Postviral gastroparesis: presentation, treatment, and outcome

Atypical Causes of Gastroparesis: Prevalence, Gastric Emptying, and Clinical Features

BACKGROUND

Gastroparesis is commonly attributed to idiopathic or diabetic causes.

GOALS

We aimed to describe atypical causes of gastroparesis and examine the clinical features and severity of delayed gastric emptying compared with idiopathic and diabetic causes.

STUDY

Between 2018 and 2021, gastroparesis patients being evaluated at our tertiary care center completed a 4-hour gastric emptying scintigraphy and questionnaires assessing for gastrointestinal disorders, including patient assessment of upper gastrointestinal symptoms. Patients were divided into groups relating to gastroparesis cause: diabetic, postsurgical (PSGp), connective tissue (CTGp), neurological and idiopathic.

RESULTS

Two hundred fifty-six patients with delayed emptying on gastric emptying scintigraphy completed the questionnaires. Gastroparesis causes included 149 (58.2%) idiopathic, 60 (23.4%) diabetic, 29 (11.3%) postsurgical, 13 (5.1%) connective tissue, and 5 (2.0%) neurological. In each group, most patients were female and White. Gastric retention at 4 hours was significantly greater in patients with diabetic (39.3±25.7% P <0.001), postsurgical (41.3±24.0% P =0.002), and connective tissue gastroparesis (37.8±20.0% P =0.049) compared with patients with idiopathic gastroparesis (25.5±17.6%). In PSGp, diabetic and idiopathic causes, the main symptoms were early satiety and postprandial fullness, whereas in CTGp, bloating and abdominal distension were the predominant symptoms. Vomiting severity was significantly greater in patients with diabetes compared with idiopathic gastroparesis (2.9±1.9 vs. 2.1±1.8 P =0.006).

CONCLUSIONS

Atypical causes contributed to gastroparesis in 47 of 256 (18.4%) patients with delayed gastric emptying. Gastric emptying was significantly more delayed in PSGp and CTGp patients. PSGp patients mainly experienced stomach fullness and early satiety, whereas CTGp patients had predominantly bloating and distension.

Postprandial Abdominal Pain Caused by Gastroptosis-A Case Report

Gastroptosis is a condition in which the stomach is displaced downward and is a condition affects the spontaneous muscle mobility in the stomach. The reason for its current prevalence remains unclear as the medical literature is scarce on the condition in children. In this study, we describe the case of a 17-year-old girl suffering from chronic, position-dependent epigastric pain. The symptoms were observed during post-meal activity, with a significant increase in pain intensity while in an upright position. An inferior stomach displacement was noted in an upper gastrointestinal X-ray study using barium.

Quantification of Interstitial Cells of Cajal in the Gastric Muscle of Patients with Gastroparesis at Per-Oral Endoscopic Pyloromyotomy: A Novel Approach for Future Research in Pathogenesis of Gastroparesis

BACKGROUND

The role of Interstitial Cells of Cajal (ICC) in the pathogenesis of gastroparesis has been suggested by previous studies due to their involvement in the transmission of neuronal signaling to the smooth muscles of the GI tract. However, studies have been limited by the inability to obtain a gastric muscle sample, since routine endoscopy can only biopsy the mucosa. We present a new technique of muscle biopsy during per-oral endoscopic pyloromyotomy (GPOEM), a novel endoscopic procedure for treatment of gastroparesis.

PATIENTS AND METHODS

All enrolled patients had diagnosed gastroparesis and had biopsies of the muscular layer at the antrum/pylorus during POEM. All GPOEM procedures took place from August 2019 to December 2019. Various demographic, disease-related, and procedure-related data were collected from chart review. ICC in the biopsy specimen was examined and quantitated.

RESULTS

Through this method, we readily expose the gastric muscle of 21 patients through dissection of a gastric submucosal tunnel during GPOEM and provide reliable muscle sample for ICC quantification. Average number of ICC were higher in clinical responders (88 ICC ± 63 vs. 39 ICC ± 24, p = 0.02), defined as those who experienced significant improvement in nausea and vomiting symptoms after GPOEM.

CONCLUSIONS

This study provides a reliable novel biopsy method for safely biopsy gastric muscle for quantitating the number of gastric ICC in patients with gastroparesis. The number of ICC may be related to the outcome of GPOEM therapy. However, further studies with larger number of patients are needed to confirm the results.

Postviral Gastroparesis Associated With SARS-CoV-2 Infection in a Pediatric Patient

Postviral gastroparesis has been described in children, but it has not yet been attributed to SARS-CoV-2 infection. Our case report describes a teenager with abdominal pain, early satiety, and vomiting who likely had an asymptomatic SARS-CoV-2 infection 2 months before presentation. Through investigation of epidemiologic links, antibody testing, and clinical course, it is hypothesized that her significant reduction in gastric emptying was due to postviral gastroparesis secondary to SARS-CoV-2. She was treated with supportive care and prokinetic agents. The patient demonstrated symptom resolution and near normalization of gastric emptying by the time of 1 month follow up.

Clinical Characterization of Pediatric Gastroparesis Using a Four-hour Gastric Emptying Scintigraphy Standard

OBJECTIVES

Four-hour gastric emptying scintigraphy (GES) is the recommended method to identify both adult and childhood gastroparesis (GP). Previous pediatric studies have, however, not used this standard. We sought to determine the characteristics and outcomes of children versus adolescents with GP using the 4-hour GES evaluation.

METHODS

We performed a retrospective chart review of pediatric patients diagnosed with GP by 4-hour GES (>10% retention at 4 hours). Demographics, body mass index, GP-related symptoms, comorbidities, etiologies, therapies (eg, medications), healthcare utilization, and response to therapy were captured systematically. Symptoms were compared from the initial versus last gastroenterology visit. Outcomes were categorized as no improvement; improvement (resolution of at least 1 symptom while remaining on therapy); and complete resolution of symptoms.

RESULTS

A total of 239 subjects (12.1 ± 4.1 years [mean ± standard deviation], 70% girls) were included. The identified characteristics of childhood GP were broad with idiopathic GP being the most common etiology. Outcomes over a median of 22 months (25%-75%: 9.0-45.5 months) were 34.8% no improvement, 34.8% some improvement, and 30.3% with complete symptom resolution. Compared to younger children, adolescents had a higher female predominance (P < 0.01) and were more likely to have nausea (P = 0.006). Girls were more likely to have abdominal pain (P = 0.001), nausea (P = 0.03), and a documented diagnosis of dysautonomia (P = 0.03). Boys were more likely to have regurgitation (P = 0.006), gastroesophageal reflux disease (P = 0.02), and rumination (P = 0.02).

