., Boston, Massachusetts, USA
| | - Kyu Shik Mun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Hospital Medical Center, Los Angeles, California, USA
| | - Kejian Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Yunjie Huang
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Pramodha Liyanage
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Hospital Medical Center, Los Angeles, California, USA
| | - John Brewington
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Ala Shaikhkhalil
- Departments of Pulmonary and Gastrointestinal Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Grace Paul
- Departments of Pulmonary and Gastrointestinal Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Anjaparavanda P Naren
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Hospital Medical Center, Los Angeles, California, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Nita AF, Chanpong A, Nikaki K, Rybak A, Thapar N, Borrelli O. Recent advances in the treatment of gastrointestinal motility disorders in children. Expert Rev Gastroenterol Hepatol 2023; 17:1285-1300. [PMID: 38096022 DOI: 10.1080/17474124.2023.2295495] [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: 04/12/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Pediatric gastrointestinal motility disorders represent some of the most challenging clinical conditions with largely undefined pathogenetic pathways and therefore limited therapeutic options. Herein, we provide an overview of the recent advances in treatment options for these disorders and their clinical impact. AREAS COVERED PubMed and Medline databases were searched for relevant articles related to the treatment of achalasia, esophageal atresia, gastroparesis, PIPO and constipation published between 2017 and 2022. In this article, we review and summarize recent advances in management of gastrointestinal motility disorders in children with a particular focus on emerging therapies as well as novel diagnostic modalities that help guide their application or develop new, more targeted treatments. EXPERT OPINION Gastrointestinal motility disorders represent one of the most challenging conundrums in pediatric age and despite significant advances in investigative tools, the palette of treatment options remain limited. Overall, while pharmacological options have failed to bring a curative solution, recent advances in minimal invasive therapeutic and diagnostic techniques have emerged as potential keys to symptom and quality of life improvement, such as ENDOFLIP, POEM, cine-MRI, fecal microbiota transplantation.
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Affiliation(s)
- Andreia Florina Nita
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Atchariya Chanpong
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Division of Gastroenterology and Hepatology, Department of Paediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
| | - Kornilia Nikaki
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Anna Rybak
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Osvaldo Borrelli
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
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Osgood PT, Essner BS, Fountain L, Sullivan EC, Meegan C, Fortunato JE. Intrapyloric Botulinum Toxin Injection for Refractory Nausea and Vomiting in Pediatric Patients. J Pediatr Gastroenterol Nutr 2023; 77:726-733. [PMID: 37794574 DOI: 10.1097/mpg.0000000000003954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVES Chronic nausea and vomiting may be associated with gastroparesis or other conditions. Poor mechanistic understanding of symptoms often precludes targeted therapy. Numerous case series suggest that intrapyloric botulinum toxin injection (IPBI) may be beneficial in treating gastroparesis and dyspepsia in children. We hypothesized that nausea, vomiting, and other symptoms, independent of gastroparesis, may improve with IPBI. We sought to identify gastric emptying (GE) and manometric patterns in IPBI responders versus nonresponders. METHODS Electronic records of 25 pediatric patients who received IPBI for refractory nausea, vomiting, or both were retrospectively reviewed. We assessed symptom improvement post-IPBI and compared symptoms, GE, and antroduodenal manometry (ADM) findings between IPBI responders and nonresponders. RESULTS At least one major symptom improved in 19 patients (76%) after IPBI. Of 22 patients completing a GE study, 14 had delayed GE with no significant difference between IPBI responders and nonresponders. Of 22 patients who underwent ADM, 18 had normal fasting peristalsis, 5 had postprandial antral hypomotility, 4 had neuropathic findings, and 19 had pylorospasm. IPBI responders, compared to nonresponders, demonstrated higher antral pressures with feeding ( P < 0.0001) and shorter duration of pylorospasm ( P = 0.0036). Antral pressures did not differ significantly with fasting or following motilin agonists. CONCLUSIONS Our findings suggest that IPBI may have therapeutic benefit in pediatric patients with chronic nausea and/or vomiting, independent of gastroparesis. ADM findings of intact antral peristalsis and elevated antral pressures, in conjunction with efficacy of IPBI, support pyloric non-relaxation as a potential contributor to nausea and/or vomiting in pediatric patients.
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Affiliation(s)
- Peter T Osgood
- From the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Bonnie S Essner
- From the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Laura Fountain
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Erin C Sullivan
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Carol Meegan
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - John E Fortunato
- From the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Mohajir WA, Khurana S, Singh K, Chong RW, Bhutani MS. Botulinum Toxin A Use in the Gastrointestinal Tract: A Reappraisal After Three Decades. Gastroenterol Hepatol (N Y) 2023; 19:198-212. [PMID: 37705841 PMCID: PMC10496347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
The discovery of botulinum toxin A (BTX)'s therapeutic properties has led to studies evaluating its usefulness in multiple medical disorders. Its use in the gastrointestinal (GI) tract has been studied for 30 years. Multiple databases, including PubMed, AccessMedicine, ClinicalKey, Cochrane Library, Embase, and Medline, were used to review research from case series to randomized controlled trials on BTX use in the GI tract. This article reviews the current literature on the efficacy of BTX and the strength of recommendations for or against its use in various disorders, including cricopharyngeal dysphagia, achalasia, nonachalasia motility disorders, gastroparesis, obesity, sphincter of Oddi disorders, chronic anal fissure, chronic idiopathic anal pain, and anismus. The appeal of BTX comes from its simplicity of administration, good safety profile, and reliability in decreasing muscular tone. However, there are several drawbacks that limit its use, including the lack of long-term efficacy and/or limited data in many GI disorders.
