American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis

European Guideline on Chronic Nausea and Vomiting-A UEG and ESNM Consensus for Clinical Management

INTRODUCTION

Chronic nausea and vomiting are symptoms of a wide range of gastrointestinal and non-gastrointestinal conditions. Diagnosis can be challenging and requires a systematic and well-structured approach. If the initial investigation for structural, toxic and metabolic disorders is negative, digestive motility and gut-brain interaction disorders should be assessed. United European Gastroenterology (UEG) and the European Society for Neurogastroenterology and Motility (ESNM) identified the need for an updated, evidence-based clinical guideline for the management of chronic nausea and vomiting.

METHODS

A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of the guideline. Relevant questions were addressed through a literature review and statements were developed and voted on according to a Delphi process.

RESULTS

Ninety-eight statements were identified and voted following the Delphi process. Overall agreement was high, although the grade of scientific evidence was low in many areas. Disagreement was more evident for some pharmacological treatment options. A diagnostic algorithm was developed, focussing on the differentiating features between gastrointestinal motility and gut-brain interaction disorders with predominant nausea and vomiting.

CONCLUSION

These guidelines provide an evidence-based framework for the evaluation and treatment of patients with chronic nausea and vomiting.

The American Neurogastroenterology and Motility Society Gastroparesis Cardinal Symptom Index-Daily Diary (ANMS GCSI-DD): Psychometric validation and meaningful change threshold in patients with idiopathic or diabetic gastroparesis

INTRODUCTION

The American Neurogastroenterology and Motility Society Gastroparesis Cardinal Symptom Index-Daily Diary (ANMS GCSI-DD) is a patient-reported outcome (PRO) instrument for gastroparesis. This study evaluated the psychometric properties of the ANMS GCSI-DD and determined a meaningful change threshold using the data from a phase 2b trial in adults with moderate-to-severe idiopathic or diabetic gastroparesis (DG).

METHODS

The psychometric properties of ANMS GCSI-DD were analyzed using other clinician- and patient-reported outcomes from 242 patients during the 12-week trial. Trial exit interviews were conducted in a cohort of 32 patients to capture their perspectives on meaningful change from the trial.

RESULTS

ANMS GCSI-DD demonstrated good performance: unidimensionality scores exhibited good fit; internal consistency reliability was >0.70; test-retest reliability was above 0.90, and convergent validity showed strong correlations (0.70-0.90) with overall severity rating and moderate correlations (0.30-0.70) with other outcomes. ANMS GCSI-DD scores discriminated among groups with varying severity of gastroparesis symptoms in known-groups validity (p < 0.001) and were responsive to symptom improvement. Triangulation of the quantitative anchor-based estimates of 0.9-1.4 category points as a meaningful change in the ANMS GCSI-DD composite score, and the qualitative exit interview findings of 0.5-1.5 as meaningful change, supports a one-point change on a five-point scale (0-4) as the meaningful change threshold.

CONCLUSION

The ANMS GCSI-DD is a reliable and valid PRO instrument to employ in clinical development for patients with moderate-to-severe idiopathic or DG, and a one-point score change in the ANMS GCSI-DD composite score is recommended as a meaningful change threshold of symptom change.

Efficacy and safety of gastric peroral endoscopic myotomy across different etiologies of gastroparesis: systematic review and meta-analysis

BACKGROUND AND AIMS

Gastric peroral endoscopic myotomy (G-POEM) is an emerging treatment for refractory gastroparesis. Although its efficacy and safety have been analyzed in previous systematic reviews and meta-analyses, no studies have compared its effectiveness based on etiology. Our study aims to evaluate the efficacy and safety of G-POEM by etiologies of gastroparesis.

METHODS

We conducted a comprehensive search in major databases until October 2023, focusing on the efficacy and safety of G-POEM by etiology. Our primary outcome was clinical success based on etiology, with an additional subgroup analysis on Gastroparesis Cardinal Symptom Index (GCSI) scores before and after G-POEM based on etiology using standard meta-analysis methods and the random-effects model. Heterogeneity was assessed using I2 statistics.

RESULTS

In our analysis of 15 studies (7 retrospective, 8 prospective) involving 982 patients (mean patient age, 50.81 years; mean follow-up, 21 months), postsurgical conditions were the most common etiology in G-POEM (290 cases), followed by idiopathic factors (287 cases) and diabetes (286 cases). Subgroup analysis revealed pooled clinical success rates of 65% (95% confidence interval [CI], 51-77; I2 = 46%) for diabetes, 70% (95% CI, 46-86; I2 = 73%) for postsurgical conditions, and 60% (95% CI, 41-77; I2 = 68%) for idiopathic etiologies. Our research also indicated that G-POEM significantly improved GCSI scores: 1.7 (95% CI, -.01 to 3.5; P = .052) for diabetes, 1.34 (95% CI, -.07 to 2.62; P = .038) for postsurgical conditions, and 1.5 (95% CI, .36-2.75; P = .01) for idiopathic patients.

CONCLUSIONS

Based on this meta-analysis, G-POEM is effective and safe for treating refractory gastroparesis irrespective of the etiology, with significant improvements in clinical success rates and GCSI scores.

Electrogastrography in Adult Gastroparesis: A Systematic Review and Meta-Analysis

BACKGROUND

Gastroparesis is a delay in gastric emptying without mechanical obstruction, lacking a clear pathophysiological mechanism, but with multiple histological abnormalities including loss of interstitial cells of Cajal, which may alter slow waves. We can assess slow waves with electrogastrography.

OBJECTIVES

To determine the prevalence and range of abnormalities in gastric slow waves in adults with gastroparesis using electrogastrography.

METHODS

We systematically searched Medline, Embase, LILACS, Web of Science, and Cochrane Register of Controlled Trials. We included studies with patients older than 18 years with gastroparesis, assessed using electrogastrography. We evaluated the percentage of duration of the recording in which the dominant power was in normogastria, tachygastria, and bradygastria; dominant frequency; power ratio; change in post-stimulus dominant power; and dominant frequency instability coefficient. Methodological quality was assessed using the Joanna Briggs Institute tool. Data were synthesized using narrative summary and meta-analysis.

RESULTS

A total of 3730 articles were reviewed, including 31 articles with 1545 patients and 340 controls. Compared to controls, gastroparetics patients had less normogastria (fasting: 50.3% versus 65.8%) (post-stimulus: 54.3% versus 66.5%), more bradygastria (fasting: 37.7% versus 13%) (post-stimulus: 31.9% versus 16.3%), and more tachygastria (fasting: 16.1% versus 4.6%) (post-stimulus: 18.3% versus 5.2%). Gastroparetics had less change in post-stimulus dominant power (1.45 dB versus 5.03 dB) and less power ratio (1.4 versus 5.26).

CONCLUSIONS

Gastroparetic patients present abnormalities in the frequency and changes in the post-stimulus power of slow waves, possibly secondary to a reduced number of interstitial cells of Cajal, as described in these patients.

Imaging analytical technique to assess gastrointestinal motility in vivo using zebrafish larvae with diabetes mellitus-like traits

In diabetes mellitus (DM), the prevalence of gastrointestinal (GI) complications, including constipation, diarrhoea, gastroparesis, and/or enteropathy, can be up to ~75%. In this study, we compared three zebrafish larvae models of DM and established an analytical protocol for GI motility. Larvae were fed with either a standard diet (SD; control), or one of three diets to induce a DM-like phenotype: excessive feeding of SD food (ED), a high-fat diet (HFD), or exposing SD-fed larvae to 30 mmol/L glucose (SDG). DM was confirmed using a body-mass index, assessment of adipose deposit areas, two glucose assays, and one insulin assay. An analytical technique, whereby GI motility was quantified using pixel differences to track displacement along the centreline of the anterior, middle, and posterior intestine (AI, MI, and PI, respectively), was developed. Our results indicated that clear DM-like traits were observed in the HFD and SGD models, but not the ED model. In the SD controls, the AI showed similar anterograde and retrograde contractions indicating normal GI mixing; the MI exhibited more prominent forward contractions, and the PI showed distinct rectal waves. Compared to the SD, the HFD and SDG models exhibited significantly increased and decreased contraction velocities and could be used as models of diarrhoea and constipation in DM, respectively, while the ED model showed comparatively little change in motility. Together, these data indicate that complex changes in GI motility are associated with diet and therapeutics used to alleviate GI complications in DM should take these into account. Ultimately, the HFD and SDG models can be used to investigate different aspects of GI motility in association to DM. Hence, zebrafish are a useful model for studying GI dysfunctions due to DM and/or DM medication side-effects.