CONCLUSIONS

Using the 4-hour GES standard, childhood GP has broad clinical characteristics and outcomes. There are several significant age- and sex-based differences in childhood GP.

Diabetic and Non-Diabetic Gastroparesis: A Retrospective Comparative Outcome Study From the Nationwide Inpatient Sample

Background

Gastroparesis (GP), meaning “gastric palsy”, is a chronic medical condition characterized by delayed or absent gastric emptying in the absence of mechanical obstruction. The primary objective of this study was to determine the patient-specific outcomes and the burden of GP on the US healthcare system.

Methods

This was a population-based, retrospective study designed to analyze data available from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. Using the International Classification of Diseases, Tenth Revision (ICD-10) codes, we identified adult (18 years or older) hospitalizations with a principal diagnosis of GP. The study sample was further classified into two distinct groups based on the presence or absence of GP, namely diabetic GP (DGP) and non-diabetic GP (NDGP). The primary outcome of our study was inpatient mortality secondary to GP while the secondary outcomes included the odds of system-based complications and the burden of the disease on the United States healthcare system.

Results

We identified 99,695 adult (≥ 18 years) hospitalizations with a principal discharge diagnosis of GP in 2016 and 2017. Of these patients, 78.1% (77,885) had DGP and 21.9% (21,810) were classified in the NDGP group. We noted a higher proportion of women (79.3% vs. 63.4%, P < 0.001), patients with a history of smoking (35.8% vs. 31.7%, P < 0.001) and chronic obstructive pulmonary disease (10.7% vs. 7.6%, P < 0.001) in the NDGP group. After adjusting for common confounders excluding age, the inpatient mortality for GP was found to be 0.25%. Furthermore, after adjustments were made for the Charlson comorbidity index (CCI), we noted higher odds of mortality in the NDGP group (0.30% vs. 0.23%, adjusted odds ratio (aOR): 3.18, 95% confidence interval (CI): 1.75 - 5.79, P < 0.001) compared to the DGP group. Additionally, patients with NDGP had a higher mean length of stay (5 vs. 4.1 days, P < 0.001) and higher mean total hospital charge ($44,100 vs. $35,500, P < 0.001) compared to those with DGP. The NDGP group also had higher odds of sepsis, deep vein thrombosis (DVT) and pulmonary embolism (PE); however, the odds of developing acute kidney injury (AKI) were lower than that of the DGP group.

Conclusions

The inpatient mortality for GP was found to be 0.25%. After adjusting for CCI, patients with NDGP had higher odds of inpatient mortality compared to the DGP group. Additionally, patients with NDGP were associated with a longer length of hospital stay, mean total healthcare cost and higher odds of complications such as sepsis, DVT and PE during the hospitalization.

The impact of risk factors on gastroparesis at an urban medical center

Background

Gastroparesis is a complex and poorly understood disease. The literature is lacking with respect to the epidemiology of patient comorbidities and their effect on gastric emptying. We aimed to describe the most common comorbid conditions among patients with gastroparesis in an urban population and quantify the effect of these comorbidities on the severity of delayed gastric emptying (DGE).

Methods

We examined the medical records of all patients diagnosed with gastroparesis at a quaternary care center between 2014 and 2015. The severity of DGE was analyzed after patients were stratified for possible causative etiologies. Likelihood ratio tests were used to assess the significance of demographic and scintigraphic variation in this population.

Results

Of the 221 patients, 56.1% were Caucasian and 31.7% were African American. Among these patients, 29.4% had evidence of medication-associated gastroparesis, 29.0% had diabetes-associated gastroparesis, and 31.7% had idiopathic disease. African American patients with gastroparesis were more likely to have diabetic gastroparesis than patients of other races (P=0.01). There was a statistically significant relationship between the number of major risk factors and the severity of a patient's DGE (P=0.004).

Conclusions

Among a diverse urban population, patients with DGE often carry multiple comorbid conditions that serve as risk factors for the development of gastroparesis, including prescriptions for narcotic medications. Greater numbers of these comorbid conditions are associated with more severe disease. Demographics are significantly associated with the etiology and severity of gastroparesis; in particular, African American patients are more likely to have diabetic gastroparesis than patients of other races.

Gastroparesis in the Pediatric Patient: Children Are Not Little Adults

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.

Update on pediatric gastroparesis: A review of the published literature and recommendations for future research

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.

Norovirus-induced Gastroparesis

Postviral gastroparesis can result from a variety of viral infections and may cause severe, persistent gastrointestinal symptoms. We report the case of an 85-year-old man with one year of persistent nausea, epigastric pain, early satiety, and 25-pound weight loss after an episode of viral gastroenteritis contracted on a cruise ship. The patient reported that he had tested positive for norovirus shortly after the onset of symptoms. Esophagogastroduodenoscopy revealed no abnormalities, and his symptoms persisted despite treatment for a positive serum H. pylori IgG antibody. Lab workup, including hemoglobin A1c, was otherwise normal, and computed tomography (CT) angiography was unremarkable. A gastric emptying study performed one year after the onset of illness revealed moderate gastroparesis. While most cases of postviral gastroparesis resolve within a year or less, there are a few reports of gastroparetic symptoms lasting two to three years or longer. The pathophysiology might involve a slowly reversible injury to gut neuromodulator cells. Antiviral treatment has not been shown to be effective; symptomatic treatment with antiemetic and prokinetic drugs may be helpful in some cases.

Case Report of gastroparesis healing: 16 years of a chronic syndrome resolved after proximal intercessory prayer

A male infant at two weeks of age was hospitalized vomiting forcefully. He had a pyloromyotomy. He did not improve with medical therapy. The diagnosis of gastroparesis was made after a nuclear medicine gastric emptying study and intestinal manometry. He required a gastrostomy tube (g-tube) and a jejunostomy tube (j-tube) for feeding. At 11 months of age, the j-tube was converted into a feeding jejunostomy with Roux-en-Y limb. For 16 years he was completely dependent on j-tube feeding. In November 2011, he experienced proximal-intercessory-prayer (PIP) at a church and felt an electric shock starting from his shoulder and going through his stomach. After the prayer experience, he was unexpectedly able to tolerate oral feedings. The g- and j-tube were removed four months later and he did not require any further special treatments for his condition as all symptoms had resolved. Over seven years later, he has been free from symptoms. This article investigates a case of PIP as an alternative intervention for resolving severe idiopathic gastroparesis when maximal medical management is not effective.

Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: a multicenter international experience

BACKGROUND

Gastroparesis is a difficult-to-treat motility disorder with a poor response to medical therapy. Gastric peroral endoscopic pyloromyotomy (G-POEM) has been offered as a novel therapy in the treatment of refractory gastroparesis. We present a multicenter case series of our experience with G-POEM.

METHODS

This is an international multicenter case series of patients who underwent G-POEM for the treatment of gastroparesis. The severity of gastroparesis was assessed by delayed gastric emptying scintigraphy (GES) and an elevated gastroparesis cardinal symptoms index (GCSI). Patients then underwent G-POEM using the submucosal tunneling technique. The primary endpoint was improvement in the GCSI score and improvement in gastric emptying on repeat scintigraphy. Secondary endpoints were technical success, complication rate, procedure duration, and length of hospital stay post-procedure.

RESULTS

G-POEM was technically successful in all 33 patients. Symptomatic improvement was seen in 28/33 patients (85 %), with a decrease in symptom score by GCSI from 3.3 to 0.8 at follow-up (P < 0.001). The mean procedure duration was 77.6 minutes (37 - 255 minutes). Mean GES improved significantly from 222.4 minutes to 143.16 minutes (P < 0.001). Complications were minimal and included bleeding (n = 1) and an ulcer (n = 1) treated conservatively. The mean length of hospital stay post-procedure was 5.4 days (1 - 14 days). The mean follow-up duration was 11.5 months (2 - 31 months).

CONCLUSION

G-POEM is a technically feasible, safe, and successful procedure for the treatment of refractory gastroparesis. A further multicenter comparative study should be performed to compare this technique to laparoscopic pyloromyotomy.

Yield of Endoscopy in Pediatric Gastroparesis

OBJECTIVES

The aim of the study was to quantify the diagnostic yield of upper endoscopy in children with gastroparesis and to develop a clinical model for gastroparesis using common symptoms and screening blood tests.

METHODS

We retrospectively reviewed charts of 196 patients of age 4 to 18 years evaluated for gastroparesis between 2009 and 2013. All patients completed a standard solid-phase gastric emptying scan and upper endoscopy within a 12-month period. We analyzed gross and histologic endoscopy findings. Symptom-based data were collected on dyspeptic symptoms and classic "red-flag" symptoms.

RESULTS

Seventy patients with gastroparesis and 126 controls were included. Clinically significant endoscopic findings were noted in 35% of controls (44/126) and 43% of gastroparetics (30/70), P = 0.345. Concordance between gross and histologic findings was low at 50%. Histologic findings included gastritis 60% (17/28), esophagitis 39% (11/28), and duodenitis 7% (2/28). In univariate and multivariate analyses, there was no meaningful correlation between symptoms and/or screening laboratory values and diagnosis of gastroparesis.

CONCLUSIONS

Clinically significant endoscopy findings were common in both controls and gastroparetics. As more than one-third of patients had findings on endoscopy, we conclude that upper endoscopy remains an important part of the evaluation process of patients with dyspeptic symptoms and suspected gastroparesis. As gross abnormalities were frequently not present with histologic changes, routine biopsy is required. There was no association between studied symptoms and the presence of gastroparesis. A comprehensive evaluation of children with dyspeptic symptoms requires endoscopy with biopsy and solid-phase gastric emptying scan to determine the underlying diagnosis.

Clinical aspects of neurointestinal disease: Pathophysiology, diagnosis, and treatment

The enteric nervous system (ENS) is involved in the regulation of virtually all gut functions. Conditions referred to as enteric neuropathies are the result of various mechanisms including abnormal development, degeneration or loss of enteric neurons that affect the structure and functional integrity of the ENS. In the past decade, clinical and molecular research has led to important conceptual advances in our knowledge of the pathogenetic mechanisms of these disorders. In this review we consider ENS disorders from a clinical perspective and highlight the advancing knowledge regarding their pathophysiology. We also review current therapies for these diseases and present potential novel reparative approaches for their treatment.

Assessment of gastric emptying in children: Establishment of control values utilizing a standardized vegetarian meal

BACKGROUND AND AIM

Disorders of gastric emptying constitute an important group of conditions in children. The diagnostic gold standard is scintigraphy, and recommendations for standardization have been published with adult normative data. Pediatric literature lacks standardized age specific normative values. Our aim was to establish normal values of solid phase gastric emptying utilizing scintigraphy in children (5-18 years) using the recommended imaging protocol and standardized meal.

METHODS

Gastric emptying was assessed by scintigraphy of a (99m) Tc-labeled vegetarian meal. Image acquisition was dynamic for first hour and static at 2, 3, and 4 h. Results were reported as percent intragastric retention; lag phase defined as time to 5% emptying.

RESULTS

Thirty (17 boys) healthy children, mean ages of 9.5 ± 3.1 (range 5 to 16) years, were enrolled. Median values (5th and 95th percentiles) for percent gastric retention at 30 min, 1, 2, 3 and 4 h were 90% (76 and 100%), 77% (56 and 96%), 33% (10 and 71%), 16% (3 and 44%), and 7% (0.5 and 22%). The median (5th and 95th percentiles) lag phase was 18 min (6 and 60 min). Lag phase had no correlation with gastric retention at 4 h.

CONCLUSIONS

This study provides valuable normative ranges for solid phase gastric emptying in children. Using adult normative data in children may be inappropriate.

Polyradiculopathy and Gastroparesis due to Cytomegalovirus Infection in AIDS: A Case Report and Review of Literature

Patient: Female, 46

Final Diagnosis: CMV gastroparesis and radiculopathy

Symptoms: Nausea • paraplegia • urinary retention • vomiting

Medication: —

Clinical Procedure: Lumbar puncture

Specialty: Infectious Diseases

Relationship of gastrointestinal symptoms and psychosocial distress to gastric retention in children

OBJECTIVES

To determine whether gastrointestinal (GI) symptoms (abdominal pain, nonpain GI symptoms, nausea) and/or psychosocial distress differ between children with/without gastroparesis and whether the severity of GI symptoms and/or psychosocial distress is related to the degree of gastroparesis.

STUDY DESIGN

Children aged 7-18 years (N = 100; 63 female patients) undergoing a 4-hour gastric emptying scintigraphy study completed questionnaires evaluating GI symptoms, anxiety, and somatization for this prospective study. Spearman correlation, Mann-Whitney, t-test, and χ(2) tests were used as appropriate for statistical analysis.