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Affiliation(s)
- Wasay A. Mohajir
- Department of Gastroenterology, Texas A&M College of Medicine and Baylor Scott & White Medical Center, Round Rock, Texas
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Shruti Khurana
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Khushboo Singh
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Reubyn William Chong
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas
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Khlevner J, Patel D, Rodriguez L. Pediatric Neurogastroenterology and Motility Disorders: What Role Does Endoscopy Play? Gastrointest Endosc Clin N Am 2023; 33:379-399. [PMID: 36948752 DOI: 10.1016/j.giec.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Although pediatric neurogastroenterology and motility (PNGM) disorders are prevalent, often debilitating, and remain challenging to diagnose and treat, this field has made remarkable progress in the last decade. Diagnostic and therapeutic gastrointestinal endoscopy emerged as a valuable tool in the management of PNGM disorders. Novel modalities such as functional lumen imaging probe, per-oral endoscopic myotomy, gastric-POEM, and electrocautery incisional therapy have changed the diagnostic and therapeutic landscape of PNGM. In this review, the authors highlight the emerging role of therapeutic and diagnostic endoscopy in esophageal, gastric, small bowel, colonic, and anorectal disorders and disorders of gut and brain axis interaction.
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Affiliation(s)
- Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, Gastrointestinal Motility Center, NewYork Presbyterian Morgan Stanley Children's Hospital, 622 West 168th Street, PH 17, New York, NY 11032, USA.
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children's Medical Center, 1465 South Grand Boulevard, St Louis, MO 63104, USA
| | - Leonel Rodriguez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Yale New Haven Children's Hospital, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
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Clinical Characteristics, Evaluation, and Management of Gastrointestinal Conditions in Pediatric Patients With Aerodigestive Disorders and Its Impact on the Airway. CURRENT PEDIATRICS REPORTS 2023. [DOI: 10.1007/s40124-023-00284-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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7
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Hirsch S, Nurko S, Rosen R. Author response to letter to the editor. Neurogastroenterol Motil 2022; 34:e14478. [PMID: 36210756 DOI: 10.1111/nmo.14478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/19/2022] [Indexed: 12/07/2022]
Affiliation(s)
- Suzanna Hirsch
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel Nurko
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Rosen
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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Hirsch S, Nurko S, Liu E, Rosen R. A prospective study of intrapyloric botulinum toxin and EndoFLIP in children with nausea and vomiting. Neurogastroenterol Motil 2022; 34:e14428. [PMID: 35811408 PMCID: PMC9648533 DOI: 10.1111/nmo.14428] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/19/2022] [Accepted: 06/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intrapyloric botulinum toxin injection (IPBI) is used to treat nausea and vomiting in children, but no prospective pediatric studies exist. The aims of the current study were to assess the efficacy of IPBI in children with refractory nausea or vomiting and to use EndoFLIP as a biomarker of IPBI response. METHODS This was a prospective observational cohort study of pediatric patients undergoing IPBI for refractory nausea, vomiting, or feeding difficulties at a tertiary center. Patients completed validated questionnaires at baseline and 1, 2, and 3 months after IPBI. A subset of patients >10 years old underwent pyloric EndoFLIP at the time of IPBI. Symptoms were compared pre- and post-IPBI, and EndoFLIP measurements were assessed in relation to baseline characteristics and response to IPBI. KEY RESULTS Forty-five patients (mean age 14.2 ± 6.0 years) received IPBI, and 23 of those patients underwent EndoFLIP. Twenty-nine patients (64%) had symptomatic improvement at 1-month follow-up, including improvements in overall GI symptoms (p = 0.003), nausea and vomiting (p = 0.009), and discomfort when eating (p = 0.006). Symptomatic improvements lasted up to 3 months. There was a trend towards lower pyloric distensibility in patients with delayed versus normal gastric emptying (4.5 ± 3.8 mm2 /mmHg in delayed vs. 8.9 ± 6.6 mm2 /mmHg in normal, p = 0.09), though there were no differences in EndoFLIP measurements between IPBI responders and non-responders (p > 0.05). CONCLUSIONS AND INFERENCES The majority of patients responded to IPBI, with significant improvements seen in nausea, vomiting, and discomfort. Pyloric EndoFLIP tended to distinguish baseline delays in gastric emptying, but it did not predict IPBI response in this patient cohort.
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Affiliation(s)
- Suzanna Hirsch
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Samuel Nurko
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
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Ezaizi Y, Hasan B, Manini ML, Absah I. Intrapyloric Botulinum Toxin A Injection for Gastroparesis and Functional Upper Gastrointestinal Symptoms in Children: Mayo Clinic Experience, Review of the Literature, and Meta-analysis. Paediatr Drugs 2022; 24:539-545. [PMID: 35768647 DOI: 10.1007/s40272-022-00518-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We aimed to assess the efficacy of intrapyloric botulinum toxin A injection (IPBTI) in children with and without gastroparesis and to perform a meta-analysis and review of the literature. METHODS We retrospectively searched our electronic health records to identify children (aged < 18 years) who underwent an esophagogastroduodenoscopy with IPBTI between 2007 and 2018 for persistent upper gastrointestinal tract symptoms. We included children with and without gastroparesis and excluded children with a history of gastrointestinal surgery, gastrointestinal obstruction, or mucosal disease that could explain their symptoms. A meta-analysis including our study findings was performed. RESULTS We identified 20 children (mean [standard deviation] age, 9.7 [5.8] years; 14 [70%] girls) with upper gastrointestinal symptoms who underwent IPBTI at our institution during the study period. Of the 20 children, 17 (85%) underwent gastric emptying scintigraphy, only nine (53%) of whom had gastroparesis. Response to IPBTI was reported in ten children (50%). Response to IPBTI did not differ by the presence of gastroparesis in included children (p = 0.64). Repeated IPBTI was performed in four children who had a response to the first injection; all four reported no benefit from the second IPBTI. There were no reported complications of IPBTI in our cohort. The meta-analysis indicated that 68% (95% confidence interval 59-78) of patients had a response to IPBTI, regardless of the presence of gastroparesis; 66% (95% confidence interval 53-78) of patients who had gastroparesis had a response to IPBTI. CONCLUSIONS Intrapyloric botulinum toxin A injection is safe in children and can offer transient relief for patients with refractory upper gastrointestinal symptoms with and without gastroparesis.