Gabapentin as an Adjunctive Therapy in Managing Visceral Hyperalgesia, Severe Feeding Intolerance, and Malnutrition in an Infant: A Case Presentation and Literature Review

A two-month-old developmentally normal full-term female presented with severe feeding intolerance, progressive weight loss, and persistent fussiness, leading to multiple emergency department visits and eventual hospitalization. Initial evaluations, including laboratory tests and imaging, were unremarkable, prompting a series of diagnostic and therapeutic interventions. A multidisciplinary approach, including empiric gastroesophageal reflux disease (GERD) therapy, was started. A gastric emptying study, upper GI, and endoscopy were done. She underwent gastrostomy tube (G-tube) placement, during which a gastric wall perforation was identified and managed intraoperatively. Multiple attempts at nutritional management, including nasoduodenal tube placement and total parenteral nutrition, were met with limited success. Gastroparesis and visceral hyperalgesia were suspected as underlying causes. Unlike previous cases documented in patients with a history of cardiac surgery, this neurologically normal patient had no such surgical history. A trial of gabapentin for possible visceral hyperalgesia resulted in a gradual improvement in oral tolerance and significant improvement with fussiness and discomfort. The patient was discharged at four months of age with gastrojejunal tube feeds and ongoing medical therapy. In this case, we highlight the utility of a gabapentin trial in an otherwise healthy patient. This case underscores the complexities of managing severe feeding disorders in infants, particularly the role of gabapentin in addressing suspected visceral hyperalgesia and failure to thrive in a patient without previous neurological or cardiac surgery.

A long-term follow-up study of gastric peroral endoscopic myotomy (G-POEM) in a large cohort of patients with postsurgical gastroparesis

INTRODUCTION

Postoperative gastroparesis occurs after surgeries which affect the upper digestive tract. Gastric peroral endoscopic myotomy (G-POEM) is a treatment for postoperative gastroparesis. The present study boasts the long-term efficacy and safety of G-POEM in a large cohort of patients.

PATIENTS AND METHODS

Gastroparesis Cardinal Symptom Index (GCSI) and Gastroesophageal Reflux Disease Questionnaire (GERDQ) were utilized for the assessment of postsurgical gastroparesis symptoms. Gastroscope was used to observe the anastomotic site. Three-dimensional ultrasound was used to measure the morphological structure of the gastric antrum and pylorus tube. Gastric emptying time was calculated by analyzing the volume change of gastric antrum.

RESULTS

Significant clinical effectiveness of G-POEM was observed. The GCSI score, including each subscale score, showed significant decrease after G-POEM. Before G-POEM, there was a negative correlation between GCSI score and the inner diameter of pylorus, as well as a positive correlation with the length of pyloric tube. The similar results were found in the scores of nausea/vomiting and postprandial fullness/early satiety subscales. No correlation was observed between GCSI score and the emptying time, nor between the emptying time and the parameters of antrum morphology. After G-POEM, no correlation was found between GCSI (including subscales) score, the emptying time, and the parameters of antrum morphology. Patients who exhibited as clinical non-responders often accompanied with GERD symptoms. After G-POEM, the score of GERDQ decreased significantly. Either before or after G-POEM, no correlation was noticed between GERDQ scores, the emptying time and the parameters of antrum morphology.

CONCLUSION

The technique of G-POEM was demonstrated as a minimally invasive approach with the long-term efficacy and safety in therapying postoperative gastroparesis.

The Efficacy of Tradipitant in Patients With Diabetic and Idiopathic Gastroparesis in a Phase 3 Randomized Placebo-Controlled Clinical Trial

BACKGROUND

Neurokinin receptor 1 antagonists are effective in reducing nausea and vomiting in chemotherapy-induced emesis. We investigated the safety and efficacy of tradipitant, a neurokinin receptor 1 antagonist, in patients with idiopathic and diabetic gastroparesis.

METHODS

A total of 201 adults with gastroparesis were randomly assigned to oral tradipitant 85 mg (n = 102) or placebo (n = 99) twice daily for 12 weeks. Symptoms were assessed by a daily symptom dairy, Gastroparesis Cardinal Symptom Index scores, and other patient-reported questionnaires. Blood levels were monitored for an exposure-response analysis. The primary outcome was change from baseline to week 12 in average nausea severity, measured by daily symptom diary.

RESULTS

The intention-to-treat (ITT) population did not meet the prespecified primary endpoint at week 12 (difference in nausea severity change drug vs placebo; P = .741) or prespecified secondary endpoints. Post hoc analyses were performed to control for drug exposure, rescue medications, and baseline severity inflation. Subjects with high blood levels of tradipitant significantly improved average nausea severity beginning at early time points (weeks 2-4). In post hoc sensitivity analyses, tradipitant treatment demonstrated strengthened effects, with statistically significant improvements in nausea at week 12.

CONCLUSIONS

Although tradipitant did not reach significance in the ITT population, a pharmacokinetic exposure-response analysis demonstrated significant effects with adequate tradipitant exposure. When accounting for confounding factors such as baseline severity inflation and rescue medication, a statistically significant effect was also observed. These findings suggest that tradipitant has potential as a treatment for the symptom of nausea in gastroparesis. (ClincialTrials.gov, Number: NCT04028492).

The role of gastric electrical stimulation in postsurgical gastroparesis: a retrospective analysis from 2 centers

BACKGROUND

Postsurgical gastroparesis, resulting from surgical interventions on the stomach or vagal nerve injury, poses significant clinical challenges with patients presenting symptoms such as nausea, vomiting, and abdominal pain. Although gastric electrical stimulation (GES) offers potential relief, its efficacy in refractory postsurgical gastroparesis requires further examination. This study evaluated the clinical response to GES in patients with refractory postsurgical gastroparesis.

METHODS

A retrospective study was conducted across 2 study sites, involving 185 patients with drug-refractory postsurgical gastroparesis who underwent both temporary and permanent GES placements. Patients were categorized based on their surgical history: bariatric surgery, Nissen fundoplication, and others. The impact of GES was evaluated using Food and Drug Administration-compliant patient-reported outcomes scores and other relevant clinical metrics at baseline, after temporary GES placement, and 6 months after permanent GES placement. All 3 groups were also analyzed by the symptom improved group vs the unimproved group at baseline and 6 months after GES placement.

RESULTS

After GES implantation, all patient groups significantly improved upper gastrointestinal symptoms. The bariatric surgery group and Nissen fundoplication group specifically identified anorexia as the most severe symptom after GES after temporary GES placement among 3 groups (2.5 [0.4-3.5] and 1.5 [0.0-2.5], respectively). Nissen fundoplication patients had the highest score of anorexia among the 3 groups 6 months after GES (3.0 [2.0-3.5], P = .018). Despite these improvements, GES did not enhance gastric emptying test results. Symptomatic improvements were notably significant in patients who initially reported higher symptom severity than those who did not.

CONCLUSION

GES shows promise in alleviating symptoms of refractory postsurgical gastroparesis, particularly in those with severe initial symptoms. However, its impact on gastric emptying remains inconclusive. Further research is needed to establish GES as a standard treatment for postsurgical gastroparesis.

