Real-time ultrasonographic assessment of antroduodenal motility after ingestion of solid and liquid meals by patients with functional dyspepsia

Serial change in gastric motility in eosinophilic gastritis with pyloric stenosis assessment by abdominal ultrasonography

Eosinophilic gastritis (EoG) is defined as the presence of upper gastrointestinal symptoms combined with histologic findings of > 30 eosinophils/high-power field (eos/hpf) in 5 hpf in any part of the gastric mucosa, except for the secondary causes of gastric eosinophilia. This is the first case report of a serial change in gastric motility in EoG with pyloric stenosis using abdominal ultrasonography. A 56-year-old woman was diagnosed with pyloric stenosis by upper gastrointestinal radiographic examination during a medical checkup. She had nausea and loss of appetite, her gastrointestinal symptom rating scale (GSRS) score was 20, and her F scale score was 20. Esophagogastroduodenoscopy (EGD) demonstrated pyloric stenosis and multiple superficial ulcerations in the antrum. Histopathological findings of gastric biopsy specimens revealed severe eosinophilic infiltration (100 eos/HPF), and the diagnosis was EoG with pyloric stenosis. Before treatment, the gastric anterior wall thickness was 6.3 mm. The gastric motility in EoG was evaluated by intra-abdominal ultrasonography. Ultrasonography showed low motility in the antrum, especially the amplitude and motility index. After 6 months of steroid treatment, her symptoms improved. Her GSRS score was 13, and her F scale score was 19. Histological eosinophilic infiltration decreased to 50 eos/HPF, showing improvement. On ultrasonography, gastric motility also improved and recovered to normal. After 12 months, several examinations confirmed improvement, including gastric motility by ultrasonography.

Ultrasound assessment of gastrointestinal luminal contents: a narrative review

Gastro-intestinal ultrasound (GIUS) is a non-invasive and cost-effective tool, widely used as a first-line diagnostic method in patients presenting with abdominal complaints, especially in patients affected by inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. In this setting, gastro-intestinal ultrasound has been especially used to evaluate the bowel wall features (thickening, stratification, vascularization) and complications related to IBD (fistulas, abscesses). Nevertheless, gastro-intestinal ultrasound can be also used to detect and evaluate the content of several segments of the gut. In fact, there is a growing interest in utilizing GIUS for suspected functional disorders, where assessing intestinal content may play a significant diagnostic role, as well as directing therapy. In our review, we provided a sonographic description of GIUS appearances of bowel content in various pathological and physiological conditions, offering potential applications in clinical practice and providing insights for further research.

Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability

The oral route is the most common choice for drug administration because of several advantages, such as convenience, low cost, and high patient compliance, and the demand and investment in research and development for oral drugs continue to grow. The rate of dissolution and gastric emptying of the dissolved active pharmaceutical ingredient (API) into the duodenum is modulated by gastric motility, physical properties of the pill, and the contents of the stomach, but current in vitro procedures for assessing dissolution of oral drugs are limited in their ability to recapitulate this process. This is particularly relevant for disease conditions, such as gastroparesis, that alter the anatomy and/or physiology of the stomach. In silico models of gastric biomechanics offer the potential for overcoming these limitations of existing methods. In the current study, we employ a biomimetic in silico simulator based on the realistic anatomy and morphology of the stomach (referred to as "StomachSim") to investigate and quantify the effect of body posture and stomach motility on drug bioavailability. The simulations show that changes in posture can potentially have a significant (up to 83%) effect on the emptying rate of the API into the duodenum. Similarly, a reduction in antral contractility associated with gastroparesis can also be found to significantly reduce the dissolution of the pill as well as emptying of the API into the duodenum. The simulations show that for an equivalent motility index, the reduction in gastric emptying due to neuropathic gastroparesis is larger by a factor of about five compared to myopathic gastroparesis.

Review of paediatric gastrointestinal physiology relevant to the absorption of orally administered medicines

Despite much progress in regulations to improve paediatric drug development, there remains a significant need to develop better medications for children. For the design of oral dosage forms, a detailed understanding of the specific gastrointestinal (GI) conditions in children of different age categories and how they differ from GI conditions in adults is essential. Several review articles have been published addressing the ontogeny of GI characteristics, including luminal conditions in the GI tract of children. However, the data reported in most of these reviews are of limited quality because (1) information was cited from very old publications and sometimes low quality sources, (2) data gaps in the original data were filled with textbook knowledge, (3) data obtained on healthy and sick children were mixed, (4) average data obtained on groups of patients were mixed with data obtained on individual patients, and (5) results obtained using investigative techniques that may have altered the outcome of the respective studies were considered. Consequently, many of these reviews draw conclusions that may be incorrect. The aim of the present review was to provide a comprehensive and updated overview of the available original data on the ontogeny of GI luminal conditions relevant to oral drug absorption in the paediatric population. To this end, the PubMed and Web of Science metadatabases were searched for appropriate studies that examined age-related conditions in the oral cavity, esophagus, stomach, small intestine, and colon. Maturation was observed for several GI parameters, and corresponding data sets were identified for each paediatric age group. However, it also became clear that the ontogeny of several GI traits in the paediatric population is not yet known. The review article provides a robust and valuable data set for the development of paediatric in vitro and in silico biopharmaceutical tools to support the development of age-appropriate dosage forms. In addition, it provides important information on existing data gaps and should provide impetus for further systematic and well-designed in vivo studies on GI physiology in children of specific age groups in order to close existing knowledge gaps and to sustainably improve oral drug therapy in children.

Gastric motility and pulmonary function in children with functional abdominal pain disorders and asthma: A pathophysiological study

Background

An association has been shown between functional abdominal pain disorders (FAPDs) and asthma. However, the exact reason for this association is obscured. The main objective of this study is to identify the possible underlying pathophysiological mechanisms for the association between FAPDs and asthma using gastric motility and lung function tests.

Methods

This was a cross-sectional comparative study that consisted of four study groups. Twenty-four children (age 7–12 years) each were recruited for four study groups; asthma only, FAPDs only, both asthma and FAPDs, and healthy controls. Asthma was diagnosed using the history and bronchodilator reversibility test. The diagnosis of FAPDs was made using Rome IV criteria. All subjects underwent ultrasound assessment of gastric motility and pulmonary function assessment by spirometry, using validated techniques.

Results

All gastric motility parameters, gastric emptying rate, amplitude of antral contraction, and antral motility index, were significantly impaired in children with FAPDs only, children with asthma only, and children with both asthma & FAPDs, compared to controls (p<0.05). Pulmonary function parameters indicating airway obstruction (FEV₁/FVC ratio, peak expiratory flow rate, FEF25-75%) were not impaired in children with FAPDs only compared to controls (p>0.05), but significantly impaired in children with asthma and children with both disorders. Antral motility index correlated with the FEV₁/FVC ratio (r = 0.60, p = 0.002) and FEF25%-75% (r = 0.49, p = 0.01) in children with both asthma and FAPDs.

Conclusions

Gastric motor functions were significantly impaired in children with asthma, children with FAPDs, and children with both disorders. Motility index, measuring overall gastric motor activity, showed a significant positive correlation with lung function parameters that measure airflow limitation. Therefore, these diseases might arise as a result of primary disturbance of smooth muscle activity in the airways and gastrointestinal wall, which could be a possible pathophysiological mechanism for this association between asthma and FAPDs.

Transcutaneous auricular vagus nerve stimulation influences gastric motility: A randomized, double-blind trial in healthy individuals

BACKGROUND

Transcutaneous auricular vagus nerve stimulation (taVNS) has been investigated regarding its therapeutic properties in several several conditions such as epilepsy, migraine and major depressive disorder and was shown to access similar neural pathways as invasive vagus nerve stimulation. While the vagus nerve's role in gut motility is physiologically established, the effect of taVNS has scarcely been investigated in humans and yielded conflicting results. Real-time gastric magnetic resonance imaging (rtMRI) is an established reproducible method to investigate gastric motility non-invasively.

OBJECTIVE

To investigate the influence of taVNS on gastric motility of healthy participants using rtMRI.