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Affiliation(s)
- Yamen Ezaizi
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA. .,Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. .,Pediatric Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Bashar Hasan
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Mhd Louai Manini
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Imad Absah
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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10
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Santucci NR, Kemme S, El-Chammas KI, Chidambaram M, Mathur M, Castillo D, Sun Q, Fei L, Kaul A. Outcomes of combined pyloric botulinum toxin injection and balloon dilation in dyspepsia with and without delayed gastric emptying. Saudi J Gastroenterol 2022; 28:268-275. [PMID: 35083974 PMCID: PMC9408736 DOI: 10.4103/sjg.sjg_493_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pyloric botulinum toxin injection has improved symptoms in children with delayed gastric emptying. We aimed to determine the clinical response to combined endoscopic intra-pyloric botulinum toxin injection and pyloric balloon dilation (IPBT-BD) in patients with dyspepsia. Methods Electronic medical records were reviewed to gather demographic data, symptoms, and follow-up on patients with dyspepsia. Cases were defined as those who underwent IPBT-BD in addition to their ongoing management. Controls received pharmacotherapy, behavioral intervention, or dietary management alone. Clinical response was defined as no change, partial, or complete improvement in symptoms within 12 months. Propensity score matching based on age, gender, and symptom duration was used to pair cases and controls. Results In total, 79 cases and 83 controls were identified. After propensity matching, 63 patients were included in each group. The mean age for cases was 14.5 ± 3.9y; 62% were females and 98% were Caucasian. Further, 83% of 46 cases and 94% of 49 controls who had scintigraphy scans showed delayed gastric emptying. After matching, 76% of cases showed partial or complete improvement compared with 49% controls within 12 months (P = 0.004). Younger children tended to respond more favorably to the procedure (P = 0.08). Conclusions In our propensity-matched analysis, combined IPBT-BD in addition to pharmacotherapy, behavioral, or dietary management clearly showed a benefit over these modalities alone. This favorable response lasted up to 12 months.
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Affiliation(s)
- Neha R Santucci
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Sarah Kemme
- Gastroenterology, Hepatology and Nutrition, Children's Hospital of Colorado, Denver, CO, United States of America
| | - Khalil I El-Chammas
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Maneesh Chidambaram
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Manav Mathur
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Daniel Castillo
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Qin Sun
- Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Lin Fei
- Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Ajay Kaul
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
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11
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AlLehibi AH, Al-Haddad M. Intragastric botulinum toxin injection: Is it the solution to all gastric ailments? Saudi J Gastroenterol 2022; 28:247-249. [PMID: 35848699 PMCID: PMC9408734 DOI: 10.4103/sjg.sjg_261_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Abed H AlLehibi
- Department of Gastroenterology & Hepatology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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12
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Rosen R. Novel Advances in the Evaluation and Treatment of Children With Symptoms of Gastroesophageal Reflux Disease. Front Pediatr 2022; 10:849105. [PMID: 35433543 PMCID: PMC9010502 DOI: 10.3389/fped.2022.849105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/18/2022] [Indexed: 12/03/2022] Open
Abstract
Gastroesophageal reflux disease has long been implicated as a cause for multiple pediatric symptoms ranging from abdominal pain and regurgitation to cough and dental erosions. Diagnostic testing has evolved greatly over the last 20 years; initial testing with pH-metry to measure esophageal acid reflux burden has evolved into measurement of both acid and non-acid reflux and liquid and gas reflux. However, measuring reflux burden alone only tells a small part of the GERD story and many symptoms originally thought to be reflux related are, in fact, related to other disorder which mimic reflux. The current paradigm which involves empiric treatment of symptoms with acid suppression has been replaced with early testing for not only gastroesophageal reflux but also for other diagnostic masqueraders. The focus for interventions has shifted away from acid suppression toward motility interventions and includes a greater recognition of both functional and motility disorders which present with reflux symptoms.
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Affiliation(s)
- Rachel Rosen
- Boston Children's Hospital, Boston, MA, United States
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13
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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.
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Affiliation(s)
- Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, United States
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14
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Miller J, Khlevner J, Rodriguez L. Upper Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1237-1253. [PMID: 34736587 DOI: 10.1016/j.pcl.2021.07.009] [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] [Indexed: 12/15/2022]
Abstract
Children with disorders affecting the sensory and motor functions of the esophagus will present primarily with swallowing dysfunction, dysphagia, and chest pain, and those with disorders affecting the normal function of the stomach will present with symptoms like abdominal pain, nausea, and vomiting. Recent advances in the mechanisms of disease and technology have increased our understanding of gastrointestinal physiology and that knowledge has been applied to develop new diagnostic studies and therapeutic interventions. We present an overview of the clinical presentation, diagnosis, and treatment of common primary and secondary functional and motility disorders affecting the upper gastrointestinal tract in children.
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Affiliation(s)
- Jonathan Miller
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale New Haven Children's Hospital, Yale University School of Medicine, 333 Cedar Street, LMP 4093, New Haven, CT 06510, USA.