Short-term symptomatic outcomes of GERD in patients with gastroparesis after gastric per oral endoscopic pyloromyotomy

Gastroparesis (Gp) patients often have gastroesophageal reflux disease (GERD). Management of GERD in Gp patients is a challenge. Many studies have shown that gastric peroral endoscopic pyloromyotomy (G-POEM or POP) is moderately effective in reducing nausea and vomiting in patients with Gp. This study aims to determine whether G-POEM can improve GERD in Gp Patients. Patients who underwent G-POEM from July 2021 to October 2022 were enrolled in the study. GERD Health-Related Quality of Life (GERD HRQL) and Reflux Symptom Index (RSI) were used to assess patients' GERD before and after G-POEM. The use of proton pump inhibitors (PPIs) before and after G-POEM were also documented. The Gastroparesis Cardinal Symptom Index (GCSI) was used to assess the severity of Gp before and after G-POEM. A 'Welch two-sample t-test' was used to find differences in GERD HRQL (health-related quality of life) and RSI scores before and after the procedure. Pearson's chi-square test was used to find differences for use of PPI before and after G-POEM. Twenty-three consecutive refractory Gp patients with 30% male (average age 63.2) and 70% female patients (average age 53.9) were enrolled. Of these, 14 had diabetes, 3 had a history of surgery, and 6 had idiopathic Gp. The mean follow-up was 41 days (range 7-61 days). There was a significant decrease in the mean GERD HRQL score from 16.5 to 6.5 after G POEM with a P-value <0.0001 (95% level of significance) and a significant decrease in mean RSI score from 15.3 to 5.2 after G-POEM with P-value <0.0001 (95% level of significance). The proportion of use of PPI before GPOEM was 0.91, and the proportion of PPI use after GPOEM was 0.43 (P = 0.0008). The mean GCSI pre- and post-GPOEM were 3.53 and 1.59, respectively. Eighteen had clinical success in Gp as defined by decreased mean GCSI score greater than 1. In this short-term outcome study, 87% of patients' GERD HRQL scores and RSI scores decreased after G-POEM. These findings indicate that GPOEM not only effectively reduces Gp symptoms but also improves GERD symptoms leading to decreased or more effective use of PPI in these patients. To our knowledge, this is the first study to comprehensively show G-POEM significantly improves GERD. Further studies with a larger patient population and long-term outcomes are needed.

The Beneficial Effects of Regular Intake of Lactobacillus paragasseri OLL2716 on Gastric Discomfort in Healthy Adults: A Randomized, Double-Blind, Placebo-Controlled Study

We investigated the effects of Lactobacillus paragasseri OLL2716 on gastrointestinal symptoms in healthy adults with gastric complaints. In this randomized, double-blind, placebo-controlled trial, 174 healthy Japanese adults were randomly assigned to an OLL2716 or placebo group, and each group consumed 85 g of yogurt containing L. paragasseri OLL2716 or placebo yogurt daily for 12 weeks. The primary endpoint was the change in gastric symptoms from baseline as per the participants' questionnaires at 6 and 12 weeks. The secondary endpoints were changes from baseline in the short-form Nepean Dyspepsia Index (SF-NDI), the Gastrointestinal Symptom Rating Scale (GSRS), and the Council on Nutrition Appetite Questionnaire-Japanese (CNAQ-J) scores at 6 and 12 weeks. The primary endpoint data showed that the changes in "epigastric pain" at 6 and 12 weeks were significantly decreased in the OLL2716 group compared with those in the placebo group. Additionally, the changes in "epigastric pain syndrome-like symptoms" were significantly decreased in the OLL2716 group compared with those in the placebo group at 6 weeks. The SF-NDI items that improved at 6 weeks were "irritable, tense, or frustrated", "enjoyment of eating or drinking", and "tension", which are sub-scales related to mental stress. The items "Over-all" in the GSRS and "feeling hungry" in the CNAQ-J significantly improved in the OLL2716 group compared with the placebo group at 12 weeks. The results suggest that regular intake of L. paragasseri OLL2716 may improve both gastric discomfort and mental stress in healthy adults with gastric complaints, such as postprandial fullness or early satiety.

Confounding Factors in the Association Between Glucagon-Like Peptide-1 Receptor Agonist Use and Retained Gastric Contents in Asymptomatic Patients Undergoing Upper Gastrointestinal Endoscopy: A Retrospective Study

Introduction The use of glucagon-like peptide-1 receptor agonists (GLP-1 RA) has gained acceptance in managing diabetic and non-diabetic patients, thanks to its benefits in treating obesity and improving cardiovascular outcomes. The potential ability of GLP-1 RA to cause retained gastric contents (RGC) which can lead to aspiration has led to the recommendation to withhold GLP-1 RA for at least one week prior to elective surgeries and procedures, including upper endoscopies and colonoscopies. However, many co-medications and conditions associated can contribute to delayed gastric emptying (DGE) and these need to be controlled to establish a clear association and incidence, which has been largely missing in most studies and reports. Our aim was to assess clinically significant delayed gastric emptying (CSDGE) related to GLP-1 RA in a "real world" situation by controlling for some common confounding factors. Method We carried out an eight-year retrospective single-center study to assess the relationship between CSDGE and the use of GLP-1 RA among asymptomatic patients undergoing upper endoscopies while controlling for common confounding factors. Result Out of the 3415 patients who had esophagogastroduodenoscopy (EGD) with or without colonoscopy (Ew/woC) during the eight-year period, 129 eligible patients were found to have CSDGE. The use of GLP-1 RA was associated with the lowest percentage frequency distribution of CSDGE, at 2%, and opiate accounted for more percentage frequency distribution, at 35%. The odds ratio for patients on GLP-1 RA who developed CSDGE was 2.5 (95% CI 0.75-8.29). All patients who had CSDGE while on GLP-1 RA were also on other medications or had conditions associated with DGE. Conclusion Our result confirmed the possible effect of confounding factors in the association between CSDGE and GLP-1 RA among asymptomatic patients undergoing Ew/woC. While the need to ensure patients' safety cannot be overemphasized, the proper approach currently favors assessing patients on a case-by-case basis while we await the results of large prospective controlled studies.

Resolution of severe gastroparesis induced by parasympathetic surge following facial trauma: a case report

BACKGROUND

Gastroparesis is a condition that affects the motility of the gastrointestinal (GI) tract, causing a delay in the emptying process and leading to nausea, vomiting, bloating, and upper abdominal pain. Motility treatment along with symptom management can be done using antiemetics or prokinetics. This study highlights the diagnostic and therapeutic challenges of gastroparesis and suggests a potential link between facial trauma and symptom remission, indicating the need for further investigation.

CASE PRESENTATION

A 46-year-old Hispanic man with hypertension, type 2 diabetes (T2D), and hyperlipidemia on amlodipine 10 mg, lisinopril 5 mg, empagliflozin 25 mg, and insulin glargine presented with a diabetic foot ulcer with probable osteomyelitis. During hospitalization, the patient developed severe nausea and vomiting. The gastroenterology team advised continuing antiemetic medicine and trying very small sips of clear liquids. However, the patient didn't improve. Therefore, the gastroenterology team was contacted again. They advised having stomach emptying tests to rule out gastroparesis as the source of emesis. In addition, they recommended continuing metoclopramide, and starting erythromycin due to inadequate improvement. Studies found a 748-min stomach emptying time. Normal is 45-90 min. An uneventful upper GI scope was done. Severe gastroparesis was verified, and the gastroenterology team advised a percutaneous jejunostomy or gastric pacemaker for gastroparesis. Unfortunately, the patient suffered a mechanical fall resulting in facial trauma. After the fall, the patient's nausea eased, and emesis stopped. He passed an oral liquids trial after discontinuation of erythromycin and metoclopramide.

CONCLUSION

This case exemplifies the difficulties in diagnosing and treating gastroparesis. An interesting correlation between parasympathetic surges and recovery in gastroparesis may be suggested by the surprising remission of symptoms following face injuries.

Esophageal Motility Abnormalities in Lung Transplant Recipients With Esophageal Acid Reflux Are Different From Matched Controls

Background/Aims

There is an increased incidence of gastroesophageal reflux disease (GERD) after lung transplantation (LT) that can be associated with graft dysfunction. It is unclear if the underlying esophageal motility changes in GERD are different following LT. This study aimed to use esophageal high-resolution manometry (HRM) to explore GERD mechanisms in LT recipients compared to matched controls.

Methods

This was a retrospective study including patients with pathologic acid reflux who underwent HRM and pH testing at our healthcare facility July 2012 to October 2019. The study included 12 LT recipients and 36 controls. Controls were matched in a 1:3 ratio for age, gender, and acid exposure time (AET).

Results

LT recipients had less hypotensive esophagogastric junction (EGJ) (mean EGJ-contractile integral 89.2 mmHg/cm in LT vs 33.9 mmHg/cm in controls, P < 0.001). AET correlated with distal contractile integral and total EGJ-contractile integral only in LT group (r = -0.79, P = 0.002 and r = -0.57, P = 0.051, respectively).