METHODS

We conducted a randomized, double-blind study using high-frequency (HF) stimulation at 25Hz or low-frequency (LF) taVNS at 1Hz after ingestions of a standardized meal in 57 healthy participants. The gastric motility index (GMI) was determined by measuring the amplitude and velocity of the peristaltic waves using rtMRI.

RESULTS

After HF taVNS, GMI was significantly higher than after LF stimulation (p = 0.005), which was mainly attributable to a higher amplitude of the peristaltic waves (p = 0.003).

CONCLUSION

We provide evidence that 4-h of taVNS influences gastric motility in healthy human participants for the first time using rtMRI. HF stimulation is associated with higher amplitudes of peristaltic waves in the gastric antrum compared to LF stimulation. Further studies are needed to investigate the effect of different frequencies of taVNS and its therapeutic properties in conditions with impaired gastric motility.

Development of a quantitative method for evaluating small intestinal motility using ultrasonography in mice

Upper gastrointestinal (GI) motility is affected by various drugs and diseases. However, changes in upper GI motility during these conditions are not well understood, as there are few quantitative in vivo methods that assess small intestinal motility in mice. Ultrasonography is a noninvasive method for imaging and evaluating the condition of the abdominal organs. The aim of the present study was to establish a novel method for evaluating small intestinal motility by using ultrasonography in mice. We measured GI motility with and without loperamide, an antidiarrheal medication, by intestinal transit using an orally administered dye, a ¹³C-octanoic acid breath test, and ultrasonography. Locomotion activity of the duodenal wall was used for quantifying the GI motility observed via ultrasonography. Our results showed that upper GI transit was significantly delayed by loperamide. The ¹³C-octanoic acid breath test revealed decreased gastric emptying in loperamide-treated mice. Through ultrasonography, large peristaltic movements were observed in the duodenum of the control mice. In contrast, after treatment with loperamide, these peristaltic movements were suppressed, and the duodenal lumen was enlarged, suggesting decreased duodenal motility. In accordance with these results, quantifiable locomotion activity was also significantly decreased. In conclusion, ultrasonography is an effective in vivo method to quantify small intestinal motility in mice.

Randomized Controlled Clinical Trial on Value of Domperidone in Functional Abdominal Pain in Children

OBJECTIVES

The aim of the study was to evaluate the therapeutic effect of domperidone on children with abdominal pain predominant functional gastrointestinal disorders (AP-FGIDs).

METHODS

One hundred children (aged 5-12 years) fulfilling Rome III criteria for AP-FGIDs were randomized into 8 weeks of domperidone or placebo treatment. Primary outcomes defined were cure and patient-reported general improvement. Secondary outcomes were reduction in the severity of abdominal pain and increase in gastric motility. Patients were followed up for 6 months.

RESULTS

Eighty-nine (42 in placebo group, 47 in domperidone group) completed the trial at 8 weeks. Seventy-nine completed the 6-month follow-up. When primary outcomes were assessed at 8 weeks, 37 (74%) in the domperidone group and 25 (50%) in the placebo group showed patient-reported general improvement (P = 0.013), whereas no significant difference was observed in cure (22 [44%] vs 14 [28%] P = 0.09). At 6-month follow-up 30 (60%) in the domperidone group and 19 (38%) in the placebo group reported cure (P = 0.028), whereas 44 (88%) in the domperidone group and 33 (66%) in the placebo group showed patient-reported general improvement (P = 0.009). When assessing secondary outcomes at 8 weeks, the domperidone group reported significant reduction in the severity of abdominal pain (54.1% vs 24.7%, P = 0.008) and an increase in the antral motility index (27.5% vs 7.2%, P = 0.029). None of the patients reported intervention-related adverse effects.

CONCLUSIONS

Domperidone may be a safe and effective therapeutic modality to achieve a lasting remission of symptoms in children with AP-FGIDs.

Acute physiological and electrical accentuation of vagal tone has no effect on pain or gastrointestinal motility in chronic pancreatitis

Background

The effective management of pain in chronic pancreatitis (CP) remains a therapeutic challenge. Analgesic drugs, such as opioids, and the underlying pathology can impair gut function. The autonomic nervous system influences hormone secretion and gut motility. In healthy volunteers, electrical (using noninvasive transcutaneous vagal nerve stimulation [t-VNS]) and physiological (using deep slow breathing [DSB]) modulation of parasympathetic tone results in pain attenuation and enhanced gut motility. Thus, the aims were to investigate whether t-VNS and DSB could enhance the parasympathetic tone, decrease pain sensitivity and improve gut motility in CP.

Patients and methods

A total of 20 patients (12 males, mean age=61 years, range: 50–78 years) with CP were randomized to short-term (60 minutes) t-VNS and DSB, or their placebo equivalent, in a crossover design. Cardiometrically derived parameters of autonomic tone, quantitative sensory testing of bone and muscle pain pressure, conditioned pain modulation (CPM) and assessments of gastroduodenal motility with ultrasound were performed.

Results

In comparison to sham, t-VNS and DSB increased cardiac vagal tone (CVT) (P<0.001). However, no changes in pain pressure thresholds for bone (P=0.95) or muscle (P=0.45) were seen. There was diminished CPM (P=0.04), and no changes in gastroduodenal motility were observed (P=0.3).

Conclusion

This explorative study demonstrated that t-VNS and DSB increased CVT in patients with CP. However, this short-lasting increase did not affect pain sensitivity to musculoskeletal pain or gastroduodenal motility. The chronic pain in CP patients is complex, and future trials optimizing neuromodulation for pain relief and improved motility are needed.

Gastric motility and emptying assessment by magnetic resonance imaging after lung transplantation: correlation with gastric emptying scintigraphy

PURPOSE

Gastroparesis is a frequent gastrointestinal complication after lung transplantation. Although gastric emptying scintigraphy (GES) is the standard technique to evaluate gastroparesis, magnetic resonance imaging (MRI) can also assess gastric motility and emptying. This study compared the results obtained by these two modalities.

METHODS

Twenty-two lung transplant recipients underwent MRI and GES after ingesting a small pancake as a test meal. Parameters assessed on MRI included antral peristaltic wave velocity and frequency, and the ratios of gastric content volume at 15 and 35 min. GES parameters included retention rates (RR) in the stomach at 30, 60, and 120 min (RR30, RR60, and RR120) and half-time of emptying (T1/2) calculated by exponential curve fitting. Correlations between MRI and GES results were evaluated.

RESULTS

Peristaltic wave velocity showed significant moderate negative correlations with RR120 (r = - 0.58, p < 0.05) and T1/2 (r = - 0.60, p < 0.05), indicating an association between reduced velocity and prolonged gastric emptying. Gastric content volume ratios on MRI showed significant moderate positive correlations with RR30 (r = 0.46, p < 0.05), RR60 (r = 0.60, p < 0.01), and T1/2 (r = 0.60, p < 0.01). There were no significant correlations between peristaltic wave frequency and GES parameters. MRI and GES parameters did not differ significantly between the six patients with and the 16 without upper gastrointestinal symptoms.

CONCLUSIONS

MRI-based determinations of gastric motility and gastric emptying correlate with GES-based gastric emptying in lung transplant recipients, suggesting that MRI is useful for evaluating patients with gastroparesis.

Tolerable pain reduces gastric fundal accommodation and gastric motility in healthy subjects: a crossover ultrasonographic study

Background

Obstacles to pain management include patients’ reluctance to inform healthcare provides about their pain, and differences in the pain management aims between patients and healthcare providers. The objective of this study was to evaluate whether tolerable pain influences gastric fundal accommodation and gastric motility in healthy subjects.

Methods

We undertook a crossover comparison study to evaluate gastric fundal accommodation and gastric motility in 74 healthy subjects in the presence or absence of tolerable pain. The intensity of tolerable pain was defined as the upper limit of pain compatible with comfortable daily life. Pain was generated by clipping a clothes pin to the ear lobe, and the intensity of pain was adjusted by inserting the gauze between the ear lobe and the pin. Gastric fundal accommodation and gastric motility were assessed by external ultrasonography. The cross-sectional area of the proximal stomach was measured after subjects had taken 100 mL-liquid meals four times, then the amplitude and frequency of antral contractions were measured.

