Gastroparesis

Therapeutic strategies in gastroparesis: Results of stepwise approach with diet and prokinetics, Gastric Rest, and PEG-J: A retrospective analysis

BACKGROUND

Gastroparesis is characterized by abnormal gastric motor function with delayed gastric emptying in the absence of mechanical obstruction. In our tertiary referral center, patients are treated with a stepwise approach, starting with dietary advice and prokinetics, followed by three months of nasoduodenal tube feeding with "gastric rest." When not successful, a percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) for long-term enteral feeding is placed.

AIM

To evaluate the effect of this stepwise approach on weight and symptoms.

METHODS

Analyses of data of all referred gastroparesis patients between 2008 and 2016.

KEY RESULTS

A total of 86 patients (71% female, 20-87 years [mean 55.8 years]) were analyzed of whom 50 (58%) had adequate symptom responses to diet and prokinetics. The remaining 36 (decompensated gastroparesis) were treated with three months gastric rest. Symptom response rate was 47% (17/36). Significant weight gain was seen in all patients, independent of symptom response. In the remaining 19 symptom non-responders, the enteral feeding was continued through PEG-J. Treatment was effective (symptoms) in 37%, with significant weight gain in all. In 84% of patients, the PEG-J is still in use (mean duration 962 days).

CONCLUSIONS AND INFERENCES

Following a stepwise treatment approach in gastroparesis, adequate symptom response was reached in 86% of all patients. Weight gain was achieved in all patients, independent of symptom response. Diet and prokinetics were effective with regard to symptoms in 58%, temporary gastric rest in 47%, and PEG-J as third step in 37% of patients.

MALAT1 as a Diagnostic and Therapeutic Target in Diabetes-Related Complications: A Promising Long-Noncoding RNA

Diabetes mellitus is a global issue with increasing incidence rate worldwide. In an uncontrolled case, it can advance to various organ-related complications leading to an increase in morbidity and mortality. Long non-coding RNA (lncRNA) Metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) appears to be a fairly novel lncRNA that is relevant to diabetes and its role in diabetic-related diseases initiation and progression have long been a subject of attention to many scholars. The expression of MALAT1 is elevated in different diabetic-related diseases. In this review, we demonstrate the various functions of MALAT1 in the different diabetes-related complications including ischemic reperfusion injury, retinopathy, cataract, atherosclerosis, cardiomyopathy, non-alcoholic steatohepatitis, gastroparesis, kidney disease, and gestational diabetes. The emerging evidence showed that the role of MALAT1 in diabetic-related complications is both pro-inflammatory and apoptosis in different cell types. These results concluded that MALAT1 is a potential diagnostic and future targeted therapy for diabetes-associated complications.

Endoscopic Botulinum Toxin for Gastroparesis: Results of a Retrospective Series

Beneficial effects of pyloric botulinum toxin injection have been described in a subgroup of gastroparesis patients. Our aim is to evaluate whether clinical, manometric and/or scintigraphic parameters are able to predict treatment outcome. Forty patients (67% female, age 49 (36–56) years) with decompensated gastroparesis treated with botulinum toxin were included in this retrospective analysis. Objective parameters were high-resolution antroduodenal manometry, gastric emptying rate (scintigraphy), and weight change. Subjective treatment outcome was assessed with a Global Physician Assessment Scale. Binary logistic regression analysis was performed to identify predictors for treatment outcome. Fourteen patients (35%) were symptom-responders, and 65% of patients were short-term weight-responders. For both subjective and objective treatment outcome, no differences were found in manometric and scintigraphic variables between responders and non-responders. Neither clinical nor manometric or scintigraphic variables could predict subjective and objective treatment outcome. In conclusion, symptom improvement is achieved in a subgroup of gastroparesis patients treated with endoscopic pyloric botulinum toxin. Although the majority of patients were able to maintain their baseline weight at short-term follow-up, a substantial group of patients needed nutritional interventions on long-term follow-up. However, none of the demographic, clinical, scintigraphic, or antroduodenal manometry variables were able to predict either subjective or objective treatment outcome.

Effects of acupuncture at different acupoints on c-fos and glial fibrillary acidic protein expression in the medulla oblongata of rats with diabetic gastroparesis

AIM: To observe the effects of acupuncture at different acupoints on the expression of c-fos and glial fibrillary acidic protein (GFAP) in the medulla oblongata of rats with diabetic gastroparesis (DGP), and to discuss whether the ministry of acupoints is the factor influencing the effect of acupoints compatibility.