Conclusions

Following LT, acid reflux is characterized by a less hypotensive EGJ compared to controls with similar AET. The strongest correlation with AET after LT was found to be esophageal peristaltic vigor. These results add to the understanding of reflux after LT and may help tailor an individualized treatment plan.

Efficacy and Safety of Gastric Per-Oral Endoscopic Myotomy (G-POEM): A Systematic Review and Meta-Analysis

BACKGROUND

Gastric per-oral endoscopic myotomy (G-POEM) is an innovative treatment that has become increasingly utilized for patients with refractory gastroparesis. The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of G-POEM for the treatment of gastroparesis.

METHODS

Individualized search strategies were developed through February 2021 in accordance with the PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions and mean difference preprocedure and postprocedure with rates estimated using random effects models. Measured outcomes included technical success, clinical success, improvement in gastroparesis cardinal symptom index (GCSI), change in gastric emptying rate, alterations in impedance planimetry (functional lumen imaging probe [FLIP]) assessment, and adverse events.

RESULTS

A total of 20 studies (n=797 patients; 67.41% female) were included. The mean age was 48.92±11.61 y, with an average duration of 4.24±1.11 y since gastroparesis diagnosis. Technical success was 98.47% [(95% CI: 97.14, 99.19);I2=0.00] with a mean myotomy length of 3.78±1.16 cm. In terms of clinical success, mean preprocedure GCSI scores were 3.38±0.37 and improved significantly postprocedure [weighted mean difference -1.56 (95% CI: -1.89 to -1.24); I2=82.53; P<0.001]. Gastric retention after 4 hours demonstrated ~50% improvement (preprocedure 43.08±9.24% versus postprocedure 22.97±10.19%; P<0.001). FLIP assessment with 40 mL and 50 mL balloons demonstrated a significant increase in diameter, distensibility index, and cross-sectional area postprocedure (all P<0.05). Procedure-associated adverse events occurred among 10.92% [(95% CI 5.09 to 19.32); I2=82.85] of patients.

CONCLUSION

G-POEM appears safe and highly effective for the treatment of patients with refractory gastroparesis regardless of symptom predominance or etiology.

The Association between Hormone Replacement Therapy and Gastroparesis in Post-Menopausal Women: A Worldwide Database Analysis

Female sex hormones have been hypothesized to influence the higher prevalence of gastroparesis in females. This study investigated the effects of hormone replacement therapy (HRT) on gastroparesis and its related symptoms, medication use, and diagnostic testing in post-menopausal women. Utilizing the TriNetX platform, we conducted a population-based cohort study involving post-menopausal women aged 50 or older, with and without HRT. One-to-one propensity score matching was performed to adjust for age, race, ethnicity, diabetes, body mass index (BMI), and hemoglobin A1c. The exclusion criteria included functional dyspepsia, cyclic vomiting syndrome, and surgical procedures. After applying the exclusion criteria, we identified 78,192 post-menopausal women prescribed HRT and 1,604,822 not prescribed HRT. Post-propensity matching, each cohort comprised 67,874 patients. A total of 210 of the post-menopausal women prescribed HRT developed an ICD encounter diagnosis of gastroparesis at least 30 days after being prescribed HRT compared to post-menopausal women not prescribed HRT (OR = 1.23, 95% CI [1.01-1.51] p-value = 0.0395). These associations persisted in sensitivity analysis over 5 years (OR = 1.65, 95% CI [1.13-2.41] p-value = 0.0086). HRT was associated with increased GI symptoms, including early satiety (OR = 1.22, 95% CI [1.03-1.45] p-value = 0.0187), domperidone use (OR = 2.40, 95% CI [1.14-5.02] p-value = 0.0163), and undergoing gastric emptying studies (OR = 1.67, 95% CI [1.39-2.01] p-value < 0.0001). HRT is linked to an increased risk of developing an ICD encounter diagnosis of gastroparesis.

Diabetic Gastroparesis: Navigating Pathophysiology and Nutritional Interventions

Diabetic gastroparesis (DGP) delays gastric emptying in diabetes patients, notably impacting those with type 1 and long-standing type 2 diabetes. Symptoms include early satiety, fullness, appetite loss, bloating, abdominal pain, and vomiting, arising from slow stomach-to-intestine food movement. DGP’s unpredictable nature complicates diagnosis and blood glucose management, leading to severe complications like dehydration, malnutrition, and bezoar formation. Understanding DGP’s mechanisms is crucial for effective management. Vagal dysfunction, disturbances in the interstitial cells of Cajal, reduced neural nitric oxide synthase, and increased oxidative stress contribute to the complex pathophysiology. Accurate diagnosis demands a comprehensive approach, utilizing tools like gastric scintigraphy and the Gastric Emptying Breath Test. Considering the complex relationship between DGP and glycemia, managing blood glucose levels becomes paramount. Nutritional interventions, tailored to each patient, address malnutrition risks, emphasizing smaller, more frequent meals and liquid consistency. DGP’s complex nature necessitates collaborative efforts for enhanced diagnostic strategies, improved pathophysiological understanding, and compassionate management approaches. This comprehensive approach offers hope for a future where individuals with DGP can experience improved well-being and quality of life.

Gastric-filling ultrasonography to evaluate gastric motility in patients with Parkinson's disease

Background

Delayed gastric emptying is a common non-motor symptom of Parkinson's disease (PD). However, there is currently no objective evaluation and diagnostic method for this condition.

Objectives

The purpose of this study was to evaluate the feasibility of gastric-filling ultrasonography for gastric motility in patients with PD and the relationship between gastric dynamics and gastrointestinal symptoms and motor symptoms of PD.

Design setting and patients

We performed a case-control study with 38 patients with PD and 34 healthy controls.

Methods

All patients underwent a 120-min ultrasonography examination using a 500-ml semi-liquid test meal. We determined the antral contraction amplitude (ACA), the antrum contraction frequency (ACF), the motility index (MI), and the gastric antral cross-sectional area (CSA). We acquired the CSA at six time points: fasting for 12 h (T0), immediately after drinking the semi-liquid test meal (T1); and at 30 (T30), 60 (T60), 90 (T90), and 120 (T120) min. We calculated the gastric emptying rate (GER) at different time points by using the CSA. We compared the GER between the groups and evaluated the correlation between the GER and gastrointestinal symptoms and motor symptoms of PD.

Results

The MI and ACF were significantly lower in the PD group compared with the control group (P < 0.05). The GER at T30 and the ACA showed no significant difference between the groups (P > 0.05). At different time points, the GER was significantly different between the PD and control groups (P < 0.001). There was no significant association between the GER and gastrointestinal symptoms; none of them were risk factors for impaired gastric emptying (odds ratio > 1). The GER was negatively correlated with the severity of PD motor symptoms (P < 0.05).

Conclusion

Patients with PD had significantly delayed gastric emptying, which was negatively correlated with the severity of PD motor symptoms. Measuring gastric emptying by gastric-filling ultrasound had good diagnostic value in clinical screening for delayed gastric motility in patients with PD.

Clinical Trial Registration

https://www.chictr.org.cn/showproj.html?proj=126304.

Relationships among symptoms of gastroparesis to those of avoidant/restrictive food intake disorder in patients with gastroparesis

BACKGROUND

Patients with symptoms of gastroparesis (Gp) often reduce food intake in attempt to manage their symptoms. Up to 40% of adults with Gp have been reported to have symptoms of a non-body image-based eating disorder, avoidant/restrictive food intake disorder (ARFID). However, whether ARFID symptoms precede or follow the diagnosis of Gp is unknown.

METHODS

From January 2021 to January 2022, consecutive adult patients with Gp at an academic center completed self-report surveys for Gp symptom severity (patient assessment of upper gastrointestinal symptoms; PAGI-SYM) and for ARFID (nine-item ARFID screen; NIAS).

KEY RESULTS

One hundred and seven patients (age 45.4 ± 17.2 yrs, 84.1% female, BMI 26.4 ± 7.3) with Gp (4-h gastric retention 33.5 ± 21.8%) were included. Eighty-two of the 107 Gp patients (77%) screened positive for ARFID. Positive ARFID screen was most often on the NIAS appetite subscale (84%) and fear subscale (76%), with a lower positive screen rate on the picky subscale (45%). Of the Gp who screened positive for ARFID, 38% reported that eating difficulties came after their Gp diagnosis, whereas 17% reported that eating difficulties preceded their Gp diagnosis, and 15% reported that both began at the same time.