Results

The median numerical rating scale of tolerable pain was 3 (interquartile rang 2–4). Gastric fundal accommodation, gastric motility and gastric emptying were all significantly impaired by tolerable pain (P < 0.001 for all comparisons).

Conclusions

Even tolerable pain can reduce gastric fundal accommodation and gastric motility, which could result in anorexia or decreased quality of life. Our findings provide important insights into pain management education for patients tolerating pain and healthcare providers encouraging patients to tolerate pain. This study was registered retrospectively.

Effect of DA-9701 on the Normal Motility and Clonidine-induced Hypomotility of the Gastric Antrum in Rats

Background/Aims

DA-9701 is a novel prokinetic agent. In the present study, we investigated the effect of DA-9701 on the motility of the gastric antrum in the normal and clonidine-induced hypomotility in an in vivo animal model.

Methods

A strain gauge force transducer was sutured on the gastric antrum to measure the contractile activity in rats. A total of 28 rats were subclassified into the 4 groups: (1) the placebo group, (2) the DA-9701 group, (3) the placebo group in the clonidine-pretreated rats, and (4) the DA-9701 group in the clonidine-pretreated rats. After the basal recording, either placebo (3% [w/v] hydroxypropylmethyl cellulose) or DA-9701 was administered. Contractile signals were measured after the administration and after a meal. In the clonidine-pretreated rats, either placebo or DA-9701 was administered. Contractile signals were measured after the administration and after a meal.

Results

Oral administration of DA-9701 did not significantly alter the motility index of the gastric antrum in the preprandial and postprandial periods, compared with the placebo group. The administration of clonidine decreased the motility index of the gastric antrum in the preprandial and postprandial periods, compared with the administration of placebo. This reduction of the antral motility by the administration of clonidine was not observed in the clonidine-pretreated DA-9701 group. The percentage of the motility index in the postprandial period was significantly greater in the clonidine-pretreated DA-9701 group, compared with the clonidine-pretreated placebo group.

Conclusions

DA-9701 improves the hypomotility of the gastric antrum induced by clonidine, suggesting its gastroprokinetic effect in the pathologic condition.

Modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity

BACKGROUND

The parasympathetic nervous system, whose main neural substrate is the vagus nerve, exerts a fundamental antinociceptive role and influences gastrointestinal sensori-motor function. Our research question was to whether combined electrical and physiological modulation of vagal tone, using transcutaneous electrical vagal nerve stimulation (t-VNS) and deep slow breathing (DSB) respectively, could increase musculoskeletal pain thresholds and enhance gastroduodenal motility in healthy subjects.

METHODS

Eighteen healthy subjects were randomized to a subject-blinded, sham-controlled, cross-over study with an active protocol including stimulation of auricular branch of the vagus nerve, and breathing at full inspiratory capacity and forced full expiration. Recording of cardiac derived parameters including cardiac vagal tone, moderate pain thresholds to muscle, and bone pressure algometry, conditioned pain modulation using a cold pressor test and a liquid meal ultrasonographic gastroduodenal motility test were performed.

KEY RESULTS

Cardiac vagal tone increased during active treatment with t-VNS and DSB compared to sham (p = 0.009). In comparison to sham, thresholds to bone pain increased (p = 0.001), frequency of antral contractions increased (p = 0.004) and gastroduodenal motility index increased (p = 0.016) with active treatment. However, no effect on muscle pain thresholds and conditioned pain modulation was seen.

CONCLUSIONS & INFERENCES

This experimental study suggests that this noninvasive approach with combined electrical and physiological modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity. These findings warrant further investigation in patients with disorders characterized with chronic pain and gastrointestinal dysmotility such as functional dyspepsia and irritable bowel syndrome.

Abdominal migraine in children: association between gastric motility parameters and clinical characteristics

Background

Approximately 0.2–1 % of children suffers from abdominal migraine (AM). Pathophysiology of AM has not been adequately studied. This study evaluated gastric motility in children with AM.

Methods

Seventeen children (6 boys), within an age range of 4–15 years, referred to a tertiary care paediatric unit, North Colombo Teaching Hospital Ragama, Sri Lanka, from 2007 to 2012, were screened. Those fulfilling Rome III criteria for AM were recruited after obtaining parental consent. None had clinical or laboratory evidence of organic disorders. Twenty healthy children (8 boys), with an age range of 4–14 years, were recruited as controls. Liquid gastric emptying rate (GE) and antral motility parameters were assessed using an ultrasound method.

Results

Average GE (41.6 % vs. 66.2 %, in controls), amplitude of antral contractions (A) (57.9 % vs. 89.0 %) and antral motility index (MI) (5.0 vs. 8.3) were lower and fasting antral area (1.8 cm² vs. 0.6 cm²) was higher in children with AM (p < 0.01). No significant difference in the frequency of antral contractions (F) (8.8/3 min vs. 9.3/3 min, p = 0.08) was found between the two groups. Scores obtained for severity of abdominal pain had a negative correlation with A (r = −0.55, p = 0.03). Average duration of abdominal pain episodes correlated with GE (r = −0.58, p = 0.02). Negative correlations were observed between duration of AM and A (r = −0.55), F (r = −0.52), and MI (r = −0.57) (p < 0.05).

Conclusions

GE and antral motility parameters were significantly lower in children with AM. A significant correlation was found between symptoms and gastric motility. These findings suggest a possible role of abnormal gastric motility in the pathogenesis of AM.

Gastric motility following ingestion of a solid meal in a cohort of adult asthmatics

BACKGROUND/AIMS

Asthmatics have abnormal esophageal motility and increased prevalence of gastroesophageal reflux disease (GERD). The contribution of gastric motility is less studied. We studied gastric myoelectrical activity, gastric emptying (GE) and their association with GERD symptoms and vagal function in adult asthmatics.

METHODS

Thirty mild, stable asthmatics and 30 healthy controls underwent real-time ultrasonography and 1 hour pre- and post-prandial cutaneous electrogastrography, following a test meal (480 kcal, 60% carbohydrate, 20% protein, 20% fat and 200 mL water). The percentage of normal slow waves and arrhythmias, dominant frequency and power, frequency of antral contractions, gastric emptying rate (GER) and antral motility index (MI) was calculated. Twenty-seven asthmatics underwent gastroscopy and in all subjects GERD symptoms were assessed by a validated questionnaire. Vagal function parameters were correlated with gastric motility parameters.

RESULTS

The asthmatics (37% male; 34.8 ± 8.4 years) and controls (50% male; 30.9 ± 7.7 years) were comparable. None had endoscopic gastric pathological changes. Twenty asthmatics described GERD symptoms. Twenty-two (73.3%) asthmatics showed a hypervagal response. Compared to controls, asthmatics had delayed GER and lower MI, lower percentage of normal gastric slow waves, more gastric dysrythmias and failed to increase the post-prandial dominant power. There was no correlation of GE and cutaneous electrogastrography parameters with presence of GERD symptoms or with vagal function.

CONCLUSIONS

Asthmatics showed abnormal gastric myoelectrical activity, delayed GE and antral hypomotility in response to a solid meal compared to controls. There was no association with vagal function or GERD symptom status.

Gastric emptying and antral motility parameters in children with functional dyspepsia: association with symptom severity

BACKGROUND AND AIMS

Functional dyspepsia (FD) is an important gastrointestinal problem with obscure etiology. Abnormal gastric motility is suggested as a possible pathophysiological mechanism for symptoms. The main objective of this study was to assess gastric motility in Sri Lankan children with FD.

METHODS

Forty-one children (19 [46.3%] males, age 4-14 years, mean 7.5 years, SD 2.6 years) referred to the Gastroenterology Research Laboratory, Faculty of Medicine, University of Kelaniya, from January 2007 to December 2011, were screened. Those fulfilling Rome III criteria for FD were recruited. None had clinical or laboratory evidence of organic disorders. Twenty healthy children were recruited as controls (eight [40%] males, age 4-14 years, mean 8.4 years, SD 3.0 years). Liquid gastric emptying rate (GE) and antral motility parameters were assessed using an ultrasound-based method.