METHODS: Sixty SD rats were randomly divided into a normal group, a model group, a Zusanli + Zhongwan group, a Zusanli + Neiguan group, and a Zusanli + non acupoint group, with 12 rats in each group. DGP was induced by intraperitoneal injection of streptozotocin (STZ) (60 mg/kg, 2%) and treated for 4 wk continuously. After treatment, small intestinal transit rate was measured with black ink, and the expression of c-fos and GFAP in the medulla oblongata was detected by immunohistochemistry.

RESULTS: In comparison with the normal control group, small intestinal transit rate of the model group was significantly decreased, and the gray values of c-fos and GFAP were decreased (P < 0.05). In comparison with the model group, small intestinal transit rates of the Zusanli + Zhongwan group, Zusanli + Neiguan group, and Zusanli + non acupoint group were significantly increased, and the gray values of c-fos and GFAP were significantly increased (P < 0.05). In comparison with the Zusanli + Zhongwan group, the gray values of c-fos and GFAP in the Zusanli + Neiguan group and Zusanli + non acupoint group were significantly decreased (P < 0.05).

CONCLUSION: Acupuncture can improve the symptoms of delayed gastric emptying in DGP rats, and regulate the expression of c-fos and GFAP in the medulla. The compatibility of local acupoints is significantly better than the compatibility of distal acupoints and nonpoints. Acupoint selection is the key factor affecting acupoint compatibility.

Enteral Nutrition for Adults in the Hospital Setting

In patients unable to tolerate oral intake, multiple options of nutrient delivery are available to the clinician. Administration of enteral nutrition (EN) has long been considered the standard of care for nutrition support among patients unable to meet energy and protein requirements orally. Healthcare practitioners must make careful decisions related to ordering, administering, and monitoring EN therapy. In the hospital setting, the registered dietitian is a key resource in enteral formula selection and method of administration, monitoring for and troubleshooting EN-related complications, and transitioning to oral feeding. The hospital setting also presents many unique challenges in providing optimal nutrition to the enterally fed patient.

Acupressure improves the postoperative comfort of gastric cancer patients: A randomised controlled trial

OBJECTIVE

This pilot study evaluated whether acupressure affected the postoperative comfort of gastric cancer patients following a subtotal gastrectomy.

METHODS

A randomised controlled trial was conducted. Sixty patients were recruited from 141-bed general surgery ward at a 3000-bed medical centre in Northern Taiwan. Participants were randomly assigned to either a control group receiving regular postoperative care or to the experimental group receiving additional acupressure at acupoints of Neiquan (P6) and Zusanli (ST36) for 3 consecutive days.

RESULTS

The similarities between two groups were in postoperative pain and the onset of postoperative nausea and vomiting (PONV) at the baseline. Following acupressure, significant differences were found in postoperative pain (P=.03) and time of first flatus (P=.04); but not PONV (P=.49), nor the time of first defecation (P=.34).

CONCLUSIONS

Acupressure is a simple, noninvasive, safe, and economical procedure for improving the comfort of patients who undergo surgery for gastric cancer. Acupressure at the P6 and ST36 acupoints can improve postoperative comfort by alleviating pain and decreasing the time until first flatus. However, additional research is necessary to elucidate how acupressure can improve postoperative outcomes.

Ghrelin microinjected into the hypothalamic arcuatus nucleus regulates gastric motility in a diabetic rat model

AIM: To study the effect of Ghrelin microinjected into the hypothalamic arcuatus nucleus (ARC) on gastric motility in rats with diabetic gastroparesis (DGP).

METHODS: Two hundred and forty Wistar rats were randomly divided into 10 groups: control group (C), saline group (NS), low-dose Ghrelin group (L), high-dose Ghrelin group (H), high-dose Ghrelin plus D-Lys6-GHRP-6 (DLS) group (H+D), DGP group (DGP), saline-treated DGP group (DGP+NS), low-dose Ghrelin-treated DGP group (DGP+L), high-dose Ghrelin-treated DGP group (DGP+H), high-dose Ghrelin plus D-Lys6-GHRP-6 (DLS)-treated DGP group (DGP+H+D). A rat diabetic model was established by intraperitoneal injection of streptozotocin (STZ). Fluorescent immunohistochemistry, reverse transcription-polymerase chain reaction (RT-PCR) and real-time quantitative polymerase chain reaction (real-time PCR) were performed to evaluate the protein and mRNA expression of Ghrelin receptor (GHS-R) in the ARC of rats. The effect of Ghrelin injection into ARC on gastric motility was observed.