CONCLUSIONS

Many (77%) patients with Gp screened positive for ARFID. In Gp patients with ARFID, the Gp diagnosis was more likely to precede the development of eating difficulties. Thus, a subset of patients with Gp may be at risk for developing ARFID. Further longitudinal research is needed to confirm findings and identify risk factors.

Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract in Cystic Fibrosis

PURPOSE OF REVIEW

To discuss all the various motility disorders impacting people with Cystic Fibrosis (PwCF) and provide diagnostic and management approaches from a group of pediatric and adult CF and motility experts and physiologists with experience in the management of this disease.

RECENT FINDINGS

Gastrointestinal (GI) symptoms coexist with pulmonary symptoms in PwCF regardless of age and sex. The GI manifestations include gastroesophageal reflux disease, esophageal dysmotility gastroparesis, small bowel dysmotility, small intestinal bacterial overgrowth syndrome, distal idiopathic obstruction syndrome, constipation, and pelvic floor disorders. They are quite debilitating, limiting the patients' quality of life and affecting their nutrition and ability to socialize. This genetic disorder affects many organ systems and is chronic, potentially impacting fertility and future family planning, requiring a multidisciplinary approach. Our review discusses the treatments of motility disorders in CF, their prevalence and pathophysiology. We have provided a framework for clinicians who care for these patients that can help to guide their clinical management.

Abdominal compartment syndrome in critically ill patients

Intra-abdominal hypertension can have severe consequences, including abdominal compartment syndrome, which can contribute to multi-organ failure. An increase in intra-abdominal hypertension is influenced by factors such as diminished abdominal wall compliance, increased intraluminal content, and certain systemic conditions. Regular measurement of intra-abdominal pressure is essential, and particular attention must be paid to patient positioning. Nonsurgical treatments, such as decompression of intraluminal content using a nasogastric tube, percutaneous drainage, and fluid balance optimization, play crucial roles. Additionally, point-of-care ultrasonography aids in the diagnosis and treatment of intra-abdominal hypertension. Emphasizing the importance of regular measurements, timely decompressive laparotomy is a definitive, but complex, treatment option. Balancing the urgency of surgical intervention against potential postoperative complications is challenging.

Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review

Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.

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.

Health-Related Social Needs in Patients With Gastroparesis: Relationships to Symptom Severity and Quality of Life

Background and Aims

Patients with health-related social needs (HRSNs) experience barriers to health care services. To identify areas of intervention, we need to understand the impact of HRSN in patients with gastroparesis. This study aimed to 1) determine types of HRSN present in patients with gastroparesis; 2) analyze relationship between HRSN and gastroparesis symptom severity and health-related quality of life (HRQL); and 3) evaluate which HRSN domains most significantly affect symptom severity and HRQL.

Methods

Patients with gastroparesis were enrolled and completed questionnaires to assess the following: 1) severity of gastroparetic symptoms using Gastroparesis Cardinal Symptom Index (GCSI); 2) HRSN using screening questionnaire; and 3) HRQL using the Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life (PAGI-QOL).

Results

Three hundred twenty-one patients with gastroparesis participated in this study. Two hundred twelve patients completed GCSI and HRSN questionnaires, and 109 additional patients completed PAGI-QOL questionnaire. Of the 321 total patients, the most common HRSN were mental health, financial strain, and food insecurity. Overall, 43% had at least one HRSN and 22% had at least 2 HRSN. The number of HRSN was directly correlated to the GCSI total symptom score (r = 0.284, P < .05) while inversely correlated to the PAGI-QOL score (r = -0.650, P < .05). Of the 7 HRSN domains studied, patients with mental health HRSN, in particular, reported more severe gastroparesis symptoms and lower quality of life.

Conclusion

A large number (43%) of patients with gastroparesis had at least 1 HRSN. Patients with HRSN reported more severe gastroparesis symptoms and lower quality of life than patients without HRSN.

Impact of outpatient gastroenterology consult on pharmacotherapy and management of gastrointestinal symptoms in Parkinson's Disease

Background & aims

Gastrointestinal (GI) symptoms are common in Parkinson's Disease (PD) patients, and GI dysmotility is thought to induce motor fluctuations, requiring escalation of levodopa therapy. The role of GI consultation in managing such symptoms, however, is unclear. In this study, we investigate the possible association between GI dysmotility symptoms and escalated LEDD therapy, as well as factors associated with GI consultation for PD symptom management.

Methods

This was a retrospective case-study of 248 PD patients evaluated by outpatient neurology at Massachusetts General Brigham Healthcare from 2018 to 2022. Logistic regression, t-test, and Fisher exact tests were performed to identify factors associated with GI consult, change in LEDD with consult, and association of consultation with GI diagnoses and treatments, respectively.

Results

Among 248 PD patients, 12.9% received GI consultation despite 96.8% having GI symptoms. Bloating was the primary symptom associated with receiving GI consultation (OR 3.59 [95% CI 1.47-8.88], p = 0.005). GI consultation increased the odds of receiving GI-specific medications (78.2% vs 46.3%, p = 0.001) and specialized GI diagnoses like gastroparesis (9.4% vs 0.46%, p < 0.001) and pelvic floor dysfunction (15.6% vs 0%, p < 0.0001). Interestingly, LEDD tended not to change after GI consultation, and dysmotility symptoms, including bloating, did not predict need for higher LEDD.

Conclusions

While treating symptoms of dysmotility may not ameliorate levodopa-based motor fluctuations as much as previously thought, GI consultations are underutilized in PD, and patients who receive GI consultation are more likely to have changes in GI diagnosis and treatment.

Imaging in Gastroparesis: Exploring Innovative Diagnostic Approaches, Symptoms, and Treatment

Gastroparesis (GP) is a chronic disease characterized by upper gastrointestinal symptoms, primarily nausea and vomiting, and delayed gastric emptying (GE), in the absence of mechanical GI obstruction. The underlying pathophysiology of GP remains unclear, but factors contributing to the condition include vagal nerve dysfunction, impaired gastric fundic accommodation, antral hypomotility, gastric dysrhythmias, and pyloric dysfunction. Currently, gastric emptying scintigraphy (GES) is considered the gold standard for GP diagnosis. However, the overall delay in GE weakly correlates with GP symptoms and their severity. Recent research efforts have focused on developing treatments that address the presumed underlying pathophysiological mechanisms of GP, such as pyloric hypertonicity, with Gastric Peroral Endoscopic Myotomy (G-POEM) one of these procedures. New promising diagnostic tools for gastroparesis include wireless motility capsule (WMC), the 13 carbon-GE breath test, high-resolution electrogastrography, and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Some of these tools assess alterations beyond GE, such as muscular electrical activity and pyloric tone. These modalities have the potential to characterize the pathophysiology of gastroparesis, identifying patients who may benefit from targeted therapies. The aim of this review is to provide an overview of the current knowledge on diagnostic pathways in GP, with a focus on the association between diagnosis, symptoms, and treatment.

Diabetic gastroparesis: clinical features, diagnosis and management

Diabetic gastroparesis carries a heavy burden on people with diabetes and the healthcare system. It remains underdiagnosed and represents challenges to treat. This article reviews the epidemiology, pathophysiology, clinical features, diagnosis and treatment of diabetic gastroparesis. The disorder is characterized by delayed gastric emptying without evidence of mechanical gastric outflow obstruction. It presents with upper gastrointestinal (GI) symptoms such as nausea, vomiting, early satiety, postprandial fullness, upper abdominal discomfort and or bloating. As the prevalence of diabetes has been growing over the last few decades, we would expect an increased incidence of delayed gastric emptying in poorly controlled diabetes and perhaps in line with the increasing use of medications that act on the GI tract such as incretin-based therapy. The disease results from multiple reversible and irreversible mechanisms. Diagnosing diabetic gastroparesis requires careful history, examination and investigations to exclude other disorders that could mimic its clinical presentation. Treatment involves a wide variety of options starting with optimization of glycaemic control, stopping any offending medications and lifestyle modifications followed by the introduction of medical therapeutics such as prokinetics. Then, surgical interventions are considered in refractory cases.