RESULTS

Average GE (45.6% vs 66.2% in controls), amplitude of antral contractions (58.2% vs 89.0%) and antral motility index (5.1 vs 8.3) were lower and fasting antral area (1.5 cm(2) vs 0.6 cm(2)) was higher in patients with FD (P < 0.01). Frequency of antral contractions (8.8 vs 9.3) did not show a significant difference (P = 0.07). Scores obtained for severity of abdominal pain negatively correlated with GE (r = -0.35, P = 0.025). Children with FD, exposed to stressful events had higher fasting antral area (1.9 cm(2)) than those not exposed to stress (1.0 cm(2)) (P = 0.02).

CONCLUSIONS

GE and antral motility parameters were significantly impaired in children with FD compared with controls. GE negatively correlated with severity of symptoms. This study points to disturbances in gastric motility as an etiological factor for FD.

Ultrasonographic assessment of liquid gastric emptying and antral motility according to the subtypes of irritable bowel syndrome in children

OBJECTIVES

Gastric motor abnormalities have been reported in adults with irritable bowel syndrome (IBS), commonly in constipation-predominant IBS (IBS-C); however, such studies are uncommon in children. Furthermore, differences of gastric motility have not been studied in children with different IBS subtypes.

METHODS

Seventy-six children (33 [43%] boys, age 4-14 years, mean 7.9 years, SD 3.0 years) fulfilling Rome III criteria for IBS and 20 healthy controls (8 [40%] boys, age 4-14 years, mean 8.4 years, SD 3.0 years) were recruited (diarrhea-predominant IBS=21, IBS-C=31, mixed IBS=19, and unsubtyped IBS=5). Liquid gastric emptying rate (GER) and antral motility were assessed using an ultrasound method.

RESULTS

Average GER (43.8% vs 66.2% in controls), amplitude of antral contractions (56.4% vs 89%), and antral motility index (5.1 vs 8.3) were lower and fasting antral area (1.6 vs 0.6) was higher in patients with IBS (P<0.0001). Frequency of antral contractions F (8.9 vs 9.3) did not show a significant difference. Patients exposed to stressful events had a significantly lower GER, compared to those not exposed to such events (P=0.03). Gastric motility parameters had no correlation with severity of symptoms. GER (42.6%, 46.3%, 39.6%), fasting antral area (1.4 cm², 1.8 cm², 1.8 cm²), amplitude of antral contractions (53%, 58.9%, 51.8%), frequency of antral contractions (8.7, 8.9, 9.2), and antral motility index (4.7, 5.3, 4.8) were not different among diarrhea-predominant IBS, IBS-C, and mixed IBS (P>0.05).

CONCLUSIONS

GER and antral motility parameters were significantly impaired in children with IBS compared with controls. GER and antral motility parameters were not different between IBS subtypes.

Use of scintigraphy to evaluate gastric accommodation and emptying: comparison with barostat

BACKGROUND AND AIM

Scintigraphy is a useful noninvasive technique for assessment of gastric motility, especially emptying, but there is little knowledge of use of the technique to assess gastric accommodation. Therefore, to clarify the usefulness of scintigraphy as a technique for assessing gastric accommodation, we compared scintigraphy with barostat, the gold standard modality.

METHODS

Twenty healthy volunteers (14 men, six women; mean age, 28.5 ± 5.4 years) were enrolled in the study. The volunteers ingested a radiolabeled ((99m) Tc) test meal and scintigraphic images were recorded. Radioactivity in the upper third and whole stomach was calculated to evaluate accommodation. In the barostat procedure, gastric accommodation was evaluated by measuring the maximum volume of the distended balloon. Thereafter, correlation between scintigraphic and barostat accommodation was investigated. Intra-and inter-observer variation of the scintigraphic test results were also assessed. Finally, the diagnostic performance of scintigraphy was evaluated by using sumatriptan as a positive control.

RESULTS

Measurements of accommodation by scintigraphy and barostat correlated (r = 0.524, P < 0.05). Sumatriptan significantly increased scintigraphically measured gastric accommodation (with sumatriptan, 51.5 ± 16.4%; without sumatriptan, 38.4 ± 13.8%) (P < 0.01), and had significantly (P < 0.05) delayed 50% half emptying time at 60, 90, 120, and 150 min after the start of the experiment. The data from repeated scintigraphic tests were highly reproducible (r = 0.804) with significant differences not observed among the investigators (inter-observer variation = 0.932, intra-observer variation = 0.898).

CONCLUSION

Gastric scintigraphy is a useful technique for assessing gastric accommodation and emptying.

Chinese herbal medicine liu jun zi tang and xiang sha liu jun zi tang for functional dyspepsia: meta-analysis of randomized controlled trials

Objectives. To assess the efficacy and safety of Liu Jun Zi Tang (LJZT) and Xiang Sha Liu Jun Zi Tang (XSLJZT) for treating functional dyspepsia. Methods. Literature searches were carried out on Medline database, Cochrane Library, CNKI database, Chinese Biomedical Literature database, Wanfang database, and VIP database up to July 2012. Hand search for further references was conducted. Study selection, data extraction, quality assessment, and data analyses were performed according to the Cochrane standards. Results. Fifteen publications in total were suitable for inclusion. There was evidence that LJZT compared with prokinetic drugs increased symptom improvement (odds ratio 1.96, 95% CI 1.15 to 3.36). There was also evidence that XSLJZT compared with prokinetic drugs increased symptom improvement (odds ratio 2.63, 95% CI 1.72 to 4.03). No adverse events were reported in LJZT or XSLJZT group in any of these randomized controlled trials. Conclusion. LJZT and XSLJZT might be more effective compared with prokinetic drugs in the treatment of functional dyspepsia, and no side effects are identified in the included trials. However, due to poor methodological quality in the majority of included studies, the potential benefit from LJZT and XSLJZT need to be confirmed in rigorously designed, multicentre, and large-scale trials.

Influence of sumatriptan on gastric accommodation and on antral contraction in healthy subjects assessed by ultrasonography

BACKGROUND

Oral sumatriptan administration has been reported to delay gastric emptying after liquid meals. The aim of this study was to determine whether delayed gastric emptying is caused by enhanced gastric accommodation, impaired antral contractions, or both using ultrasonography.

METHODS

Ten healthy volunteers were enrolled in this randomized two-way crossover study. After overnight fasting, the subjects received the liquid meal 60 min after ingesting a 50 mg sumatriptan tablet with 50 mL of water or 50 mL of water alone (control). The cross-sectional area of the proximal stomach was measured in a supine position after every 100 mL. The frequency and amplitude of the antral contractions were measured in a slightly backward sitting position. The intragastric distribution of the liquid meal was assessed by calculating the proximal stomach/distal stomach ratio (prox/distal ratio).

KEY RESULTS

The cross-sectional area after drinking 100, 200, and 300 mL of the liquid meal (oral sumatriptan vs control) was 34.49 vs 15.11 cm(2) (P = 0.0051), 48.00 vs 30.61 cm(2) (P = 0.0166), and 58.67 vs 47.19 cm(2) (P = 0.0125), respectively. There was no significant difference in the amplitude of contractions, contraction cycle, motility index, and prox/distal ratio (97.15 vs 97.93%, P = 0.0745; 19.42 vs 19.5 s, P= 0.8590; and 887.58 vs 889.22, P = 0.5751; 9.75 vs 8.41, P = 0.8785; respectively).

CONCLUSIONS & INFERENCES

Oral sumatriptan administration enhanced gastric accommodation after the ingestion of liquid nutrients, but had no significant effect on antral contractions or intragastric distribution in healthy subjects.

Therapeutic efficacy of acotiamide in patients with functional dyspepsia based on enhanced postprandial gastric accommodation and emptying: randomized controlled study evaluation by real-time ultrasonography

BACKGROUND

Improvement in subjective symptoms has been reported in functional dyspepsia (FD) patients administered with acotiamide. Improvement was confirmed in meal-related symptoms, such as postprandial fullness, upper abdominal bloating, and early satiety. We examined the mechanism underlying the effects of acotiamide on gastric accommodation reflex (GAR) and gastroduodenal motility in FD patients.