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Comparison of Symptom Control in Pediatric Gastroparesis Using Endoscopic Pyloric Botulinum Toxin Injection and Dilatation. J Pediatr Gastroenterol Nutr 2021; 73:314-318. [PMID: 34091544 DOI: 10.1097/mpg.0000000000003195] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The objective of this study was to assess the tolerance and efficacy of endoscopic intrapyloric botulinum toxin injection compared with pyloric dilatation in children with gastroparesis. METHODS This was a retrospective descriptive multicentre study that included pediatric patients treated between 2010 and 2018 at 4 tertiary hospitals. RESULTS Data were collected for 24 patients. The median age at diagnosis was 2.5 years (range 0.5-4.7). A total of 46 endoscopic procedures were performed. The endoscopic procedure was multiple in 63% of patients. Among the interventions, 76% were successful and 15% were unsuccessful. The recurrence rate was 57% and the median time to recurrence was 3.7 months (0.1-73). The efficacy did not differ significantly between the 2 methods at the first intervention and as a second-line treatment. The recurrence rate also did not differ significantly between the 2 methods. No complications were reported. The median follow-up was 19.8 months (1.7-61.7). CONCLUSIONS In this retrospective multicentre study, endoscopic management of gastroparesis by balloon dilatation or botulinum toxin was safe in children and seemed to be partially efficient within the first months. Symptoms recurred frequently and required repetition of the interventions.
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Rybak A, Sethuraman A, Nikaki K, Koeglmeier J, Lindley K, Borrelli O. Gastroesophageal Reflux Disease and Foregut Dysmotility in Children with Intestinal Failure. Nutrients 2020; 12:nu12113536. [PMID: 33217928 PMCID: PMC7698758 DOI: 10.3390/nu12113536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/09/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022] Open
Abstract
Gastrointestinal dysmotility is a common problem in a subgroup of children with intestinal failure (IF), including short bowel syndrome (SBS) and pediatric intestinal pseudo-obstruction (PIPO). It contributes significantly to the increased morbidity and decreased quality of life in this patient population. Impaired gastrointestinal (GI) motility in IF arises from either loss of GI function due to the primary disorder (e.g., neuropathic or myopathic disorder in the PIPO syndrome) and/or a critical reduction in gut mass. Abnormalities of the anatomy, enteric hormone secretion and neural supply in IF can result in rapid transit, ineffective antegrade peristalsis, delayed gastric emptying or gastroesophageal reflux. Understanding the underlying pathophysiologic mechanism(s) of the enteric dysmotility in IF helps us to plan an appropriate diagnostic workup and apply individually tailored nutritional and pharmacological management, which might ultimately lead to an overall improvement in the quality of life and increase in enteral tolerance. In this review, we have focused on the pathogenesis of GI dysmotility in children with IF, as well as the management and treatment options.
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Affiliation(s)
- Anna Rybak
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
- Correspondence:
| | - Aruna Sethuraman
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London E1 2AJ, UK;
| | - Jutta Koeglmeier
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Keith Lindley
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Osvaldo Borrelli
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
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17
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Hirsch S, Nurko S, Mitchell P, Rosen R. Botulinum Toxin as a Treatment for Feeding Difficulties in Young Children. J Pediatr 2020; 226:228-235. [PMID: 32599032 PMCID: PMC9531944 DOI: 10.1016/j.jpeds.2020.06.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/28/2020] [Accepted: 06/19/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine the effectiveness of intrapyloric botulinum toxin injection (IPBI) for treatment of feeding disorders and associated gastrointestinal symptoms in very young children. STUDY DESIGN A single-center retrospective study of patients 2 months to 5 years old who received IPBI at Boston Children's Hospital from May 2007 to June 2019 was performed. Charts were reviewed for demographic data, comorbidities, symptoms leading to IPBI, oral and tube feeding data, symptom improvement after IPBI, and need for repeat injections. The primary outcome was symptom improvement at the first gastroenterology clinic visit following IPBI. Secondary outcomes included improvement in oral feeding, decreases in tube feeding, and need for repeat injections. The χ2 or Fisher exact tests and multivariate logistic regression were used to identify factors associated with symptomatic improvement. RESULTS A total of 85 patients who received 118 injections were included in the final analysis; 57 patients (67%) had partial or complete improvement in symptoms after IPBI. Among the 55 patients with enteral tubes, there was an improvement in feeding, with more patients receiving at least some oral feeds after IPBI compared with before (26/55 vs 15/55; P = .004) and fewer patients receiving postpyloric feeds after IPBI compared with before (12/55 vs 21/55; P = .01). Twenty-six patients (31%) received repeat IPBI within 1 year, with only 6 patients receiving IPBI more than twice. CONCLUSIONS IPBI is safe and effective in young children. Children with enteral tubes show improvement in oral feeding and reduction in need for postpyloric feeding after IPBI.
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Affiliation(s)
- Suzanna Hirsch
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Samuel Nurko
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Paul Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA.
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Abstract
Although the definition of gastroparesis in children is the same as in adults, there are key differences between gastroparesis in these two populations in presentation, diagnosis, treatment and outcomes. Infants and younger children with gastroparesis tend to be male, present with vomiting as their primary symptom and are more likely to experience the resolution of their symptoms over time. Adolescents with gastroparesis tend to be female, present with abdominal pain as their primary symptom and have a less favorable short- and medium-term outcome, sharing some similarities with adults with gastroparesis. Despite the fact that validated diagnostic criteria for gastroparesis are lacking in infants and younger children, these age groups make up nearly half of children with gastroparesis in some studies. The diagnosis and treatment of children with gastroparesis has thus far relied heavily on research studies performed in adults, but it is becoming increasingly clear that gastroparesis in children is a distinct entity and there are limitations to the applicability of data obtained from adults to the care of children.
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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.