Buspirone for early satiety and symptoms of gastroparesis: A multi-centre, randomised, placebo-controlled, double-masked trial (BESST)

BACKGROUND

Patients with gastroparesis and related disorders have symptoms including early satiety, postprandial fullness and bloating. Buspirone, a 5-HT1 receptor agonist, may improve fundic accommodation.

AIM

To determine if buspirone treatment improves early satiety and postprandial fullness in patients with symptoms of gastroparesis.

METHODS

This 4-week multi-centre clinical trial randomised patients with symptoms of gastroparesis and moderate-to-severe symptoms of fullness (Gastroparesis Cardinal Symptom Index [GCSI] early satiety/postprandial fullness subscore [ES/PPF]) to buspirone (10 mg orally) or placebo three times per day. The primary outcome was a change in the ES/PPF from baseline to 4 weeks. The primary analysis was per protocol intention-to-treat ANCOVA of between-group baseline vs. 4-week differences (DoD) in ES/PPF adjusted for baseline ES/PPF. Results are reported using both nominal and Bonferroni (BF) p values.

RESULTS AND CONCLUSIONS

Ninety-six patients (47 buspirone, 49 placeboes; 92% female, 50% delayed gastric emptying, 39% diabetic) were enrolled. There was no between-groups difference in the 4-week ES/PPF primary outcome: -1.16 ± 1.25 (SD) on buspirone vs -1.03 ± 1.29 (SD) on placebo (mean DoD: -0.11 [95% CI: -0.68, 0.45]; p = 0.69). Buspirone performed better than placebo in patients with severe-to-very severe bloating at baseline compared to patients with none to moderate: (ES/PPF DoD = -0.65 vs. 1.58, pTX*GROUP  = 0.003; pBF  = 0.07). Among individual GCSI symptoms, only bloating appeared to improve with buspirone vs. placebo.

CONCLUSIONS

Patients with moderate-to-severe early satiety/postprandial fullness and other symptoms of gastroparesis did not benefit from buspirone treatment to improve the ES/PPF primary outcome compared with placebo. There was a suggestion of the benefit of buspirone in patients with more severe bloating.

TRIAL REGISTRATION

ClinicalTrials.gov NCT0358714285.

A Systematic Review of the Long-Term Clinical Success of Gastric Peroral Endoscopic Myotomy for Refractory Gastroparesis

Gastroparesis is a chronic and debilitating gastrointestinal disorder with few medical treatment options. Traditional surgical management has involved laparoscopic pyloromyotomy or gastric stimulation. In recent years, gastric peroral endoscopic myotomy (GPOEM) has become an attractive, less invasive option for patients with refractory gastroparesis. There is little information on the long-term clinical success of GPOEM in patients with refractory gastroparesis. This systematic review aims to evaluate the data on this procedure's long-term clinical efficacy and safety. A comprehensive literature review was done in PubMed, EMBASE, Ovid, and Google Scholar databases from the date of earliest entry in May 2017 up to August 15, 2022. The Gastroparesis Cardinal Symptom Index (GCSI) score, adverse reaction, and length of stay were analyzed. Eleven studies were eligible for inclusion (900 patients), seven of the studies were retrospective, while four were prospective. The GCSI is a 6-point Likert scale questionnaire that assesses improvement in gastroparesis. An average decrease of GCSI by 1 point compared to baseline GCSI for all patients (described as clinical success) was found in 662 patients out of 713 (92.8%) at one-year follow-up, 421 out of 460 (91.5%) at two-year follow-up, 270 out of 270 (100%) at three-year follow-up, and 102 out of 102 (100%) at four-year follow-up. Adverse events occurred in 62 out of 835 patients (in nine studies), with two of the most frequent being bleeding and mucosal tears. GPOEM is an effective and safe treatment option for patients with refractory gastroparesis, with symptom improvement noted up to four years postoperatively.

Gastroparesis: The Complex Interplay with Microbiota and the Role of Exogenous Infections in the Pathogenesis of the Disease

Gastroparesis (GP) is a disorder of gastric functions that is defined by objective delayed gastric emptying in the absence of mechanical obstruction. This disease is characterized by symptoms such as nausea, post-prandial fullness, and early satiety. GP significantly impacts patients' quality of life and contributes to substantial healthcare expenses for families and society. However, the epidemiological burden of GP is difficult to evaluate, mainly due its significant overlap with functional dyspepsia (FD). GP and FD represent two similar diseases. The pathophysiology of both disorders involves abnormal gastric motility, visceral hypersensitivity, and mucosal inflammation. Moreover, both conditions share similar symptoms, such as epigastric pain, bloating, and early satiety. The latest evidence reveals that dysbiosis is directly or indirectly connected to gut-brain axis alterations, which are the basis of pathogenesis in both FD and GP. Furthermore, the role of microbiota in the development of gastroparesis was demonstrated by some clinical studies, which found that the use of probiotics is correlated with improvements in the gastric emptying time (GET). Infections (with viruses, bacteria, and protozoa) represent a proven etiology for GP but have not been sufficiently considered in current clinical practice. Previous viral infections can be found in about 20% of idiopathic GP cases. Moreover, delayed gastric emptying during systemic protozoal infections represents a huge concern for compromised patients, and few data exist on the topic. This comprehensive narrative review analyzes the relationship between microorganisms and GP. We explore, on the one hand, the correlation between gut microbiota dysbiosis and GP pathogenesis, including treatment implications, and, on the other hand, the association between exogenous infections and the etiology of the disease.

A randomized, double-blind, placebo-controlled, phase 2b study of the efficacy and safety of velusetrag in subjects with diabetic or idiopathic gastroparesis

BACKGROUND

This study assessed the efficacy and safety of velusetrag-a 5-HT₄ agonist with pan-gastrointestinal prokinetic activity-for gastroparesis symptom management and gastric emptying (GE).

METHODS

In this multicenter, double-blind, randomized, placebo-controlled study, subjects with diabetic or idiopathic gastroparesis received velusetrag 5, 15, or 30 mg or placebo for 12 weeks. The primary efficacy outcome was a 7-day mean Gastroparesis Cardinal Symptom Index 24-h composite score (GCSI-24H) change from baseline at week 4; GE was evaluated using scintigraphy (GES) and breath tests, and safety from adverse events (AEs).

KEY RESULTS

232 subjects (183 females; 113 idiopathic gastroparesis) received treatment from February 2015 through June 2017. Least-squares mean improvement from baseline GCSI-24H (primary endpoint) at week 4 was -1.5 following velusetrag 5 mg vs -1.1 following placebo (treatment difference, -0.4; 95% confidence interval, -0.75 to -0.03; nominal p = 0.0327; Hochberg-adjusted p = 0.0980 [not significant]). Symptom improvement from baseline was achieved only with velusetrag 5 mg, which resulted in greater improvement from baseline vs placebo in all gastroparesis core symptoms, especially in subjects with idiopathic gastroparesis. Improvement from baseline GE by GES was greater in subjects receiving velusetrag (all doses) vs placebo; >70% of subjects receiving velusetrag 30 mg had GE normalization at 4 h. Treatment-emergent AEs were generally mild.

CONCLUSIONS AND INFERENCES

Velusetrag treatment was generally well-tolerated and associated with improved GE vs placebo in subjects with diabetic or idiopathic gastroparesis; however, only the lowest dose, velusetrag 5 mg, was associated with short-term improvement in gastroparesis symptoms.

CLINICALTRIALS

GOV: NCT02267525.

Semaglutide delays 4-hour gastric emptying in women with polycystic ovary syndrome and obesity

AIM

To evaluate the effect of once-weekly subcutaneous semaglutide 1.0 mg on the late digestive period of gastric emptying (GE) after ingestion of a standardized solid test meal by using technetium scintigraphy, the reference method for this purpose.

METHODS

We conducted a single-blind, placebo-controlled trial in 20 obese women with polycystic ovary syndrome (PCOS; mean [range] age 35 [32.3-40.8] years, body mass index 37 [30.7-39.8] kg/m² ) randomized to subcutaneous semaglutide 1.0 mg once weekly or placebo for 12 weeks. GE was assessed after ingestion of [^99mT c] colloid in a pancake labelled with radiopharmaceutical by scintigraphy using sequential static imaging and dynamic acquisition at baseline and at Week 13. Estimation of GE was obtained by repeated imaging of remaining [^99mT c] activity at fixed time intervals over the course of 4 hours after ingestion.