RESULTS

Children with gastroparesis (n = 25) were younger than those with normal emptying (12.6 ± 3.5 vs 14.3 ± 2.6 years, P = .01). Because questionnaire responses from 7- to 10-year-old children were inconsistent, only patient-reported symptoms from 11- to 18-year-olds were used. Within this older group (n = 83), children with gastroparesis (n = 17) did not differ from children with normal emptying in severity of GI symptoms or psychosocial distress. In children with gastroparesis, gastric retention at 4 hours was related inversely to vomiting (r = -0.506, P = .038), nausea (r = -0.536, P = .019), difficulty finishing a meal (r = -0.582, P = .014), and Children's Somatization Inventory score (r = -0.544, P = .024) and positively correlated with frequency of waking from sleep with symptoms (r = 0.551, P = .022).

CONCLUSIONS

The severity of GI symptoms and psychosocial distress do not differ between children with/without gastroparesis who are undergoing gastric emptying scintigraphy. In those with gastroparesis, gastric retention appears to be inversely related to dyspeptic symptoms and somatization and positively related to waking from sleep with symptoms.

Functional dyspepsia in children

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.

Nausea predicts delayed gastric emptying in children

OBJECTIVES

To assess whether the gastroparesis cardinal symptom index (GCSI), or any individual symptom, is associated with delayed gastric emptying in children, and to assess understanding of symptoms associated with delayed gastric emptying.

STUDY DESIGN

Fifty children (36 F), 5-18 years of age, undergoing gastric emptying scintigraphy (GES) at Lurie Children's Hospital in Chicago, Illinois, completed Likert-type GCSI and symptom comprehension questionnaires. Correlation of GES results (normal or abnormal) with questionnaire results using the Wilcoxon rank sum test.

RESULTS

Seventy percent of subjects had a normal GES. Children reported understanding most terms of GCSI (average score 2.59, range 0-3). The GCSI was not associated with delayed gastric emptying. Nausea was associated with delayed gastric emptying only (numerical P = .04, word P = .02). Results were not altered when poorly understood terms were excluded.

CONCLUSIONS

The GCSI is not associated with delayed gastric emptying in children. Lack of association does not seem to be related to lack of understanding. Nausea alone was the only symptom that showed an association with delayed gastric emptying on GES.

The importance of interstitial cells of cajal in the gastrointestinal tract

Gastrointestinal (GI) motility function and its regulation is a complex process involving collaboration and communication of multiple cell types such as enteric neurons, interstitial cells of Cajal (ICC), and smooth muscle cells. Recent advances in GI research made a better understanding of ICC function and their role in the GI tract, and studies based on different types of techniques have shown that ICC, as an integral part of the GI neuromuscular apparatus, transduce inputs from enteric motor neurons, generate intrinsic electrical rhythmicity in phasic smooth muscles, and have a mechanical sensation ability. Absence or improper function of these cells has been linked to some GI tract disorders. This paper provides a general overview of ICC; their discovery, subtypes, function, locations in the GI tract, and some disorders associated with their loss or disease, and highlights some controversial issues with regard to the importance of ICC in the GI tract.

Clinical presentation, response to therapy, and outcome of gastroparesis in children

OBJECTIVES

The aims of the present study was to define the clinical features, response to therapy, and outcome of pediatric gastroparesis.

METHODS

Retrospective review of 230 children with gastroparesis. Demographics, gastric emptying times, symptoms, response to medications, and outcome were determined for each of 3 groups (infants, children, and adolescents).

RESULTS

Mean age was 9 years, with boys predominating among infants and girls among adolescents. Postviral gastroparesis occurred in 18% and mitochondrial dysfunction (MD) in 8%. Symptoms varied with age, with children experiencing more vomiting and adolescents reporting more nausea and abdominal pain. The addition of promotility drugs was an effective therapy. Overall rates of symptom resolution were 22% at 6 months, 53% at 18 months, and 61% at 36 months, with median time to resolution of 14 months. Factors associated with symptom resolution included younger age, male sex, postviral gastroparesis, shorter duration of symptoms, response to addition of promotility therapy, and absence of MD. In multivariate analysis, longer duration of symptoms and MD both predicted lower rates of resolution, whereas younger age and response to addition of promotility therapy predicted a higher rate.

CONCLUSIONS

Pediatric gastroparesis is a complex condition with variable symptomatology and outcome depending on multiple parameters. Understanding the clinical features and response to therapy will improve our diagnosis and treatment of this disorder.

Postinfectious gastroparesis: a case series of three adolescent females

Postinfectious gastroparesis (PIGP) is a subgroup of idiopathic gastroparesis rarely reported in adolescents. This study describes 3 adolescent females with severe PIGP, who each underwent extensive workup prior to referral to a pediatric gastroenterologist. PIGP may be an underrecognized disorder in pediatrics, particularly in adolescents, and if untreated, can lead to significant morbidity.

Gastroparesis: concepts, controversies, and challenges

Patients with gastroparesis often present a challenge to the treating physician. Postprandial symptoms with nausea and vomiting may not only lead to nutritional and metabolic consequences, but also cause significant disruptions to social activities that often center around food. While the definition of gastroparesis focuses on impaired gastric emptying, treatment options that affect gastric function are limited and often disappointing. The female predominance, the mostly idiopathic nature of the illness with a common history of abuse, and coexisting anxiety or depression show parallels with other functional disorders of the gastrointestinal tract. These parallels provided the rationale for some initial studies investigating alternative therapies that target the brain rather than the stomach. This emerging shift in medical therapy comes at a time when clinical studies suggest that gastric electrical stimulation may exert its effects by modulating visceral sensory processing rather than altering gastric motility. Physiologic and detailed anatomic investigations also support a more complex picture with different disease mechanisms, ranging from impaired accommodation to apparent visceral hypersensitivity or decreased interstitial cells of Cajal to inflammatory infiltration of myenteric ganglia. Delayed gastric emptying remains the endophenotype defining gastroparesis. However, our treatment options go beyond prokinetics and may allow us to improve the quality of life of affected individuals.

Use of fluoroscopy to study in vivo motility in mouse pups

OBJECTIVES

Few methods exist to noninvasively study in vivo gastrointestinal motility in animal models of enteric infections. None have been used on mouse pups, which often display more severe symptoms during enteric infections than adult mice. This study sought to determine whether digital fluoroscopy could be used to evaluate gastrointestinal motility in mouse pups as well as adult mice.