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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
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20
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Febo‐Rodriguez L, Chumpitazi BP, Shulman RJ. Childhood gastroparesis is a unique entity in need of further investigation. Neurogastroenterol Motil 2020; 32:e13699. [PMID: 31407456 PMCID: PMC7015769 DOI: 10.1111/nmo.13699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite increasing knowledge regarding gastroparesis (GP) in adults, little is known regarding the incidence, prevalence, and natural history of childhood GP. Exacerbating the knowledge gap in pediatric GP is both the lack of normative data for gastric emptying scintigraphy in children and lack of GP-specific pediatric reported outcome measures. PURPOSE The aim of this article was to review the available literature on pediatric GP and identify similarities and differences with studies in adults. We performed a comprehensive search in MEDLINE and Google Scholar from inception to April 2019 for articles published in English using the following combination of keywords: gastroparesis, pediatric gastroparesis, outcomes, metoclopramide, erythromycin, domperidone, cisapride, and gastric neurostimulator. The limited available pediatric data, often retrospective, suggest marked differences between adult and pediatric GP in several aspects including etiology, concomitant co-morbidities (eg, psychiatric disorders), clinical symptom presentation, diagnostic evaluation, response to therapies, and clinical outcome. Further research in pediatric GP is needed and holds the promise to further elucidate the mechanisms of this disorder in children and lead to pediatric-focused therapies.
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Affiliation(s)
- Liz Febo‐Rodriguez
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
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Di Lorenzo C. Gastroparesis in children: Paralysis for the child or the provider? Neurogastroenterol Motil 2020; 32:e13792. [PMID: 32103613 DOI: 10.1111/nmo.13792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/12/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, OH, USA
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22
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Setya A, Nair P, Cheng SX. Gastric electrical stimulation: An emerging therapy for children with intractable gastroparesis. World J Gastroenterol 2019; 25:6880-6889. [PMID: 31908392 PMCID: PMC6938723 DOI: 10.3748/wjg.v25.i48.6880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
Management of gastroparesis remains challenging, particularly in pediatric patients. Supportive care and pharmacological therapies for symptoms remain the mainstay treatment. Although they are effective for mild and some moderately severe cases, often time they do not work for severe gastroparesis. There are a few prokinetics available, yet the use of these drugs is limited by a lack of persistent efficacy and/or safety concerns. Currently, the only modality for adult patients with severe intractable gastroparesis is surgery, e.g., pyloroplasty and partial gastrectomy, however, this option is generally considered too radical for a growing child. Novel therapeutic approaches, particularly those which are less invasive, are needed. This article explores gastric electrical stimulation (GES), a new therapy for gastroparesis. Unlike others, it neither needs medications nor gastrectomy; rather, it treats through the use of microelectrodes to deliver high-frequency low energy electric stimulation to the pacemaker area of the stomach. Thus, it is tolerated and safe in children. Like in adult patients, GES appears to work in releasing symptoms, improving nutrition, and enhancing the quality of life; it also helps wean off medications and eliminate many needs for hospitalization. Considering the transient nature of gastroparesis in children in many occasions, GES is considered a “bridging” therapy after failed medical interventions and before surgery.
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Affiliation(s)
- Aniruddh Setya
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
| | - Priyanka Nair
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
| | - Sam Xianjun Cheng
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
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23
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Botulinum Toxin as a Treatment for Refractory Gastroparesis: a Literature Review. ACTA ACUST UNITED AC 2018; 16:479-488. [DOI: 10.1007/s11938-018-0187-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Khashab MA, Benias PC, Swanstrom LL. Endoscopic Myotomy for Foregut Motility Disorders. Gastroenterology 2018; 154:1901-1910. [PMID: 29454796 DOI: 10.1053/j.gastro.2017.11.294] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 11/19/2017] [Accepted: 11/27/2017] [Indexed: 12/13/2022]
Abstract
Peroral endoscopic myotomy (POEM) is an advanced endoscopic procedure classically performed for the treatment of achalasia. The procedure is based on principles of submucosal endoscopy and is composed of a mucosal incision, submucosal tunneling, myotomy, and mucosal closure. Multiple published studies that collectively include more than 6000 patients reported clinical success in more than 80% to 90% of patients. Recent literature also suggested durability of response over a medium-term follow-up. POEM is associated with a low rate of adverse events when performed by experienced operators. Gastroesophageal reflux is not infrequent after POEM but does not seem significantly different from reflux that occurs after Heller myotomy. POEM also seems to be effective in the treatment of spastic esophageal disorders (eg, jackhammer and diffuse esophageal spasm). Last, the role of gastric POEM (G-POEM) in the treatment of gastroparesis has been investigated in recent studies with promising results.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland.
| | - Petros C Benias
- Division of Gastroenterology and Hepatology, Zucker School of Medicine at Northwell, Manhasset, New York
| | - Lee L Swanstrom
- The Oregon Clinic, Portland, Oregon; Institute for Image Guided Surgery, Strasbourg, France
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Abstract
Gastrointestinal motility disorders in the pediatric population are common and can range from benign processes to more serious disorders. Performing and interpreting motility evaluations in children present unique challenges. There are primary motility disorders but abnormal motility may be secondary due to other disease processes. Diagnostic studies include radiographic scintigraphic and manometry studies. Although recent advances in the genetics, biology, and technical aspects are having an important impact and have allowed for a better understanding of the pathophysiology and therapy for gastrointestinal motility disorders in children, further research is needed to be done to have better understanding of the pathophysiology and for better therapies.
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Affiliation(s)
- Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02155, USA.
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26
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Tillman EM, Smetana KS, Bantu L, Buckley MG. Pharmacologic Treatment for Pediatric Gastroparesis: A Review of the Literature. J Pediatr Pharmacol Ther 2016; 21:120-32. [PMID: 27199619 DOI: 10.5863/1551-6776-21.2.120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There have been a number of agents that have been tried for treatment of gastroparesis over the past 3 decades, with varying levels of success. Guidelines exist for the management of gastroparesis in adults; however, even though the cause of gastroparesis in children is similar to that in adults, no guidelines exist for treating pediatric gastroparesis as studies on the topic are limited. With what little information we have on pediatric gastroparesis, medications used in children's studies do not seem to demonstrate the same results as in adult patients with gastroparesis; thus, future studies of whether certain medications are effective for treating pediatric gastroparesis and at what dose still need to be conducted. Pharmacological treatment options for pediatric gastroparesis do not show a clear correlation of resolving or even maintaining gastroparesis-associated symptoms or disease state. This article reviews the available studies of drugs that have shown some efficacy, with an emphasis on pediatric studies.