RESULTS

From baseline to the study end, semaglutide increased the estimated retention of gastric contents by 3.5% at 1 hour, 25.5% at 2 hours, 38.0% at 3 hours and 30.0% at 4 hours after ingestion of the radioactively labelled solid meal. Four hours after ingestion, semaglutide retained 37% of solid meal in the stomach compared to no gastric retention in the placebo group (P = 0.002). Time taken for half the radiolabelled meal to empty from the stomach was significantly longer in the semaglutide group than the placebo group (171 vs. 118 min; P < 0.001).

CONCLUSION

Semaglutide markedly delayed 4-hour GE in women with PCOS and obesity.

2023 update on the clinical management of gastroparesis

INTRODUCTION

Gastroparesis is characterized by symptoms suggesting gastric retention of food and objective evidence of delayed gastric emptying in the absence of a mechanical obstruction. Nausea, vomiting, early satiety, and postprandial fullness are the classic symptoms of gastroparesis. Gastroparesis is increasingly encountered by physicians. There are several recognized etiologies of gastroparesis, including diabetic, post-surgical, medication-induced, post-viral, and idiopathic.

AREAS COVERED

A comprehensive literature review was conducted to identify studies discussing gastroparesis management. Dietary modifications, medication adjustments, glucose control, antiemetic agents, and prokinetic agents are all part of gastroparesis management. In this manuscript, we detail treatments evolving for gastroparesis, including nutritional, pharmaceutical, device, and recent advanced endoscopic and surgical therapies. This manuscript concludes with a speculative viewpoint on how the field will evolve in 5 years' time.

EXPERT OPINION

Identification of the dominant symptoms (fullness, nausea, abdominal pain, and heartburn) helps to direct management efforts of the patients. Treatments for refractory (treatment resistant) symptoms may include gastric electric stimulation and intra-pyloric interventions like botulinum toxin and endoscopic pyloromyotomy. Understanding the pathophysiology of gastroparesis, relating pathophysiologic abnormalities to specific symptoms, new efficacious pharmacotherapies, and better understanding of the clinical predictors of response of therapies, are priorities for future research in the field of gastroparesis.

Pulmonary vein isolation-induced vagal nerve injury and gastric motility disorders detected by electrogastrography: The side effects of pulmonary vein isolation in atrial fibrillation (SEPIA) study

INTRODUCTION

Safety of pulmonary vein isolation (PVI) has been established in clinical studies. However, despite prevention efforts the incidence of damage to (peri)-esophageal tissue has not decreased, and the pathophysiology is incompletely understood. Damage to vagal nerve branches may be involved in lesion progression to atrio-esophageal fistula. Using electrogastrography, we assessed the incidence of periesophageal vagal nerve injury (VNI) following atrial fibrillation ablation and its association with procedural parameters and endoscopic results.

METHODS

Patients were studied using electrogastrography, endoscopy, and endoscopic ultrasound before and after cryoballoon (CB) or radiofrequency (RF) PVI. The incidence of ablation-induced neuropathic pattern (indicating VNI) in pre- and postprocedural electrogastrography was assessed and correlated with endoscopic results and ablation data.

RESULTS

Between February 2021 und January 2022, 85 patients (67 ± 10 years, 53% male) were included, 33 were treated with CB and 52 with RF (38 with moderate power moderate duration [25-30 W] and 14 with high power short duration [50 W]). Ablation-induced VNI was detected in 27/85 patients independent of the energy form. Patients with VNI more frequently had postprocedural endoscopically detected pathology (8% mucosal esophageal lesions, 36% periesophageal edema, 33% food retention) but there was incomplete overlap. Pre-existing esophagitis increased the likelihood of VNI. Ablation data and esophageal temperature data did not predict VNI.

CONCLUSION

PVI-induced VNI is quite common and independent of ablation energy source. VNI is part of (peri)-esophageal damage and only partially overlaps with endoscopic findings. VNI-associated acidic reflux may be involved in the complex pathophysiology of esophageal lesion progression to fistula.

Risk of Adverse Events Associated with Domperidone and Metoclopramide in Gastroparesis: Systematic Review and Meta-analysis

BACKGROUND

Dopamine antagonists are the main pharmacological options to treat gastroparesis. The aim of this study was to conduct a systematic literature review (SLR) to evaluate the profile of adverse events (AEs) of dopamine antagonists used in the treatment of children and adults with gastroparesis.

METHODS

We searched EMBASE and MEDLINE up to March 25, 2021, for relevant clinical trials and observational studies. We conducted a proportional meta-analysis to estimate the pooled occurrence of AEs (%), with 95% confidence interval (CI), from arm-level data across studies and the comparative occurrence of AEs from placebo-controlled clinical trials (odds ratio [OR] with 95% CI).

RESULTS

We identified 28 studies assessing AEs experienced by patients treated for gastroparesis with domperidone and metoclopramide; 22 studies contributed data to the meta-analyses. Cardiovascular, neurological, and endocrine AEs were commonly observed, with point incidences varying from 1 to > 50%. Clinically important AEs, such as QTc prolongation, occurred in 5% of patients treated with domperidone (95% CI: 3.32-8.62). Restlessness, an extrapyramidal AE, occurred in 15% of patients (95% CI: 7.48-26.61) treated with metoclopramide, with a 7-fold increase compared with patients receiving placebo (OR: 7.72; 95% CI: 1.27-47.05). Variation in terminology to describe extrapyramidal events precluded further pooled analyses. Additional meta-analyses were not feasible due to discrepancies in the assessment and reporting of the AEs.

CONCLUSIONS

The evidence confirms concerns of cardiovascular, extrapyramidal, and endocrine AEs in patients with gastroparesis treated with domperidone and metoclopramide. Imprecise AE reporting limits firm interpretation and conclusions.

REGISTRATION

PROSPERO international prospective register of systematic reviews (registration number: CRD42021248888).

Hair Loss in Patients with Gastroparesis: A Sign of Nutritional Deficiency in Gastroparesis?

INTRODUCTION

Some patients with gastroparesis (Gp) report hair loss. The aim of this study was to investigate the prevalence of patient-reported hair loss in Gp patients, analyze hair loss association to severity of Gp and nutritional deficiencies, and study effects of multivitamin treatment on hair loss.

METHODS

Patients with Gp were questioned about hair characteristics, Gp symptoms, and diet. Patients with hair loss had blood drawn for vitamin levels. Patients with hair loss were treated with daily multivitamin and assessed 8 weeks later.

RESULTS

Hair loss was reported in 65 of 143 patients with Gp (45.5%), occurring similarly in idiopathic and diabetic Gp. Hair loss was most commonly noticed while washing and/or combing hair. Patients with hair loss had more severe nausea, abdominal pain, stomach fullness, loss of appetite, abdominal discomfort, bloating, retching, stomach distension, vomiting, early satiety, postprandial fullness, and constipation. Hair loss patients lost more weight over prior 6 months. Patients with hair loss had similar gastric retention on gastric emptying scintigraphy. Overall, 29 of 61 (47.5%) patients with hair loss had at least one abnormal bloodwork result. After 8 weeks of treatment with a daily multivitamin, 17 of 41 (41%) patients had improvement in hair loss.

CONCLUSION

Hair loss occurred in 46% of patients with Gp, being associated with more severe symptoms, loss of weight, and several vitamin deficiencies, although not a specific one. Treatment with multivitamins improved hair loss in 40% of patients. Presence of hair loss in patients with Gp should prompt nutritional evaluation and supplementation.

Gastrointestinal Tract Considerations Part I

The upper gastrointestinal (GI) tract is frequently involved in systemic sclerosis (SSc) and may impact quality of life, physical function and survival. Although we are currently very proactive in terms of screening for heart and lung involvement, patients with SSc are not routinely screened for GI involvement. This review details the available investigations for common upper GI symptoms in SSc, including dysphagia, reflux and bloating and provides advice as to how to integrate these investigations into current clinical care.