MATERIALS AND METHODS

Fluoroscopic imaging studies were performed on normal 6- to 8-week-old adult mice and 12-day-old pups to develop protocols for evaluating gastric and intestinal wall movements and changes in stomach sizes. These protocols were then applied to evaluate motility in an established rotavirus mouse model. Imaging studies were performed on adult mice at 0, 2, and 4 days postinfection and on 12-day-old pups at 2 days postinfection.

RESULTS

Fluoroscopic studies revealed postnatal differences of gastric peristalsis and rates of intestinal contractions between normal mouse pups and adult mice. Studies of the rotavirus mouse model revealed that differences in gastric function occur between rotavirus-infected and control mouse pups, but no discernible difference occurs between infected and control adult mice. In contrast, there were no detectable differences in rates of intestinal wall movements between control pups with normal stools and infected pups with loose stools.

CONCLUSIONS

These results demonstrate that fluoroscopy can evaluate in vivo motility in mouse pups and by doing so provide findings that are clinically relevant to the study of enteric infections in young.

Gastroparesis: approach, diagnostic evaluation, and management

Gastroparesis is a chronic motility disorder of the stomach that involves delayed emptying of solids and liquids, without evidence of mechanical obstruction. Although no cause can be determined for the majority of cases, the disease often develops as a complication of abdominal surgeries or because of other underlying disorders, such as diabetes mellitus or scleroderma. The pathophysiology behind delayed gastric emptying is still not well-understood, but encompasses abnormalities at 3 levels--autonomic nervous system, smooth muscle cells, and enteric neurons. Patients will often cite nausea, vomiting, postprandial fullness, and early satiety as their most bothersome symptoms on history and physical examination. Those that present with severe disease may already have developed complications, such as the formation of bezoars or masses of undigested food. In patients suspected of gastroparesis, diagnostic evaluation requires an initial upper endoscopy to rule out mechanical causes, followed by a gastric-emptying scintigraphy for diagnosis. Other diagnostic alternatives would be wireless capsule motility, antroduodenal manometry, and breath testing. Once gastroparesis is diagnosed, dietary modifications, such as the recommendation of more frequent and more liquid-based meals, are encouraged. Promotility medications like erythromycin and antiemetics like prochlorperazine are offered for symptomatic relief. These agents may be frequently changed, as the right combination of effective medications will vary with each individual. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, are considered. Future areas of research are based on current findings from clinical studies. New medications, such as hemin therapy, are emerging because of a better understanding of the pathophysiology behind gastroparesis, and present treatment options, such as gastric electric stimulation, are evolving to be more effective. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future.

Gastroparesis associated with gastroptosis presenting as a lower abdominal bulking mass in a child: a case report

BACKGROUND

Gastroparesis is defined as an inhibition of the gastric motility associated with delayed gastric emptying, which is mainly presented with acute dyspepsia. Gastroptosis is the downward displacement of the stomach.

CASE REPORT

We report a rare case of secondary gastroparesis due to gastroptosis in an 11-year-old female child. The patient complained for bulking mass in the left lower quadrate presented a week ago, which was mimicking a large abdominal hernia. The laboratory and radiological exams revealed an excessive gastroptosis associated with gastroparesis. We searched the literature but we failed to find other cases with idiopathic gastroptosis in a child. The patient was treated conservatively and six months after the initial diagnosis and treatment the patient does not complains for dyspepsia.

CONCLUSION

Gastroparesis associated with gastroptosis is a rare entity that can be treated conservatively with acceptable results.

Clinical management of motility disorders in children

We review the current clinical evaluation and management of the most common esophageal and gastrointestinal motility disorders in children based on the literature and our experience in a pediatric motility center in the United States. The disorders discussed include esophageal achalasia, pre- and post-fundoplication motility disorders, gastroparesis, motility disorders occurring after repair of congenital atresias, motility disorders associated with gastroschisis, chronic intestinal pseudo-obstruction, motility after intestinal transplantation, motility disorders after colonic resection for Hirschsprung's disease, chronic functional constipation, and motility disorders associated with imperforate anus.

Interobserver variability in antroduodenal manometry

Interobserver variability affects investigations involving assessment of complex visual data, such as histopathology, radiology and motility. This study assessed interobserver variation for interpretation of antroduodenal manometry (ADM), as this has not been previously investigated. Thirty-five ADM recordings from children aged 0.3-18 years were independently evaluated by five experienced paediatric gastroenterologists who were blinded to cases' clinical histories. Intra-class correlation (ICC) was analysed for detection and measurement of phase three of the migrating motor complex (MMC) and Cohen's kappa statistic was calculated between observer pairs for detection of specific motility features and final diagnosis. Observers were unanimous on the differentiation of normal and abnormal motility in 63% of cases. There was excellent interobserver agreement for the number of phase three of the MMC in fasting (ICC = 0.82, P < 0.0001) and for measurements of phase three of the MMC (ICC = 0.9999, P < 0.0001). Detection of other normal and abnormal motility patterns varied more. Objective findings such as the presence of phase three of the MMC correlated more closely than findings that involved the integration of several variables, such as final diagnosis. However, these data overall indicate that agreement between expert observers for the distinction of normal and abnormal antroduodenal motility compares favourably with other standard medical assessments.

Management of gastroparesis

Gastroparesis presents with nausea, vomiting, early satiety and abdominal discomfort, as well as a range of nongastrointestinal manifestations in association with delays in gastric emptying. The disorder may be a consequence of systemic illnesses, such as diabetes mellitus, occur as a complication of gastroesophageal surgery or develop in an idiopathic fashion and may mimic other disorders with normal gastric emptying. Some cases of idiopathic gastroparesis present after a viral infection. Management relies primarily on therapies that accelerate gastric emptying or reduce vomiting, although endoscopic or surgical options are available for refractory cases. Current research is focusing on the cellular and molecular mechanisms underlying development of delayed gastric emptying, as well as factors unrelated to motor dysfunction that may elicit some symptoms. Future pharmaceuticals will target the contractile and nonmotor defects via novel pathways. Novel electrical stimulation techniques will be employed either alone or in combination with medications.