METHODS

Thirty-four FD patients (mean age, 40.4 years) were examined ultrasonographically before and after 14-18 days of acotiamide (100 mg t.i.d.) or placebo administration. To assess GAR, expansion rate in cross-sectional area of the proximal stomach was measured after every 100-mL ingestion, using a straw, of up to 400 mL of a liquid meal (consommé soup, 13.1 kcal; 400 mL) in a supine position. Next, we measured gastric emptying rate (GER), motility index (MI, antral contractions), and reflux index (RI, duodenogastric reflux) to assess gastroduodenal motility. Patients also completed a survey based on the seven-point Likert scale both before and after drug administration.

KEY RESULTS

Of the 37 cases, 19 and 18 were administered with acotiamide and placebo A respectively, significant difference was observed in GAR between the acotiamide and placebo groups (21.7%vs 4.4%) after 400 mL ingestion. GER significantly accelerated after treatment in the acotiamide group (P = 0.012), no significant differences were observed in MI and RI between the two groups. Improvement rates were 35.3 and 11.8% for the acotiamide and placebo groups.

CONCLUSIONS & INFERENCES

Acotiamide significantly enhances GAR and GER in FD patients. Acotiamide may have therapeutic potential for FD patients.

Delayed gastric emptying rates and impaired antral motility in children fulfilling Rome III criteria for functional abdominal pain

BACKGROUND

Gastric sensorymotor dysfunctions have been implicated in the pathophysiology of some functional gastrointestinal disorders, such as functional dyspepsia and irritable bowel syndrome. Therefore, we hypothesized that abnormal gastric emptying and impaired antral motility are possible underlying mechanisms of symptoms in children with functional abdominal pain (FAP).

METHODS

Hundred and two children [37 (36.3%) males, 4-14 years, mean 7.8 years, SD 2.7 years] fulfilling Rome III criteria for FAP were recruited for this study. An age and sex compatible group of healthy children (n = 20) were selected as controls [8 (40%) males, 4-14 years, mean 8.4 years, SD 3.0 years]. Liquid gastric emptying rate (GER) and antral motility parameters (amplitude of antral contractions, frequency of antral contractions and antral motility index) were assessed using a previously reported ultrasound method.

KEY RESULTS

Average GER (42.1% vs 66.2% in controls), amplitude of antral contractions (56.5% vs 89%), frequency of contractions per 3 min (8.5 vs 9.3), and antral motility index (4.9 vs 8.3) were significantly lower in patients with FAP compared with controls (P < 0.01). Fasting antral area was higher in patients (1.4 vs 0.6, P < 0.0001). GER negatively correlated with the scores obtained for severity of abdominal pain (r = -0.29, P = 0.004).

CONCLUSIONS & INFERENCES

Gastric emptying rate and antral motility parameters were significantly impaired in patients with FAP and GER negatively correlated with symptom severity. These findings highlight the possible role of gastrointestinal motility abnormalities in the pathophysiology of childhood FAP.

Long-term Ultrasonographic Follow-up Study of Gastric Motility in Patients with Functional Dyspepsia

Although patients with functional dyspepsia complain of epigastric symptoms, the relation between these symptoms and gastric motility remains controversial. There are few reports on the clinical course of functional dyspepsia, including changes in gastric motility, observed over a considerably long period. We conducted a study to examine association between changes in symptoms and changes in ultrasonographically evaluated gastric motility over a long-term follow-up period in patients with functional dyspepsia. Forty patients (18 men, 22 women; mean age, 53.7 years) with functional dyspepsia were followed up by medical interview, physical examination, endoscopy, and ultrasonography for gastric motility. Follow-up ranged from 1.0 to 7.8 years (mean, 3.0 years). Ultrasonographic evaluation of gastric motility included gastric emptying rate and antral contractions. During the follow-up period, patients were treated with proton pump inhibitors, H2-blockers, or prokinetics. Symptoms improved in 21 patients (group A), but symptoms persisted or worsened in 19 patients (group B). There were no significant differences in clinical characteristics between the two groups. Gastric motility improved in group A but not in group B. In conclusion, improved gastric motility appears to correspond to and may explain improved symptoms in some patients with functional dyspepsia.

Real-time ultrasonographic evaluation of canine gastric motility in the postprandial state

Gastric motility is affected by several pathological conditions which may induce upper gastrointestinal clinical symptoms. The pathogenesis of canine gastric motility disorders is poorly understood because of methodological limitations. This study aimed at establishing a simple method for evaluating postprandial gastric motility in dogs. Gastric motility was ultrasonographically assessed in 7 healthy beagles using a technique previously described in humans. The motility index (MI), an indicator of gastric antral motility, was calculated by measuring the area of the gastric antrum in both a contracted and relaxed phase and by counting the number of contractions. The MI was measured every 30 min for 3 hr after feeding and compared with gastric emptying as assessed by a (13)C-octanoic acid breath test. The MI at 30 min had the lowest variability in the 7 dogs (mean SD, 9.77 ± 0.42; coefficient of variance, 4.25%), and a significant correlation was observed with gastric emptying coefficient (R(2)=0.8126, P=0.005) and half-emptying time (R(2)=0.654, P=0.027). When atropine was administered, a significant decrease in the MI at 30 min was observed compared with the control (9.77 ± 0.42 vs. 5.19 ± 0.22, P=0.0003). In conclusion, evaluation of the MI at 30 min is suitable for assessing gastric motility and enables us to assess gastric motility simply in a short time. By using this method, further studies for the pathogenesis of canine gastric motility disorders are warranted.

Gastric dysmotility after liquid bolus ingestion in systemic sclerosis: an ultrasonographic study

Gastric involvement appears quite commonly in systemic sclerosis (SSc). The aim of this study was to evaluate gastric wall motility using ultrasonography, a noninvasive method able to track both filling and emptying of fundus and antrum. The study was performed in 20 SSc patients and 20 healthy control subjects. Gastric filling and emptying were evaluated by transabdominal ultrasonography, measuring changes in fundus and antral areas over a 1-h period after ingestion of a liquid bolus (500 ml of mineral water). Areas of both gastric fundus and antrum at basal evaluation were found to be smaller in SSc patients than in healthy controls. Gastric filling was significantly reduced after ingestion of liquid bolus. Gastric emptying was delayed both in fundus and antrum. No significant differences of gastric wall motility have been observed in different subsets of SSc patients. Our findings show that gastric dysmotility is frequent and severe in SSc patients, contributing to the gastrointestinal disturbances which are very common in this disease.

Efficacy of mosapride citrate in proximal gastric accommodation and gastrointestinal motility in healthy volunteers: a double-blind placebo-controlled ultrasonographic study

BACKGROUND

Mosapride citrate, a 5-hydroxytryptamine-4 receptor agonist, enhances antral contractions and gastric emptying, but its effects on proximal gastric accommodation and gastroduodenal motility have not been fully studied. The aim of the present study was to clarify the effects of mosapride citrate on proximal gastric accommodation and gastroduodenal motility in healthy volunteers, using ultrasonography.

METHODS

Fourteen healthy volunteers (mean age 25.3 years) were treated for 14 days with mosapride citrate (15 mg b.d.) or a placebo in a double-blind randomized fashion. Before and after drug treatment, ultrasonographic assessment of gastroduodenal motility was performed. For assessment of the gastric accommodation reflex, the cross-sectional area of the proximal stomach was measured after the incremental ingestion, with a straw, of up to 400 ml of a liquid meal (consommé soup: 13.1 kcal, 400 ml); this was done with the subject in a supine position. Gastric emptying, antral contractions, and the duodenogastric reflux were observed as described previously.

RESULTS

In the subjects treated with mosapride citrate, the expansion rate of the cross-sectional area of the proximal stomach was significantly greater after the ingestion of 400 ml as compared to that of the subjects treated with the placebo. Similarly, gastric emptying and antral contractions increased significantly in the mosapride citrate group as compared to the placebo group. Although the duodenogastric reflux tended to decrease in the mosapride citrate group, it showed no significant difference between the two groups.

CONCLUSIONS

This study shows that mosapride citrate enhances the meal-induced gastric accommodation reflex and promotes adequate gastroduodenal coordination and motility in healthy volunteers.