RESULTS: The number of GHS-R immunoreactive neurons and the relative level of GHS-R mRNA/β-actin in the ARC of normal rats were 10.0/mm² ± 2.1/mm² and 0.48 ± 0.13, while in DGP rats the values decreased to 3.0/mm² ± 0.7/mm² and 0.21 ± 0.10 (both P < 0.05). Microinjection of 0.05 or 0.5 nmol Ghrelin into the ARC could increase the amplitude of gastric motility in a dose-dependent manner (L: 14.6 g ± 2.2 g vs NS: 8.14 g ± 1.58 g, P < 0.05; H: 22.28 g ± 4.10 g vs NS: 8.14 g ± 1.58 g, P < 0.01; NS: 8.14 g ± 1.58 g vs L: 14.6 g ± 2.2 g, P < 0.05), and the frequency of gastric motility was also increased significantly (L: 7.45/min ± 0.87/min vs NS: 5.18/min ± 0.61/min, P < 0.05; H: 10.98/min ± 1.03/min vs NS: 5.18/min ± 0.61/min, P < 0.01; H: 10.98/min ± 1.03/min vs L: 7.45/min ± 0.87/min, P < 0.05). In DGP rats, gastric motility decreased with an enhanced amplitude (2.21 g ± 0.89 g vs 8.14 g ± 1.58 g, P < 0.05) and an increased frequency (1.81/min ± 0.2/min vs 5.18/min ± 0.61/min, P < 0.05). The administration of 0.5 mmol Ghrelin into the ARC could increase gastric motility in DGP rats (amplitude: DGP + H: 5.04 g ± 1.11 g vs DGP + NS: 2.14 g ± 0.23 g or DGP + L: 3.58 g ± 1.11 g, P < 0.05; frequency: DGP + H: 3.81/min ± 0.43/min vs DGP + NS: 1.8/min ± 0.19/min or DGP + L: 2.3/min ± 0.29/min, P < 0.05). The GHS-R antagonist, D-Lys3-GHRP-6, could totally block the effects of Ghrelin.

CONCLUSION: Gastric motility disorder in diabetic rats is partly caused by decreased expression of GHS-R in the hypothalamus. Ghrelin could regulate the genesis of DGP through the GHS-R in the ARC.

Spectrum of gastroparesis in children

BACKGROUND

Gastroparesis (GP) is characterized by delayed gastric emptying in the absence of mechanical outlet obstruction. Symptoms may include nausea, vomiting, bloating, early satiety, abdominal pain, and weight loss. Delayed gastric emptying of a solid-phase meal assessed by radionuclear scintigraphy is the criterion standard for diagnosis. The prevalence of GP is difficult to estimate due to the lack of a validated, widely available diagnostic test that can be applied in primary care. The extent of this problem in children is unknown.

METHODS

We studied a cohort of children with GP diagnosed by radionuclear scintigraphy to identify demographics, symptoms, comorbidities, treatment, and outcomes. A retrospective analysis of 239 patients between ages 0 and 21 years was performed.

RESULTS

The mean age of presentation was 7.9 years, and boys and girls were almost equally affected, that is, 48.5% and 51.5%, respectively. Vomiting was the most frequent presenting symptom (68%), followed by abdominal pain (51%), nausea (28%), weight loss (27%), early satiety (25%), and bloating (7%). Almost 75% of patients responded to intravenous erythromycin administered provocatively during gastric scintigraphy. In a majority of the patients, no cause was identified, that is, idiopathic GP (70%), followed by drugs (18%) and postsurgical (12.5%) causes. Only 4% patients had diabetic GP, and our population was essentially narcotic naïve (2%). After an average of 24 months' follow-up, the most common complication was esophageal reflux (67%). Despite different therapeutic modalities, by the end of the follow-up period, a significant improvement in symptoms was reported by an average of 60%, regardless of sex, age, or degree of emptying delay.

CONCLUSIONS

GP has a good prognosis in childhood despite different etiologies, symptom presentation, and therapy.

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.