Differences in intragastric pH in diabetic vs. idiopathic gastroparesis: relation to degree of gastric retention

Evidence suggests that distinct mechanisms underlie diabetic and idiopathic gastroparesis. Differences in gastric acid in gastroparesis of different etiologies and varying degrees of gastric stasis are uninvestigated. We tested the hypotheses that 1) gastric pH profiles show differential alteration in diabetic vs. idiopathic gastroparesis and 2) abnormal pH profiles relate to the severity of gastric stasis. Sixty-four healthy control subjects and 44 gastroparesis patients (20 diabetic, 24 idiopathic) swallowed wireless transmitting capsules and then consumed (99m)Tc-sulfur colloid-labeled meals for gastric scintigraphy. Gastric pH from the capsule was recorded every 5 s. Basal pH was higher in diabetic (3.64 +/- 0.41) vs. control subjects (1.90 +/- 0.18) and idiopathic subjects (2.41 +/- 0.42; P < 0.05). Meals evoked initial pH increases that were greater in diabetic (4.98 +/- 0.32) than idiopathic patients (3.89 +/- 0.39; P = 0.03) but not control subjects (4.48 +/- 0.14). pH nadirs prior to gastric capsule evacuation were higher in diabetic patients (1.50 +/- 0.23) than control subjects (0.58 +/- 0.11; P = 0.003). Four-hour gastric retention was similar in diabetic (18.3 +/- 0.5%) and idiopathic (19.4 +/- 0.5%) patients but higher than control subjects (2.2 +/- 0.5%; P < 0.001). Compared with control subjects, those with moderate-severe stasis (>20% retention at 4 h) had higher basal (3.91 +/- 0.55) and nadir pH (2.23 +/- 0.42) values (P < 0.05). In subgroup analyses, both diabetic and idiopathic patients with moderate-severe gastroparesis exhibited increased pH parameters vs. those with mild gastroparesis. In conclusion, diabetic patients with gastroparesis exhibit reduced gastric acid, an effect more pronounced in those with severely delayed gastric emptying. Idiopathic gastroparetic subjects exhibit nearly normal acid profiles, although those with severely delayed emptying show reduced acid vs. those with mild delays. Thus both etiology and degree of gastric stasis determine gastric acidity in gastroparesis.

Dyspeptic symptoms in children: the result of a constipation-induced cologastric brake?

BACKGROUND & AIMS

Patients with constipation frequently complain of dyspeptic symptoms that may be explained by reflex inhibition of upper-gastrointestinal motor activity by colonic stimuli. We sought to evaluate the following: (1) the prevalence of functional constipation (FC) and gastric emptying characteristics in children with functional dyspepsia (FD), and (2) the efficacy of osmotic laxatives on constipation, dyspeptic symptoms, and gastric motility.

METHODS

We recruited 42 children (males/females, 22/20; mean age, 80.5 mo) affected by FD (Rome II criteria). All subjects underwent ultrasonographic measurement of the total gastric emptying time (TGEt) at baseline (T0) and after 3 months (T3). Children's bowel habits and the dyspeptic symptomatic score were evaluated at entry and after 1 (T1), 2 (T2), and 3(T3) months. Constipated patients were treated with osmotic laxatives for 3 months. Dyspeptic children without constipation represented the comparison group.

RESULTS

FC was present in 28 of 42 (66.6%) patients. Constipated dyspeptic children had significantly more prolonged TGEt than subjects without constipation (median value [interquartile range], 180 (50) vs 150 (28) min, respectively; P = .004). Patients on osmotic laxatives had a significant decrease in TGEt at 3 months (P < .001). The median dyspeptic symptomatic score as well as the number and consistency of evacuations per week significantly improved at T1 in comparison with T0 and even more at T2 and T3 (P < .001, for each).

CONCLUSIONS

In our study group, the majority of children with FD were affected by FC associated with delayed gastric emptying. Normalization of bowel habit may improve gastric emptying as well as dyspeptic symptoms.

Gastric electrical stimulation for children with intractable nausea and gastroparesis

PURPOSE

Gastric electrical stimulation (GES) has been performed in adults as a treatment of refractory nausea and vomiting in patients who have failed medical treatment, but has not been used in children.

METHODS

Nine patients with chronic nausea and vomiting with a mean age of 14 years were evaluated for temporary GES. All 9 patients subsequently underwent placement of a temporary followed by permanent GES device. Symptoms were recorded at baseline, after temporary GES, and then after permanent GES using a Likert scale for gastroparesis. Statistical analysis was performed using a paired Student's t test.

RESULTS

At baseline, all patients were symptomatic and most had delayed solid gastric emptying. As a group, there was a significant improvement in combined symptoms score (P = .04), nausea (P = .039), and vomiting (P = .0016). Gastric emptying and electrogastrogram values did not change significantly. Follow-up ranged from 8 to 42 months, with 7 of the 9 patients reporting sustained improvement in symptoms and improved quality of life.

CONCLUSIONS

Gastric electrical stimulation can be successfully applied to adolescents with intractable nausea and gastroparesis symptoms who fail medical therapy. There is a significant improvement in symptoms over a prolonged period, and there are no adverse effects of the GES. Long-term efficacy of this therapy in children needs to be established.

Interstitial cells of Cajal in health and disease. Part I: normal ICC structure and function with associated motility disorders

Ramon y Cajal (1852-1934) is considered to be one of the founders of the field of neuroscience. In 1911, he described interstitial neurons in the gut, noting that they were primitive accessory components that perhaps modify smooth muscle contraction, themselves subject to regulation from principle neurons. The accuracy of his description of their appearance and activities has led to these cells now being called the interstitial cells of Cajal (ICC). Thuneberg and Faussone-Pellegrini were instrumental in bringing these cells to the attention of gastroenterologists and pathologists in the early 1980s. Subsequently, the development of antibodies to c-kit has allowed routine identification of the ICC in pathology specimens. c-Kit is a transmembrane protein kinase which has as ligand stem cell factor and is involved in cell development in a variety of cell lineages. In the gut musculature, ICC and mast cells are the only cells that have prominent c-kit expression. The ICC are now known to play an important role in gut motility and absent or disordered ICC networks have been identified in a variety of motility disorders.

Gastroparesis: symptoms, evaluation, and treatment

Gastroparesis presents with gastrointestinal symptoms and nongastrointestinal manifestations in association with objective delays in gastric emptying. The condition may complicate several systemic disorders or may be idiopathic in nature. The diagnosis is made by directed evaluation to exclude organic diseases, which can mimic the clinical presentation of gastroparesis coupled with quantification of gastric emptying. Current therapies rely on dietary modifications, medications to stimulate gastric evacuation, and agents to reduce vomiting. Endoscopic and surgical options are increasingly used for cases refractory to medication treatment.

Post-infectious gastroparesis: clinical and electerogastrographic aspects

AIMS

Post-infectious gastroparesis (PIGP) is a subgroup of idiopathic gastroparesis. The aim of this study was to identify post-viral gastroparesis and to characterize clinical and electrogastrographic aspects of the disease and their usefulness as a diagnostic tool.