Role of Endoscopy in Motility Disorders of Upper Gastrointestinal Tract

Gastrointestinal motility disorders have a wide range of symptoms and affect patients' quality of life. With the advancement of endoscopy, the diagnostic and therapeutic roles of endoscopy in motility disorders is becoming more significant. Endoscopy is necessary to rule out possible organic diseases in patients with suspected motility disorders and provide significant clues for their diagnosis. Moreover, interventional endoscopy may be a primary or alternative treatment option for selected patients with motility disorders, and it is becoming a promising field as new therapeutic applications are developed and utilized for various motility disorders. This review may provide suitable indications for the use of endoscopy in diagnosing and treating motility disorders of the upper gastrointestinal tract.

The Role of Pediatric Gastroenterologists in the Evaluation of Complex Aerodigestive Disorders

PURPOSE OF REVIEW

Children with aerodigestive disorders frequently have concerns regarding difficulty breathing, swallowing, and growing. In this review, we explored the role of pediatric gastroenterologists in the evaluation of complex aerodigestive disorders and the overall approach to these often-challenging patients.

RECENT FINDINGS

Pediatric gastroenterologists evaluate children with aerodigestive concerns ranging from dysphagia and gastroesophageal reflux to complex congenital abnormalities such as esophageal atresia. Diagnostic tools, such as multichannel intraluminal impedance-pH monitoring, are used for diagnosing gastroesophageal reflux and assessing the correlation with symptoms. Endoscopic evaluation, and in some complex cases, with therapeutic dilations may also be performed. Gastrointestinal dysmotility evaluation with manometry studies are also being increasingly utilized. Multidisciplinary aerodigestive programs can provide a coordinated approach to children with complex airway, pulmonary and gastrointestinal tract disorders. A pediatric gastroenterologist's expertise and specialized skills not only offer many diagnostic tools for these complicated medical cases but are also important in long term medical management.

Evidence for the Involvement of Cytokines Modulation and Prokinetic Properties in Gastric Ulcer Healing Effects of Helicteres sacarolha A. St.-Hil. A. Juss

Preparations of Helicteres sacarolha (Malvaceae) leaves and roots are used in the form of decoction, infusion or maceration, to treat gastrointestinal disturbances, among others. Studies supporting some of its ethnomedicinal uses are still incipient. The present study aimed to investigate it potential effect on chronic ulcer, ulcerative colitis and possible prokinetic activities as part of its mechanism of action. The powdered leaves of Helicteres sacarolha (HEHs) was prepared by maceration in 70 % hydroethanolic solution. Its qualitative phytochemical constituents were investigated by direct flow injection analysis coupled to atmospheric pressure chemical ionization ion trap tandem mass spectrometry (FIA-APCI-IT-MSⁿ ). The gastric ulcer healing effect was evaluated in acetic acid induced chronic ulcer in mice and the lesions were evaluated, including analysis of blood plasma cytokine levels. The prokinetic properties (gastric emptying and intestinal transit) were carried out in mice. Potential anti-ulcerative colitis activity was evaluated in rats using 2,4,6-trinitrobenzenesulfonic acid (5 % TNBS) -induced colitis. All animal experiments were carried out at the doses of 20, 50 and 250 mg/kg (p.o.). Eight compounds were putatively identified, specifically lariciresinol, and its derivatives, kaempferol derivatives and Tricin-O-Glc. The extract promoted increased gastric ulcer healing at all doses tested. Modulation of the cytokines involved inhibition of some key pro-inflammatory cytokines with maximum effect on IL-1β (70 %, 50 mg/kg, p<0.05), TNF-α (79 %, 20 mg/kg, p<0.01), and in the anti-inflammatory cytokines, namely IL-10 (57 %, 50 mg/kg, p<0.05) and IL-17 (79 %, only at 50 mg/kg, p<0.05). Histological findings demonstrated a mitigated inflammatory activity, and tissues undergoing regeneration. HEHs treatment caused delayed gastric emptying, and increased intestinal transit, but had no effect in the experimentally induced ulcerative colitis. We report for the first time putatively the presence of Lariciresinol and tricin derivatives from the hydroethanolic leaves extract of H. sacarolha. Its possible mechanism of actions of gastric ulcer healing involves cytokines modulation, mitigation of inflammatory response and tissue regeneration and provoked opposing effect in the gastrointestinal system. The present study demonstrates the therapeutic potential of H. sacarolha leaves used in Brazilian ethnomedicine in the treatment of chronic gastric ulcer.

A New Paradigm Shift in Gastroparesis Management

Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα+ cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.

Novel insights into the pathogenic impact of diabetes on the gastrointestinal tract

Type 2 and type 1 diabetes are common endocrine disorders with a progressively increasing incidence worldwide. These chronic, systemic diseases have multiorgan implications, and the whole gastrointestinal (GI) tract represents a frequent target in terms of symptom appearance and interdependent pathophysiological mechanisms. Metabolic alterations linked with diabetic complications, neuropathy and disrupted hormone homeostasis can lead to upper and/or lower GI symptoms in up to 75% of diabetic patients, with multifactorial involvement of the oesophagus, stomach, upper and lower intestine, and of the gallbladder. On the other hand, altered gastrointestinal motility and/or secretions are able to affect glucose and lipid homeostasis in the short and long term. Finally, diabetes has been linked with increased cancer risk at different levels of the GI tract. The presence of GI symptoms and a comprehensive assessment of GI function should be carefully considered in the management of diabetic patients to avoid further complications and to ameliorate the quality of life. Additionally, the presence of gastrointestinal dysfunction should be adequately managed to improve metabolic homeostasis, the efficacy of antidiabetic treatments and secondary prevention strategies.

Imaging Review of Gastrointestinal Motility Disorders

The motor function of the gastrointestinal tract relies on the enteric nervous system, which includes neurons spanning from the esophagus to the internal anal sphincter. Disorders of gastrointestinal motility arise as a result of disease within the affected portion of the enteric nervous system and may be caused by a wide array of underlying diseases. The etiology of motility disorders may be primary or due to secondary causes related to infection or inflammation, congenital abnormalities, metabolic disturbances, systemic illness, or medication-related side effects. The symptoms of gastrointestinal dysmotility tend to be nonspecific and may cause diagnostic difficulty. Therefore, evaluation of motility disorders requires a combination of clinical, radiologic, and endoscopic or manometric testing. Radiologic studies including fluoroscopy, CT, MRI, and nuclear scintigraphy allow exclusion of alternative pathologic conditions and serve as adjuncts to endoscopy and manometry to determine the appropriate diagnosis. Additionally, radiologist understanding of clinical evaluation of motility disorders is necessary for guiding referring clinicians and appropriately imaging patients. New developments and advances in imaging techniques have allowed improved assessment and diagnosis of motility disorders, which will continue to improve patient treatment options. Online supplemental material is available for this article. ^©RSNA, 2022.

Diagnostic Modalities Used in Diagnosing Gastroparesis: A Clinical Review

Gastroparesis is associated with abnormal gastric motility characterized by delayed gastric emptying without any obvious mechanical gastric outlet obstruction or blockage. Gastroparesis is associated with significant morbidity and mortality. It is pertinent to make a timely diagnosis of gastroparesis so that prompt treatment can be initiated. The purpose of this clinical review article is to help the internist and the primary care providers to get a better idea of various diagnostic modalities used in diagnosing gastroparesis. We have also discussed the advantages and disadvantages of various diagnostic modalities based on the latest evidence.

Gastroparesis in pregnancy

Gastroparesis is a functional gastrointestinal disorder that more commonly affects women, with most cases being diagnosed during childbearing age. However, there is a paucity of data and guidelines to specifically highlight the epidemiology, disease course, maternal and fetal impact, and the management of existing gastroparesis during pregnancy. Apart from metoclopramide, there is no approved therapy specifically indicated for gastroparesis. More importantly, pregnant and breastfeeding women are excluded from clinical trials evaluating pharmacologic agents in the management of gastroparesis. This poses a real challenge to healthcare providers in counseling and managing patients with gastroparesis. In this systematic review, we summarize the current available literature and the knowledge gaps in the impact of pregnancy on gastroparesis and vice versa. We also highlight the efficacy and safety profiles of available pharmacologic and nonpharmacologic therapies in the management of patients with gastroparesis, with emphasis on judicious use of dietary approaches that are deemed relatively safe during pregnancy.