Evaluation of duodenal hypersensitivity induced by duodenal acidification using transnasal endoscopy

BACKGROUND AND AIM

Although duodenal hypersensitivity has been suggested as one of the causes of functional dyspepsia (FD), a practical method to clarify this has not yet been established. The aim of this study was to evaluate whether patients with FD have duodenal hypersensitivity to acid, using transnasal endoscopy.

METHODS

In all, 44 patients with FD and 16 healthy volunteers were enrolled, and all the subjects received transnasal endoscopy in the morning after overnight fasting. After ordinary transnasal endoscopy, an infusion tube was introduced into the duodenal bulb by transnasal endoscopy and acid (20 mL, 0.1 N HCl, 20 mL/min, 36.5 degrees C) was injected via the infusion tube. The severity of 12 symptoms was assessed by each subject using a 100-mm visual analogue scale. The maximum severity scale was defined as the maximum score of the symptom severity scale. The total score was defined as the aggregate score of the maximum severity scale of the 12 symptoms. The maximum severity scales and the total scores between patients with FD and healthy volunteers were evaluated.

RESULTS

The maximum severity scales of nine symptoms increased significantly more after acid infusion in patients with FD than in healthy volunteers (P < 0.05). There were significant differences in the total scores (patients with FD vs healthy volunteers 233.8 +/- 37.8 vs 63.9 +/- 14.6, mean +/- standard error of the mean, P < 0.001).

CONCLUSIONS

Duodenal acidification using transnasal endoscopy enabled the evaluation of duodenal hypersensitivity to acid in healthy volunteers and patients with FD.

Ecabet sodium induces neuronal nitric oxide synthase-derived nitric oxide synthesis and gastric adaptive relaxation in the human stomach

BACKGROUND

Gastric adaptive relaxation (GAR) is a major factor of functional dyspepsia (FD). Nitric oxide (NO) could be the key molecule responsible for GAR. We previously reported that the physiological gastric reservoir ability can be evaluated by measuring the cross-sectional area of the proximal stomach by abdominal ultrasonography (US). Ecabet sodium (ES), a gastro-protective antiulcer agent, has been shown to improve symptoms in FD patients. We examined the effects of ES on GAR in humans and on NO synthesis in vitro.

METHODS

GAR was measured by US in 14 subjects, 8 of whom had a pressure sensor inserted into their stomach, after treatment with ES, placebo, or no drugs. NO was measured in SH-SY 5Y cells using a fluorescent indicator. Neuronal, endothelial and inducible NO synthase (nNOS, eNOS and iNOS, respectively) expressions were examined in SH-SY 5Y cells by Western blotting.

RESULTS

Compared to placebo, ES induced significantly greater dilatation of the proximal stomach after the subjects drank 300-400 ml water (P < 0.05). After ES intake, the intragastric pressure did not change significantly, but it tended to be lower (n = 8; P = 0.15). ES increased NO production and nNOS expression, but not iNOS or eNOS expression, in SH-SY 5Y cells in vitro. Pretreatment with non-selective NO synthase (NOS) inhibitor, but not with iNOS-selective inhibitor, reduced NO production by ES.

CONCLUSION

ES may promote GAR in humans through nNOS-related NO; therefore, it may be useful for patients with FD.

Efficacy of Rikkunshito, a traditional Japanese medicine (Kampo), in treating functional dyspepsia

BACKGROUND

Rikkunshito, a traditional Japanese (Kampo) medicine, is widely prescribed as an oral preparation for the treatment of functional dyspepsia (FD). In our previous study, we reported that extracorporeal ultrasonography (US) is a useful technique for the assessment of the gastric accommodation reflex (AR) and duodenogastric motility. In this study, we examined the effects of Rikkunshito on the gastroduodenal function in patients with FD.

METHODS

Sixteen FD patients (median age, 45 y) underwent US, before and after 14 days of treatment with Rikkunshito (7.5 g b.d.). For assessment of the AR, a cross-sectional area of the proximal stomach was measured after incremental ingestion of a liquid meal up to 400-mL. The expansion rate was used as the parameter to determine the AR. Then, the gastric emptying rate (GER), motility index (MI), and reflux index (RI) were evaluated using previously reported methods.

RESULTS

Although no significant changes were observed in the total score of the Gastrointestinal Symptom Rating Scale (GSRS), the scores of 3 of the 15 symptoms of GSRS decreased significantly after treatment with Rikkunshito. The expansion rate of the proximal stomach was significantly greater after treatment with Rikkunshito than before the treatment. Although the GER and MI increased significantly, no significant differences in the RI were observed after treatment with Rikkunshito.

CONCLUSION

These observations suggested that Rikkunshito may be beneficial for the treatment of FD patients with impaired AR and gastric motility. These results also suggested that Rikkunshito has a therapeutic potential for FD and GERD.

Chinese herbal medicine modified xiaoyao san for functional dyspepsia: meta-analysis of randomized controlled trials

BACKGROUND

To critically assess the evidence of modified xiaoyao san (MXS) for treating functional dyspepsia (FD).

METHODS

Systematic literature searches were carried out on the Medline database, CNKI database, Wanfang Data, VIP Information and the Cochrane Library. Reference lists located were checked for further relevant publications. Experts in the field and manufacturers of identified products were contacted for unpublished material. Studies were selected according to predefined inclusion and exclusion criteria. All randomized clinical trials of MXS for treating FD were included. Study selection, data extraction and validation were carried out by at least two reviewers with disagreements being settled by discussion. Weighted means and 95% confidence intervals were calculated and sensitivity analyses were carried out.

RESULTS

Thirty-three potentially relevant articles were retrieved for further evaluation. Fourteen were suitable for inclusion in the meta-analysis. There was evidence that MXS compared with prokinetic drugs reduced symptoms (odds ratio 3.26, 95% CI 2.24 to 4. 47). There was evidence that MXS + prokinetic drugs compared with prokinetic drugs reduced symptoms (odds ratio 4.32, 95% CI 2.64 to 7.08).

CONCLUSION

MXS appears to be more effective compared to prokinetic drugs in the treatment of FD and no serious side-effects were identified. However, the evidence remains weak due to publication bias and methodological flaws, which may amplify the therapeutic benefit of MXS.

Selected interventions in nuclear medicine: gastrointestinal motor functions

The measurement of gastrointestinal functions by the use of scintigraphy is established in clinical practice and research. The most commonly used test is the gastric-emptying test, which is acknowledged as the gold standard to measure gastric motility and is conducted according to a consensus statement from the national nuclear medicine and motility societies. Other techniques are somewhat more esoteric (eg, measurement of gastric accommodation with single-photon emission computed tomography) or the scintigraphic approach is not the acknowledged gold standard (eg, colonic transit, rectoanal angle, and emptying, esophageal transit). The performance characteristics of many of the scintigraphic measurements have been published and the pros and cons established in the literature. Pharmacologic interventions may also be used during scintigraphy to aid in diagnosis and treatment. Gastrointestinal scintigraphy is an integral and important component of the assessment of gastrointestinal function.

Sonographic assessments of gastrointestinal and biliary functions

Ultrasound has been established as a routine work-up imaging method in abdominal diseases. It assesses the morphology of intra-abdominal organs and depicts the normal and pathological anatomy of the gastrointestinal tract as well as of the biliopancreatic system. Ultrasound is the method of choice for visualisation of motion sequences since it is, in contrast to other imaging methods, a real-time method. The non-invasiveness and the repeatability of the method are important advantages when performing investigations of functional processes. Therefore, ultrasound is most suited for functional studies. Up to now, functional ultrasound and its potential have been undervalued. Functional ultrasound provides a widely available method to increase our understanding of functional processes and motility. The authors review the options of functional ultrasound and discuss its practical relevance.