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Affiliation(s)
- Emma M Tillman
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Keaton S Smetana
- Department of Pharmacy, University of Kentucky Heathcare, Lexington, Kentucky
| | - Likeselam Bantu
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Merrion G Buckley
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
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Abstract
Chronic nausea is a highly prevalent, bothersome, and difficult-to-treat symptom among adolescents. When chronic nausea presents as the predominant symptom and is not associated with any underlying disease, it may be considered a functional gastrointestinal disorder and named "functional nausea." The clinical features of functional nausea and its association with comorbid conditions provide clues to the underlying pathophysiological mechanisms. These may include gastrointestinal motor and sensory disturbances, autonomic imbalance, altered central nervous system pathways, or a combination of these. This review summarizes the current knowledge on mechanisms and treatment strategies for chronic, functional nausea in children.
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Islam S, McLaughlin J, Pierson J, Jolley C, Kedar A, Abell T. Long-term outcomes of gastric electrical stimulation in children with gastroparesis. J Pediatr Surg 2016; 51:67-71. [PMID: 26526207 DOI: 10.1016/j.jpedsurg.2015.10.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 10/06/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastric electrical stimulation (GES) has been used in adults with gastroparesis. However its use has been limited in children. We describe the largest experience with GES in children with long-term outcomes. METHODS Data were collected on children who underwent GES over a 10-year period. Data regarding demographics, medical history, hospital course, and outcomes were collected and analyzed. Symptom scores (validated Likert scores) were compared using a paired Student's t test. RESULTS Overall, 97 patients underwent GES, and a majority were teenage Caucasian girls. Ninety-six had temporary GES (tGES), and 66 had improvement in their symptoms. A total of 67 underwent permanent implantation (pGES), and there was significant reduction in all individual symptoms (p<0.001) as well as the total symptom score (TSS) (p<0.0001) at 1, 6, 12, and >12 months. Recurrence of symptoms leading to device removal occurred in 7 cases. Forty-one patients had continued improvement in symptoms for over 12 months, with a mean follow-up of 3.5 years (range 1-9 years). CONCLUSIONS This study represents the largest experience of systematic application of GES in children. GES is a safe and effective therapy for selected children with intractable GP with continued symptomatic improvement at 1 year and beyond.
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Affiliation(s)
- Saleem Islam
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States.
| | - Jillian McLaughlin
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Justine Pierson
- Division of Plastic Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Christopher Jolley
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
| | - Archana Kedar
- Internal Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Thomas Abell
- Division of Gastroenterology, Department of Medicine, University of Louisville, Louisville, KY, United States
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Ukleja A, Tandon K, Shah K, Alvarez A. Endoscopic botox injections in therapy of refractory gastroparesis. World J Gastrointest Endosc 2015; 7:790-798. [PMID: 26191343 PMCID: PMC4501969 DOI: 10.4253/wjge.v7.i8.790] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 01/31/2015] [Accepted: 05/06/2015] [Indexed: 02/05/2023] Open
Abstract
Gastroparesis (GP) is a common disease seen in gastroenterology practice particularly in western countries, and it may be underdiagnosed. The available drug therapies for this condition are quite disappointing. Botulinum toxin type A (BT) has been found to be effective therapy in various spastic disorders of smooth muscle of gastrointestinal tract. However, the benefits of BT injections in GP have been unclear. Several retrospective and open label studies have shown clinical advantages of intrapyloric Botulinum toxin type A injections, while two small randomized trials did not show positive results. Therefore, the available published studies yielded conflicting results leading to fading out of botox therapy for GP. We recognize possible clinical benefit of BT injections without any disadvantages of this treatment. We are calling for revisiting the endoscopy guided botox therapy in refractory GP. In this review we discuss important features of these studies pointing out differences in results among them. Differences in patient selection, doses and method of administration of botox toxin in the prior studies may be the cause of conflicting results. The mechanism of action, indications, efficacy and side-effects of BT are reviewed. Finally, we recognize limited evidence to recommend BT in GP and calling attention for future research in this field since no advances in drug management had been made in the last two decades.
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Abstract
PURPOSE OF REVIEW Gastroparesis is a disorder with delayed gastric emptying in the absence of mechanical obstruction. It is one of the more common dysmotilities that occur in the gastrointestinal tract, and is thought to primarily affect adults. Pediatric cases of gastroparesis were considered rare; however, recent evidence suggests growing recognition in children and adolescents. Therefore, it is important for the pediatric caregiver to understand the condition and the treatment options available. RECENT FINDINGS The majority of patients are women, and presentation is usually with symptoms of persistent nausea, emesis, postprandial pain and bloating, and early satiety. Weight loss may occur in some cases, though this is not universal. The majority of cases are idiopathic, with diabetes mellitus the second most common cause. SUMMARY Treatment consists of symptomatic relief with medication to counteract the nausea, emesis, pain, bloating, gastroesophageal reflux, early satiety, and improve gastric emptying. Dietary modification is also used with small meals and avoidance of high fiber and fat-containing foods. Recalcitrant cases of gastroparesis require the use of additional approaches such as jejunal feeds, intrapyloric botulinum toxin, gastric emptying procedures such as pyloroplasty, and gastric electrical stimulation. We will review these options in this article.