Diabetes mellitus and gastric emptying: questions and issues in clinical practice

It is long known that both type 1 and type 2 diabetes can be associated with changes in gastric emptying; a number of publications have linked diabetes to delayed gastric emptying of variable severity and often with poor relationship to gastrointestinal symptomatology. In contrast, more recent studies have reported accelerated gastric emptying when adjusted for glucose concentration in patients with diabetes, indicating a reciprocal relationship between gastric emptying and ambient glucose concentrations. This review proposes that gastroparesis or gastroparesis diabeticorum, a severe condition characterized by a significant impairment of gastric emptying accompanied by severe nausea, vomiting, and malnutrition, is often overdiagnosed and not well contrasted with delays in gastric emptying. The article offers a clinically relevant definition of gastroparesis that should help differentiate this rare condition from (often asymptomatic) delays in gastric emptying. The fact that delayed gastric emptying can also be observed in non-diabetic individuals under experimental conditions in which hyperglycaemia is artificially induced suggests that a delay in gastric emptying rate when blood glucose concentrations are high is actually an appropriate physiological response to hyperglycaemia, slowing further increases in blood glucose. The article discusses the strengths and weaknesses of various methodologies for assessing gastric emptying, especially with respect to the diabetes population, and reviews newer diabetes therapies that decelerate the rate of gastric emptying. These therapies may be a beneficial tool in managing postprandial hyperglycaemia because they attenuate rapid surges in glucose concentrations by slowing the delivery of meal-derived glucose.

Intestinal electrical stimulation decreases postprandial blood glucose levels in rats

BACKGROUND

Reducing postprandial blood glucose concentrations in diabetic patients might contribute to optimal glycemic control. Gastrointestinal electrical stimulation has been proposed as a novel therapy for both gastrointestinal motility disorders and obesity. The present study investigated the effects and underlying mechanisms of intestinal electrical stimulation (IES) on postprandial blood glucose levels in rats.

METHODS

Electrical stimulation electrodes were implanted into the duodenal wall of 33 male Sprague-Dawley rats. The blood glucose and insulin levels were measured before and after a glucose tolerance test both with and without electrical stimulation. In addition, the gastric emptying and intestinal flow rates were measured.

RESULTS

IES applied immediately after the glucose tolerance test caused a significant decrease in the rising phase slope and the maximal serum blood glucose level. Additionally, the area under the curve of the blood glucose levels was reduced by approximately 50%. Insulin secretion decreased by 21%. The main reduction in insulin secretion was during the first 30 minutes after the glucose tolerance test. IES also caused a nearly 80% decrease of the gastric emptying rate and a 40% increase in the flow rate of nutrients inside the intestine. The effect was immediate after IES activation and reversible.

CONCLUSION

These results suggest that IES applied to the duodenum can reduce postprandial blood glucose levels. The possible etiology is the modulating of gastric emptying and intestinal flow rate.

Gastroparesis: Current diagnostic challenges and management considerations

Gastroparesis refers to abnormal gastric motility characterized by delayed gastric emptying in the absence of mechanical obstruction. The most common etiologies include diabetes, post-surgical and idiopathic. The most common symptoms are nausea, vomiting and epigastric pain. Gastroparesis is estimated to affect 4% of the population and symptomatology may range from little effect on daily activity to severe disability and frequent hospitalizations. The gold standard of diagnosis is solid meal gastric scintigraphy. Treatment is multimodal and includes dietary modification, prokinetic and anti-emetic medications, and surgical interventions. New advances in drug therapy, and gastric electrical stimulation techniques have been introduced and might provide new hope to patients with refractory gastroparesis. In this comprehensive review, we discuss gastroparesis with emphasis on the latest developments; from the perspective of the practicing clinician.

Vagotomy upregulates expression of the N-methyl-D-aspartate receptor NR2D subunit in the stomach

BACKGROUND

N-methyl-D-aspartate (NMDA) receptor is the major excitatory neurotransmitter receptor in the central nervous system. Recent evidence has pointed to expression of NMDA receptor in peripheral non-neuronal tissues and organs; however, little is known about the expression of the receptor in the stomach. The present study identified what types of NMDA receptor subunits are expressed in the rat stomach and examined whether vagotomy affects their expression.

METHODS

To see the expression and distribution of the mRNAs and proteins for the NMDA receptor subunits, real-time reverse transcription-polymerase chain reaction, Western blotting, in situ hybridization, and immunohistochemistry were carried out on rat stomach with and without vagotomy.

RESULTS

Of the NMDA receptor subunits, NR1, NR2 (2A, 2B, 2C, 2D), and NR3 (3A, 3B), all NR subunit mRNAs except for the NR2B subunit mRNA were expressed in the intact rat stomach, with huge expression of NR2D mRNA. Expression of NR2D subunit mRNA and protein significantly increased after vagotomy. Increased expression was found in mucosal cells, the myenteric plexus, and the outer membrane of the stomach with vagotomy.

CONCLUSIONS

Vagotomy upregulates expression of the NR2D subunit in the stomach and therefore, the NR2D subunit may be implicated in gastric motility.