Clinical effects of STW 5 (Iberogast) are not based on acceleration of gastric emptying in patients with functional dyspepsia and gastroparesis

STW 5, a herbal extract, is effective for the treatment of symptoms in patients with functional dyspepsia (FD). However, its mode of action is still unclear and a modulation of gastric motility is hypothesized. This multicentre, placebo-controlled double-blind study addressed the question of whether STW 5 accelerates gastric emptying in patients with FD and gastroparesis. One-hundred and three patients diagnosed with FD were randomly assigned to a treatment with either STW 5 or a liquid placebo for 28 days. The primary end point of the study was a change of a validated gastrointestinal symptom (GIS) score under treatment. Additionally, patients underwent a (13)C octanoic acid breath test for the assessment of the gastric half-emptying time (t(1/2)). Patients with prolonged t(1/2) were diagnosed with gastroparesis and requested to repeat the test at the end of treatment. A change of t(1/2) was defined a secondary study end point. t(1/2) was prolonged in 48.6% of patients in the STW 5 group and in 43.8% of the placebo group. During treatment, t(1/2) increased non-significantly in patients treated with STW 5 (+23 +/- 109 min; P = 0.51) and slightly accelerated among patients in the placebo arm (-26 +/- 51 min; P = 0.77) (P = 0.49). The improvement of the GIS (P = 0.08) and the proportion of patients with a treatment response (P = 0.03) were more pronounced in the STW 5 group. Our findings suggest that the clinical effects of STW 5 in patients with FD and gastroparesis are not directly mediated by an acceleration of gastric emptying. A clear-cut correlation with symptom improvement is still lacking.

Real-time evaluation of dyspeptic symptoms and gastric motility induced by duodenal acidification using noninvasive transnasal endoscopy

BACKGROUND

Although different pathophysiological mechanisms have been suggested to be involved in functional dyspepsia, a practical method to clarify them has not been established. The aim of this study was to evaluate dyspeptic symptoms and gastric motility induced by duodenal acidification using transnasal endoscopy.

METHODS

Fourteen healthy volunteers (mean age, 32 years) were enrolled. Transnasal endoscopy was performed on all fasting volunteers. Dyspeptic symptoms and antral contractions were evaluated before and after duodenal infusions of pure water (20 ml/min for 5 min) and acid (0.1 N HCl, 20 ml/min for 5 min). The severity of various symptoms was assessed by each subject using a 10-cm visual analog scale every 2 min. The maximum severity scale was calculated as the mean of the individual maximum values. The motility number was defined as the mean number of antral contractions in 1 min.

RESULTS

The maximum severity score for a heavy feeling in the stomach and other symptoms significantly increased after the acid infusion compared with after the pure water infusion. During pure water infusion, there were no changes in the motility number. On the other hand, the motility number significantly decreased after duodenal acidification (before vs. after, 2.93 +/- 0.12 times vs. 1.11 +/- 0.23 times, P < 0.0001).

CONCLUSIONS

Duodenal acid exposure induces dyspeptic symptoms and inhibits antral motility. Transnasal endoscopy enabled us to evaluate both dyspeptic symptoms and gastric motility simultaneously.

Gastric myoelectrical and motor abnormalities in children and adolescents with functional recurrent abdominal pain

BACKGROUND AND AIMS

Recurrent abdominal pain is common among children and adolescents. The majority of the affected patients have no apparent cause for their symptoms. This study evaluated gastric myoelectrical activity and motility abnormalities in children and adolescents with functional recurrent abdominal pain.

METHODS

Forty-two children with functional recurrent abdominal pain [19 (45.2%) males, mean 8 years, SD 3 years, 19 functional abdominal pain, 9 irritable bowel syndrome, 9 functional dyspepsia, 1 abdominal migraine, 1 aerophagia and 3 non-specific abdominal pain according to Rome III criteria] and 20 healthy children [10 (50%) males, mean 9 years, SD 2.7 years] from the same geographical area underwent electrogastrography (EGG), and ultrasonographic assessment of gastric emptying rate and antral motility.

RESULTS

Average gastric emptying rate, amplitude of antral contractions and antral motility index were lower in patients (46.5%, 74.3% and 6.5 respectively) compared to controls (66.17%, 89% and 8.3 respectively) (P < 0.001). Gastric emptying rate had a negative correlation with scores obtained for severity of symptoms (r = -0.63, P < 0.0001). Postprandial dominant frequency instability co-efficient (post-DFIC) was higher in patients than in controls (27.83% vs 18.3%, P = 0.0087), and correlated with the symptom score (r = 0.26, P = 0.045).

CONCLUSIONS

Gastric emptying and antral motility were significantly impaired in patients, indicating a possible role for gastric motility disturbances in the pathogenesis of childhood functional recurrent abdominal pain. Further studies, including therapeutic trials, are needed to confirm this association and for recommendation of prokinetic drugs in its management.

Relation between histologic gastritis and gastric motility in Japanese patients with functional dyspepsia: evaluation by transabdominal ultrasonography

BACKGROUND

Whether mucosal inflammation affects gastric motility in patients with functional dyspepsia (FD) is controversial. Few reports discuss gastric motility in relation to histologic gastritis. We examined the relation between gastric motility and histologic gastritis in Japanese patients with FD.

METHODS

Subjects were 198 patients examined by ultrasonography (US) and endoscopic biopsy. Histologic gastritis scores were compared to three US gastric motility indices: the motility index (MI), gastroduodenal reflux index (RI), and gastric emptying rate (GER). In cases of gastritis with a high inflammation score (score 2-3), the macrophages in biopsy specimens were counted and compared to the motility indices.

RESULTS

Of the 198 patients, 159 were Helicobacter pylori positive. Comparison of 39 age-and sex-matched H. pylori-positive and 39 H. pylori-negative patients showed that the MI was lower in H. pylori-positive patients (6.78+/-2.17 vs. 7.63+/-2.35, P<0.05), and the RI was higher (5.64+/-4.70 vs. 2.13+/-2.58, P<0.01). Among H. pylori-positive patients, US revealed a decreased MI in patients with a high inflammation score (score 2-3) in the antrum compared with the MI of those with a low inflammation score (score 0-1) (6.52+/-2.38 vs. 7.82+/-1.89, P<0.01). The number of macrophages was not associated with motility indices in patients with a high inflammation score.

CONCLUSION

Histologic gastritis with severe inflammation may inhibit gastric motility.

Strategy for treatment of nonerosive reflux disease in Asia

The paper is to review the clinical and pathophysiologic differences between of nonerosive reflux disease (NERD) and reflux esophagitis (RE), and to propose a treatment strategy for NERD, especially for patients in Asia. A Medline search was performed regarding the clinical and pathophysiologic differences between NERD and RE, and treatment of NERD and RE. The characteristics of NERD patients in Asia are as follows: (1) high proportion of female patients, (2) low frequency of hiatal hernia, (3) high frequency of H pylori infection, (4) severe glandular atrophy of the gastric mucosa, and (5) frequent resistance to proton pump inhibitor (PPI) therapy. In Asian NERD patients, exposure of the esophagus to acid is not increased, and esophageal motility is normal. These characteristics are similar to those of patients in Western countries. Our recommended first-choice treatment is administration of PPI in combination with a prokinetic agent. However, at present, because there is limited evidence regarding effective treatments for NERD, it is best to try several different treatment strategies to find the best treatment for each patient.

Treatment of functional dyspepsia with serotonin agonists: a meta-analysis of randomized controlled trials

BACKGROUND

Functional dyspepsia (FD) is often treated with serotonin agonists; however, the efficacy of such agents has recently been questioned. The aim of this study was to perform a meta-analysis of randomized controlled trials (RCTs) comparing serotonin agonists with other types of prokinetics in patients with FD.

METHODS

Included studies were RCTs that compared serotonin agonists, including cisapride and mosapride, with dopamine antagonists, including metoclopramide and domperidone, and an opiate agonist, trimebutine, in patients with FD. Studies were identified by searching the Medline database (January 1951 - January 2005) and Cochrane Library (Issue 4, 2004), and by manual searches. The difference in the probability of patients' responses between the serotonin agonists and control agents was used as a summary statistic for the treatment effect. Meta-regression analysis was used to detect sources of heterogeneity.

RESULTS

Five studies were identified. In total, 467 subjects were assigned to a serotonin agonist arm, and 322 subjects were assigned to a control arm. In the overall analysis, the summary statistic was 0.019 (95% confidence interval [CI]: -0.055 to 0.093; P = 0.612), indicating that the patients' responses to serotonin agonists were similar to those to control agents. However, in the stratified meta-analysis of cisapride and mosapride, mosapride had a 6.7% greater probability of producing a response compared with control agents (summary statistic: 0.067; 95% CI: 0.010-0.124; P = 0.021), whereas no significant effect was observed with cisapride.