METHODS

Patients diagnosed with gastroparesis were defined as PIGP if they had a clear history of an acute viral illness prior to the development of their symptoms. All patients underwent evaluation of gastric emptying and electrogastrography (EGG).

RESULTS

Seven patients met the criteria for diagnosis of PIGP. Patients' age ranged from 3 months to 47 years. A specific virus was identified in two patients (one cytomegalovirus [CMV] and one Epstein-Barr virus [EBV]). EGG was pathological in six out of seven patients. In four out of seven patients, symptoms resolved spontaneously within 4 weeks to 12 months, three patients had improved but were still symptomatic at the time of the writing of this work.

CONCLUSION

We conclude that post-infectious gastroparesis is an uncommon and often over looked condition. It is self-limiting in most cases. EGG is pathological in most patients.

Gastrointestinal motility disorders in adolescent patients: transitioning to adult care

A wide spectrum of gastrointestinal motility disorders present in childhood. Some are unique to children, especially congenital disorders including certain pseudo-obstruction disorders or those associated with anatomic developmental defects, whereas others are common adult disorders, such as achalasia, that rarely manifest in children. This article reviews the pediatric presentations and sequelae of childhood gastrointestinal motility disorders and then discusses long-term management issues for these children as they progress into adulthood. The goal is to optimize medical care and ensure the adequate nutritional status essential for neurocognitive and psychosocial development of the child. Multidisciplinary care from specialists, including gastroenterologists, psychologists, and pain specialists, is often required to optimize the lives of these patients.

Mechanisms of disease: the pathological basis of gastroparesis--a review of experimental and clinical studies

The pathogenesis of gastroparesis is complicated and poorly understood. This lack of understanding remains a major impediment to the development of effective therapies for this condition. Most of the scientific information available on the pathogenesis of gastroparesis has been derived from experimental studies of diabetes in animals. These studies suggest that the disease process can affect nerves (particularly those producing nitric oxide, but also the vagus nerve), interstitial cells of Cajal and smooth muscle. By contrast, human data are sparse, outdated and generally inadequate for the validation of data obtained from experimental models. The available data do, however, suggest that multiple cellular targets are involved. In practice, though, symptoms seldom correlate with objective measures of gastric function and there is still a lot to learn about the pathophysiology of gastroparesis. Future studies should focus on understanding the molecular pathways that lead to gastric dysfunction, in animal models and in humans, and pave the way for the development of rational therapies.

Pediatric Gastrointestinal Nuclear Medicine

General localization of gastrointestinal bleeding through the use of labeled red blood cells may be performed in children, or (99m)Tc-pertechnetate may be used if a Meckel's diverticulum is suspected. As in adults, cholecystitis and biliary leak may be assessed in children via (99m)Tc-IDA derivatives. Gastroesophageal reflux can be evaluated by oral consumption of the child's usual diet labeled with (99m)Tc sulfur colloid. For the scintigraphic determination of pulmonary aspiration, a relatively high concentration of tracer within a drop of liquid is placed beneath the child's tongue followed by dynamic imaging of the respiratory tract. Colonic transit scintigraphy can aid in the identification and therapeutic decision-making in patients with functional fecal retention, the most common cause of chronic constipation in children. (18)F-DOPA positron emission tomography is useful for classifying pancreatic involvement in infantile hyperinsulinism as focal or diffuse, thereby differentiating between patients who should receive curative focal pancreatic resection versus those who should receive medical management. Assessment of protein-losing enteropathy can be conducted scintigraphically and, compared with fecal alpha-1 antitrypsin collection, the scintigraphic method can detect esophageal and gastric protein loss. Also, scintigraphic quantification of protein loss can be performed without the requirement for fecal collection. Intestinal inflammation in children with inflammatory bowel disease can be evaluated using (99m)Tc white blood cells. The scintigraphic method is safe, accurate, well-tolerated by children and complementary to endoscopy in most patients.

The difficult patient with gastroparesis

Gastroparesis is often difficult to manage. First of all, exact criteria for making a diagnosis of gastroparesis have not been established, and merely finding delayed gastric emptying does not justify the label. Furthermore, the relationship between symptoms and gastric emptying rate is poor, and the number of therapies with proven efficacy is extremely limited. A number of technical investigations are helpful to establish the anatomy and motor function of the upper gastrointestinal tract. In most cases where gastroparesis can be presumed or established, prokinetic therapy will be tried. A number of agents are available, with variable efficacy and tolerance. Rarely, in case of debilitating refractory symptoms, experimental or invasive therapies can be tried such as injection of botulinum toxin, enteral feeding tube insertion, gastric electrical stimulation or surgery.

Gastrointestinal symptoms after infectious diarrhea: a five-year follow-up in a Swedish cohort of adults

BACKGROUND & AIMS

Gastrointestinal infection is a well-recognized trigger for functional bowel disorder. This study evaluated gastrointestinal symptoms and risk factors for their development after diarrheal disease of proven or strongly suspected infectious etiology in adults.

METHODS

The cohort of patients was derived from a previous study that determined the rate at which enteropathogens could be isolated at the time of diarrheal disease in adults. After 5 years, 717 of 851 patients were accessible for a questionnaire asking for persistence of gastrointestinal symptoms.

RESULTS

Of 508 returned questionnaires, 333 were from patients with no previous gastrointestinal complaints. Forty-one (12%) of them had gastrointestinal symptoms for 3 months or more after the infectious diarrhea, and 31 (9%) still had symptoms at the end of the follow-up period. Irritable bowel syndrome was most common (68%), but other functional bowel disorder diagnoses were found in all but one of the others. Female gender (odds ratio, 2.65, 95% confidence interval, 1.28-5.50) and use of antibiotic treatment (odds ratio, 2.37; 95% confidence interval, 1.07-5.25) were risk factors for development of postinfectious functional bowel disorder. No increase in risk was associated with the type of enteropathogen causing diarrhea.

CONCLUSIONS

Infectious diarrhea in previously healthy adults carried a substantial risk of triggering postinfectious functional bowel disorder. Irritable bowel syndrome was the most common, but other functional bowel disorders were also found. We did not find any new clinical tools that would facilitate the prediction of long-standing symptoms.

Loss of interstitial cells of Cajal network in severe idiopathic gastroparesis

AIM

To report a case of severe idiopathic gastroparesis in complete absence of Kit-positive gastric interstitial cells of Cajal (ICC).

METHODS

Gastric tissue from a patient with severe idiopathic gastroparesis unresponsive to medical treatment and requiring surgery was analyzed by conventional histology and immunohistochemistry.