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Brisinda G, Sivestrini N, Bianco G, Maria G. Treatment of gastrointestinal sphincters spasms with botulinum toxin A. Toxins (Basel) 2015; 7:1882-916. [PMID: 26035487 PMCID: PMC4488680 DOI: 10.3390/toxins7061882] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/10/2015] [Accepted: 05/21/2015] [Indexed: 02/05/2023] Open
Abstract
Botulinum toxin A inhibits neuromuscular transmission. It has become a drug with many indications. The range of clinical applications has grown to encompass several neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum toxin A provides benefit in diseases of the gastrointestinal tract. Although toxin blocks cholinergic nerve endings in the autonomic nervous system, it has also been shown that it does not block non-adrenergic non-cholinergic responses mediated by nitric oxide. This has promoted further interest in using botulinum toxin A as a treatment for overactive smooth muscles and sphincters. The introduction of this therapy has made the treatment of several clinical conditions easier, in the outpatient setting, at a lower cost and without permanent complications. This review presents current data on the use of botulinum toxin A in the treatment of pathological conditions of the gastrointestinal tract.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Nicola Sivestrini
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Giuseppe Bianco
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Giorgio Maria
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
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Arbizu RA, Rodriguez L. Use of Clostridium botulinum toxin in gastrointestinal motility disorders in children. World J Gastrointest Endosc 2015; 7:433-437. [PMID: 25992183 PMCID: PMC4436912 DOI: 10.4253/wjge.v7.i5.433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/06/2014] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
More than a century has elapsed since the identification of Clostridia neurotoxins as the cause of paralytic diseases. Clostridium botulinum is a heterogeneous group of Gram-positive, rod-shaped, spore-forming, obligate anaerobic bacteria that produce a potent neurotoxin. Eight different Clostridium botulinum neurotoxins have been described (A-H) and 5 of those cause disease in humans. These toxins cause paralysis by blocking the presynaptic release of acetylcholine at the neuromuscular junction. Advantage can be taken of this blockade to alleviate muscle spams due to excessive neural activity of central origin or to weaken a muscle for treatment purposes. In therapeutic applications, minute quantities of botulinum neurotoxin type A are injected directly into selected muscles. The Food and Drug Administration first approved botulinum toxin (BT) type A in 1989 for the treatment of strabismus and blepharospasm associated with dystonia in patients 12 years of age or older. Ever since, therapeutic applications of BT have expanded to other systems, including the gastrointestinal tract. Although only a single fatality has been reported to our knowledge with use of BT for gastroenterological conditions, there are significant complications ranging from minor pain, rash and allergic reactions to pneumothorax, bowel perforation and significant paralysis of tissues surrounding the injection (including vocal cord paralysis and dysphagia). This editorial describes the clinical experience and evidence for the use BT in gastrointestinal motility disorders in children.
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Rinaldi ML, Fransson BA, Barry SL. Botulinum toxin A as a treatment for delayed gastric emptying in a dog. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2014; 55:673-677. [PMID: 24982520 PMCID: PMC4060911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A toy Australian shepherd dog was referred for bile peritonitis following excision of a biliary mucocele. Subsequent delayed gastric emptying was refractory to prokinetic therapy but responded to injection of botulinum toxin A into the muscularis layer of the pylorus; a novel therapy for delayed gastric emptying in dogs.
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Abstract
Functional dyspepsia (FD) is a widely prevalent problem in pediatrics, reportedly occurring in 3% to 27% of children and accounting for considerable impact on quality of life and health care costs. FD is defined by the Rome III classification as persistent upper abdominal pain or discomfort, not related to bowel movements, and without an organic cause, that is present for at least 2 months prior to diagnosis. Abnormal sensory perception, motor dysfunction, and psychosocial factors have been implicated in the causation of FD. Hypersensitivity to gastric distension, delayed gastric emptying, antral hypomotility, and gastric dysrhythmia are some abnormalities that have been noted in FD. Diagnosis of FD is based on a thorough history and examination, and an appropriate selection of tests based on clinical judgment, the presence of alarm signs, and response to treatment. A positive diagnosis of FD helps to shift focus from further testing to treatment of symptoms. The majority of children with dyspepsia do not have mucosal lesions on endoscopy; hence, endoscopy is not mandatory for the diagnosis of FD. Helicobacter pylori is an uncommon cause of dyspepsia in children, and test and treat strategy is discouraged. Delayed gastric emptying may be present in up to 70% of children with dyspepsia. A biopsychosocial approach to treatment involving medications, psychological and social supports, and complementary therapies is advocated. Proton pump inhibitors (PPIs) and prokinetics are commonly used first-line medications. PPIs are preferred when epigastric pain is the predominant symptom, whereas prokinetics may be chosen when postprandial fullness or early satiety is the main symptom. PPIs may be more efficacious and cost-effective than H2 blockers according to adult data.
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Ambartsumyan L, Rodriguez L. Gastrointestinal motility disorders in children. Gastroenterol Hepatol (N Y) 2014; 10:16-26. [PMID: 24799835 PMCID: PMC4008955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The most common and challenging gastrointestinal motility disorders in children include gastroesophageal reflux disease (GERD), esophageal achalasia, gastroparesis, chronic intestinal pseudo-obstruction, and constipation. GERD is the most common gastrointestinal motility disorder affecting children and is diagnosed clinically and treated primarily with acid secretion blockade. Esophageal achalasia, a less common disorder in the pediatric patient population, is characterized by dysphagia and treated with pneumatic balloon dilation and/or esophagomyotomy. Gastroparesis and chronic intestinal pseudo-obstruction are poorly characterized in children and are associated with significant morbidity. Constipation is among the most common complaints in children and is associated with significant morbidity as well as poor quality of life. Data on epidemiology and outcomes, clinical trials, and evaluation of new diagnostic techniques are needed to better diagnose and treat gastrointestinal motility disorders in children. We present a review of the conditions and challenges related to these common gastrointestinal motility disorders in children.