CONCLUSION

The data suggest that mosapride may be more effective than cisapride for the treatment of FD. Although FD is a chronic condition, efficacy was assessed over short periods in the studies used for the present meta-analysis. Long-term RCTs are needed to confirm the effect.

Meta-analysis of the effects of prokinetic agents in patients with functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is often treated with prokinetic agents; however, the efficacy of prokinetic agents in patients with FD has been questioned recently. The aim of this study was to perform a meta-analysis of the effects of prokinetic agents in patients with FD.

METHODS

Prokinetic agents, including metoclopramide, domperidone, trimebutine, cisapride, itopride and mosapride, used for treatment of FD between 1951 and 2005 were identified. Twenty-seven studies were selected. Difference in the probability of response between the interventional drug and placebo was used as a summary statistic for the treatment effect. Meta-regression analysis was used to detect sources of heterogeneity.

RESULTS

In total, 1844 subjects were assigned to an experimental arm, and 1591 subjects were assigned to a placebo arm. Publication bias was ruled out by funnel plot and statistical testing (P = 0.975). In the overall analysis, the summary statistic was 0.295 (95% confidence interval: 0.208-0.382, P < 0.001), indicating that the interventional drug has 30% excess probability of producing a response compared with placebo. The most significant source of heterogeneity was the year of publication (P < 0.001).

CONCLUSION

The data clearly indicate that prokinetic agents are significantly more effective than placebo in the treatment of FD. Although FD is a chronic condition, efficacy was assessed over short periods. Long-term randomized controlled trials are needed to confirm the effect.

The use of electrogastrography and external ultrasonography to evaluate gastric motility in Crohn's disease

Although Crohn's disease is associated with various digestive symptoms, there have been few reports on gastric motility. In this study, we conducted a study of gastric motility in Crohn's disease using 20 healthy subjects (N group) and 15 patients with Crohn's disease (C group) by electrogastrography (EGG) using a Nipro electrogastrograph. An EGG was recorded for 30 minutes in a fasting state and after ingestion of 300 ml of a liquid meal. As an index of gastric emptying, the rate of change in the cross-sectional area of the gastric antrum was measured 1 and 15 minutes after ingestion of the liquid meal by external ultrasonography. In an EGG frequency analysis, waveforms with a peak of 3 cycles/minute (cpm) were noted in the N group, and the peak amplitude increased significantly after the ingestion of food. In the C group, division of the normal-gastria component was noted after the ingestion of food in 5 patients (33.3%). In a comparison of the peak amplitudes of fasting brady-gastria, normal-gastria, and tachy-gastria between the N and C groups, the peak amplitude was significantly increased in normal-gastria in the N group, and in brady-gastria and tachy-gastria in the C group. In a comparison of the rates of food ingestion-induced changes in the peak amplitudes for brady-gastria, normal-gastria, and tachy-gastria between the N and C groups, the peak amplitudes were significantly increased in normal-gastria in the N group, but not in the C group. In the case of gastric emptying investigated by external ultrasonography, the rate of food ingestion-induced change in the cross-sectional antrum area was significantly lower in the C group (50.5+/-9.2%) than in the N group (65.0+/-8.5%). For gastrointestinal motility, a 3 cpm normal-gastria represents efficient gastric motility. In the C group, the peak amplitudes of brady-gastria and tachy-gastria were significantly increased, but were low in normal-gastria in the fasting EGG, postprandial division of the normal-gastria component was noted, and the rate of food ingestion-induced increase in the normal-gastria peak amplitude was significantly lower than that in the N group, suggesting that patients with Crohn's disease have a functional abnormality in, not only the small and large intestine, but also the stomach.

Recent insights into digestive motility in functional dyspepsia

Functional gastrointestinal disorders, such as functional dyspepsia (FD) and irritable bowel syndrome, are common pathologies of the gut. FD is a clinical syndrome defined as chronic or recurrent pain or discomfort of unknown origin in the upper abdomen. The pathophysiological mechanisms responsible for FD have not been fully elucidated, but new ideas regarding its pathophysiology and the significance of the pathophysiology with respect to the symptom pattern of FD have emerged. In particular, there is growing interest in alterations in gastric motility, such as accommodation to a meal or gastric emptying, and visceral sensation in FD. The mechanisms underlying impaired gastroduodenal motor function are unclear, but possible factors include abnormal neurohormonal function, autonomic dysfunction, visceral hypersensitivity to acid or mechanical distention, Helicobacter pylori infection, acute gastrointestinal infection, psychosocial comorbidity, and stress. Although the optimum treatment for FD is not yet clearly established, acid-suppressive drugs, prokinetic agents, eradication of H. pylori, and antidepressants have been widely used in the management of patients with FD. The therapeutic efficacy of prokinetics such as itopride hydrochloride and mosapride citrate in the treatment of FD is supported by the results of relatively large and well-controlled studies. In addition, recent research has yielded new therapeutic agents and modalities for dysmotility in FD, including agonists/antagonists of various sensorimotor receptors, activation of the nitrergic pathway, kampo medicine, acupuncture, and gastric electric stimulation. This review discusses recent research on the pathophysiology of and treatment options for FD, with special attention given to digestive dysmotility.

Relationships between intragastric food maldistribution, disturbances of antral contractility, and symptoms in functional dyspepsia

We investigated the relationships between intragastric food maldistribution and antral dysmotility in functional dyspepsia, and whether these abnormalities relate to meal-induced symptoms. Intragastric distribution of food throughout gastric emptying was determined in patients (n = 24) and controls (n = 38) after a liquid nutrient meal labeled with (99m)technetium phytate. Antral contractility was also periodically assessed by dynamic scintigraphy and postprandial symptoms were monitored with visual analog scales. Residence of food in the proximal stomach was decreased in 8 (33%) and antral contractility was increased in 9 (37.5%) and decreased in 2 (8%) patients. Proximal and distal stomach motor abnormalities were neither significantly correlated nor associated. Increased antral contractility was significantly correlated (Rs = 0.54; P < .01) with postprandial nausea. We conclude that diminished residence of food in the proximal stomach and disturbed antral contractility occur independently in different subsets of functional dyspepsia patients. Increased antral contractility seems to play a role in postprandial nausea in functional dyspepsia.

Apresentação da técnica de estudo do tempo de esvaziamento gástrico por meio da ultra-sonografia

OBJETIVO: Descrever a técnica de avaliação do esvaziamento gástrico em crianças. MATERIAIS E MÉTODOS: Foram estudadas 14 crianças voluntárias saudáveis, com idades de 2 a 11 anos. As crianças ingeriram leite modificado, na proporção de 200 ml/m² de superfície corporal. A área do antro gástrico foi medida em todos os pacientes no tempo zero, antes da ingestão do meio de contraste, e aos 60, 90, 120 e 150 minutos após a ingestão do meio de contraste. RESULTADOS: A dieta foi bem tolerada pelos pacientes. Foi observado que em 150 minutos após a ingestão do alimento, 85% dos pacientes apresentaram-se com esvaziamento gástrico total. CONCLUSÃO: A ultra-sonografia é método seguro e barato, sendo uma alternativa para o estudo do esvaziamento gástrico.

Prokinetic effect of a Kampo medicine, Hange-koboku-to (Banxia-houpo-tang), on patients with functional dyspepsia

Limited evidence is available as to whether Kampo medicine modifies gastrointestinal function in humans. We investigated the effect of a Kampo medicine, Hange-koboku-to (Banxia-houpo-tang, HKT), on patients with functional dyspepsia (FD) and on healthy volunteers with regard to gastric motility. The gastric emptying rate (GER) in FD patients was significantly lower than in the healthy subjects. GER in FD patients and in healthy volunteers showed a significant increase after 2 weeks of medication with HKT. Furthermore, gastrointestinal symptoms improved significantly in the FD patients after the administration of HKT. These results suggest that HKT improves delayed gastric emptying and acts as a prokinetic agent.