RESULTS

Gastric pacemaker cells expressing Kit receptor had completely disappeared while the local level of stem cell factor, the essential ligand for its development and maintenance, was increased. No signs of cell death were observed in the pacemaker region.

CONCLUSION

These results are consistent with the hypothesis that a lack of Kit expression may lead to impaired functioning of ICC. Total gastrectomy proves to be curative.

Motility disorders of the gastrointestinal tract

Over the past decades our knowledge of normal and abnormal gastrointestinal motility has increased tremendously. The availability of manometry to study bowel contraction patterns, laparoscopy to perform full thickness bowel biopsies for histological examination, have added to the investigative armamentarium and helped better diagnose motility disorders. However, the development of newer therapies for bowel motility disorders has been disappointingly slow. Newer modalities such as gastric and bowel pacing provides some hope for the future. In this article we have provided an overview of some of the common motility disorders in children and discussed their management.

Childhood functional gastrointestinal disorders: child/adolescent

The Rome II pediatric criteria for functional gastrointestinal disorders (FGIDs) were defined in 1999 to be used as diagnostic tools and to advance empirical research. In this document, the Rome III Committee aimed to update and revise the pediatric criteria. The decision-making process to define Rome III criteria for children aged 4-18 years consisted of arriving at a consensus based on clinical experience and review of the literature. Whenever possible, changes in the criteria were evidence based. Otherwise, clinical experience was used when deemed necessary. Few publications addressing Rome II criteria were available to guide the committee. The clinical entities addressed include (1) cyclic vomiting syndrome, rumination, and aerophagia; 2) abdominal pain-related FGIDs including functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain; and (3) functional constipation and non-retentive fecal incontinence. Adolescent rumination and functional constipation are newly defined for this age group, and the previously designated functional fecal retention is now included in functional constipation. Other notable changes from Rome II to Rome III criteria include the decrease from 3 to 2 months in required symptom duration for noncyclic disorders and the modification of the criteria for functional abdominal pain. The Rome III child and adolescent criteria represent an evolution from Rome II and should prove useful for both clinicians and researchers dealing with childhood FGIDs. The future availability of additional evidence-based data will likely continue to modify pediatric criteria for FGIDs.

Postinfectious gastroparesis related to autonomic failure: a case report

BACKGROUND AND AIM

Severe dysautonomia may be secondary to viral infections, resulting in impaired autoimmune, cardiovascular, urinary and digestive dysfunction. Herein, we present a case of a 31-year-old white female patient who had severe gastroparesis related to autonomic failure following an episode of acute gastroenteritis. This seems to be the first report providing thorough assessment of the enteric and autonomic nervous system by analysis of full-thickness small intestinal biopsies, cardiovagal testing and autopsy.

HOSPITAL COURSE

This patient affected by a severe gastroparesis was treated with antiemetics, prokinetics, analgesics and gastric electrical stimulation to control symptoms. Nutritional support was made using jejunal feeding tube and, in the final stage of disease, with total parenteral nutrition. Autonomic studies revealed minimal heart rate variability and a disordered Valsalva manoeuvre although the enteric nervous system and the smooth muscle layer showed a normal appearance. Hospital courses were complicated by episodes of bacteraemia and fungemia. Serum antiphospholipid antibodies were noted but despite anticoagulation, she developed a pulmonary embolism and shortly thereafter the patient died. Autopsy revealed acute haemorrhagic Candida pneumonia with left main pulmonary artery thrombus. Sympathetic chain analysis revealed decreased myelinated axons with vacuolar degeneration and patchy inflammation consistent with Guillain-Barre syndrome. The evaluation of the enteric nervous system in the stomach and small bowel revealed no evidence of enteric neuropathy or myopathy.

CONCLUSION

A Guillain-Barre-like disease with gastroparesis following acute gastroenteritis is supported by physiological and autonomic studies with histological findings.

Dyspepsia and irritable bowel syndrome after a Salmonella gastroenteritis outbreak: one-year follow-up cohort study

BACKGROUND & AIMS

It has been reported that some patients develop functional digestive disorders, particularly irritable bowel syndrome (IBS), after acute gastroenteritis (AGE). However, the presence of dyspepsia has not been specifically addressed. We prospectively evaluated development of dyspepsia and IBS during a 1-year follow-up in a cohort of adult patients affected by a Salmonella enteritidis AGE outbreak.

METHODS

Questionnaires were sent to 1878 potential participants at baseline and 3, 6, and 12 months; 677 had experienced a Salmonella enteritidis AGE on June 23, 2002, and 1201 had not (randomly selected controls, matched for village of residence, age, and sex). At 12 months, 271 patients and 335 controls returned the questionnaires. Data permitted the establishment of dyspepsia and IBS diagnosis by Rome II criteria.

RESULTS

Before the AGE outbreak, the prevalence of dyspepsia was similar in cases and controls (2.5% vs 3.8%); the prevalence of IBS was also similar (2.9% vs 2.3%). At 3, 6, and 12 months, the prevalence of both dyspepsia and IBS had increased significantly in exposed compared with unexposed subjects. Overlap between dyspepsia and IBS was frequent. At 1 year, the relative risk for development of dyspepsia was 5.2 (95% confidence interval, 2.7-9.8) and for IBS was 7.8 (95% confidence interval, 3.1-19.7). Prolonged abdominal pain and vomiting during AGE were positive predictors of dyspepsia. No predictive factors for IBS were found.

CONCLUSIONS

Salmonella gastroenteritis is a significant risk factor not only for IBS but also for dyspepsia; at 1 year of follow-up, 1 in 7 and 1 in 10 subjects developed dyspepsia or IBS, respectively.

Inflammation as a basis for functional GI disorders

The term 'Functional diseases' implies symptoms arising from an organ without overt pathology. However this is more apparent than real since inflammation often leaves changes in nerves and mucosal function only apparent with specialised techniques. Acute onset functional dyspepsia accounts for around 1/5 of functional dyspepsia and is characterised by early satiety, nausea, vomiting and weight loss. Impaired postcibal fundal accommodation may underlie some of these symptoms. Post infectious gastroparesis is much rarer and is associated with markedly delayed gastric emptying and antral hypomotility. Approximately 1/10 of IBS cases describe a post infectious onset. Post infectious IBS is typically of the diarrhoea-predominant type. Post inflammatory functional diseases tend to be associated with less psychological abnormalities and have a better prognosis than other functional diseases. There are isolated anecdotal reports of symptom response to anti-inflammatory treatments but larger controlled trials are needed.