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Affiliation(s)
- Lusine Ambartsumyan
- Dr Ambartsumyan is the director of the Gastrointestinal Motility Program at Seattle Children's Hospital in Seattle, Washington. Dr Rodriguez is the codirector of the Colorectal Center at the Center for Motility and Functional Gastrointestinal Disorders at Boston Children's Hospital and Harvard Medical School in Boston, Massachusetts
| | - Leonel Rodriguez
- Dr Ambartsumyan is the director of the Gastrointestinal Motility Program at Seattle Children's Hospital in Seattle, Washington. Dr Rodriguez is the codirector of the Colorectal Center at the Center for Motility and Functional Gastrointestinal Disorders at Boston Children's Hospital and Harvard Medical School in Boston, Massachusetts
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Krishnan B, Babu S, Walker J, Walker AB, Pappachan JM. Gastrointestinal complications of diabetes mellitus. World J Diabetes 2013; 4:51-63. [PMID: 23772273 PMCID: PMC3680624 DOI: 10.4239/wjd.v4.i3.51] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 04/14/2013] [Accepted: 04/19/2013] [Indexed: 02/05/2023] Open
Abstract
Diabetes mellitus affects virtually every organ system in the body and the degree of organ involvement depends on the duration and severity of the disease, and other co-morbidities. Gastrointestinal (GI) involvement can present with esophageal dysmotility, gastro-esophageal reflux disease (GERD), gastroparesis, enteropathy, non alcoholic fatty liver disease (NAFLD) and glycogenic hepatopathy. Severity of GERD is inversely related to glycemic control and management is with prokinetics and proton pump inhibitors. Diabetic gastroparesis manifests as early satiety, bloating, vomiting, abdominal pain and erratic glycemic control. Gastric emptying scintigraphy is considered the gold standard test for diagnosis. Management includes dietary modifications, maintaining euglycemia, prokinetics, endoscopic and surgical treatments. Diabetic enteropathy is also common and management involves glycemic control and symptomatic measures. NAFLD is considered a hepatic manifestation of metabolic syndrome and treatment is mainly lifestyle measures, with diabetes and dyslipidemia management when coexistent. Glycogenic hepatopathy is a manifestation of poorly controlled type 1 diabetes and is managed by prompt insulin treatment. Though GI complications of diabetes are relatively common, awareness about its manifestations and treatment options are low among physicians. Optimal management of GI complications is important for appropriate metabolic control of diabetes and improvement in quality of life of the patient. This review is an update on the GI complications of diabetes, their pathophysiology, diagnostic evaluation and management.
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Saliakellis E, Fotoulaki M. Gastroparesis in children. Ann Gastroenterol 2013; 26:204-211. [PMID: 24714281 PMCID: PMC3959432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 02/14/2013] [Indexed: 11/10/2022] Open
Abstract
Historically, gastroparesis is characterized by delayed gastric emptying of fluids and/or solids without evidence of a mechanical gastric outlet obstruction. To provide a thorough, evidence-based overview of the diagnosis, treatment, outcome and future advances for gastroparesis in children, a web search (PubMed, Cochrane Database of Systematic Reviews, EMBASE, Clinical Evidence) was performed. Original articles and reviews were identified, examined and included as appropriate. The prevalence of gastroparesis is vague in adults and unknown in children. It is suspected on the presence of symptoms indicating gastric dysmotility (nausea, vomiting, early satiety, postprandial fullness, failure to thrive, weight loss) and is confirmed on the demonstration of delayed gastric emptying. It can be assessed with various methods from which gastric emptying scintigraphy of a radiolabeled solid meal is considered as the golden standard. Therapeutic approaches include: dietary modifications, medical treatment (prokinetics, antiemetics, intrapyloric injection of botulinum toxin, enteral feeds via jejunostomy, total parenteral nutrition) and surgical interventions (laparoscopic placement of gastric pacemaker) aiming at alleviating symptoms and maintaining optimal nutritional status. Gastroparesis in children can be challenging to diagnose and treat. Specific protocols for the evaluation of gastric emptying and for a stepwise management are required to optimise future outcomes.
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Affiliation(s)
- Efstratios Saliakellis
- Department of Pediatric Gastroenterology, Academy of Pediatric Gastroenterology, Great Ormond Street Hospital, NHS Foundation Trust, London, UK (Efstratios Saliakellis)
| | - Maria Fotoulaki
- 4th Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece (Maria Fotoulaki),
Correspondence to: Maria Fotoulaki, MD, PhD, 41, Alexandrou Michailidi, 54641, Thessaloniki, Greece, Tel.: +30 6944 949964, Fax: +30 2310 991538, e-mail:
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Abstract
PURPOSE OF REVIEW Gastroparesis is a common disorder that produces symptoms of gastric retention in the absence of physical obstruction. Extensive research into the clinical features, pathophysiology, diagnostic evaluation, and therapy of gastroparesis in the past several years has offered insight into the condition. This review provides updated information on gastroparesis focusing on new findings from the past few years. RECENT FINDINGS Large database studies have characterized clinical profiles in idiopathic and diabetic gastroparesis and are defining roles of gastric and extragastric factors in symptom genesis. Dietary deficiencies in gastroparesis have been clarified. Histologic study of full thickness gastric tissue in severe gastroparesis shows heterogeneous enteric neuronal, smooth muscle, interstitial cell, and inflammatory abnormalities. Advances in gastric emptying testing include wireless motility capsules and nonradioactive breath tests. The importance of glycemic control in diabetic gastroparesis is a focus of current investigation. Novel therapies include new prokinetics (ghrelin agonists), increased focus on antiemetic agents including antidepressants, and next generation gastric stimulators. Studies are being initiated to delineate the natural history of gastroparesis. SUMMARY Much has been learned recently on the causes, clinical presentations, and management of gastroparesis. Current ongoing investigation provides promise for further gains in the years ahead.
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