Clinical assessment of delayed gastric emptying and diabetic complications using gastric emptying scintigraphy: Involvement of vascular disorder

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.

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.

Pooled Analysis of Gastric Emptying in Patients With Obesity: Implications for Oral Absorption Projection

PURPOSE

Gastric emptying time is one of limiting factors that determines the pharmacokinetic properties of drugs administered by mouth. Despite the high prevalence of obesity worldwide, modifications in gastric emptying time have not been systematically addressed in this set of patients. The current analysis aims to quantitatively address obesity-related changes in gastric emptying time of solids, semisolids, and liquids compared with lean individuals, highlighting the relevant pharmacokinetic implications of oral drug absorption in patients with obesity.

METHODS

We searched the Cochrane Library, PubMed, Web of Science, and Embase for all relevant articles published until November 1, 2020. Differences in gastrointestinal variables in relation to gastric emptying between obese and lean individuals were quantified by weighted mean difference (WMD) and ratio of means (RoM). Robustness of the analyses was evaluated by subgroup analysis and publication bias test.

FINDINGS

A total of 17 studies with 906 participants were included. The gastric half-emptying time of solids (WMD, -10.4 minutes; P = 0.001; RoM, 0.90; P = 0.01) and liquids (WMD, -6.14 minutes; P < 0.001; RoM, 0.83, P = 0.03) was significantly shorter in individuals with obesity compared with lean individuals. These findings were confirmed by the subgroup analyses and publication bias tests.

IMPLICATIONS

Our pooled analysis systemically quantifies the differences in gastric half-emptying time between individuals with obesity and lean individuals, facilitating better understanding and prediction of drug absorption in individuals with obesity through physiologically based pharmacokinetic approaches. Obesity is associated with a faster transit of both solids and liquids through the stomach.

Proximal and Distal Gastric Retention Patterns in Gastroparesis and the Impact of Gastric Per-Oral Endoscopic Myotomy: A Retrospective Analysis Using Gastric Emptying Scintigraphy

Gastroparesis is a debilitating disease of insufficient gastric emptying and visceral hypersensitivity characterized by nausea, vomiting, early satiety, and bloating. Gastric emptying scintigraphy (GES), in combination with typical symptoms and normal esophagogastroduodenoscopy findings, is used to diagnose the disease. Gastric per-oral endoscopic pyloromyotomy (G-POEM) has emerged as a novel technique for treating gastroparesis, with up to an 80% success rate. This procedure involves myotomy of the distal stomach. We hypothesize that responders to this therapy are characterized by more distal dysmotility than nonresponders, as defined by GES retention patterns. Methods: We used regional gastric emptying measurements from diagnostic GES to determine the proximal or distal predominance of disease for each patient. We then compared treatment response and symptoms in each patient to total gastric half-emptying time (T_½), proximal gastric T_½, and a ratio comparing the 2 values. Results: In total, 47 patients underwent G-POEM during the study period. A significant difference (P < 0.01) was found in proximal-to-total T_½ ratio between responders and nonresponders. A significant difference between pre- and postprocedural proximal-to-total T_½ ratios was identified for each patient. No correlations were identified between motility patterns and symptoms or in motility patterns among the different etiologies of the disease. Conclusion: Proximal-to-total T_½ ratio may represent an important patient selection factor for G-POEM versus other treatment modalities going forward. Local retention patterns in GES may not inform the symptom profile in gastroparesis.

Association Between Gastric Emptying Time and Incidence of Cardiovascular Diseases in Subjects With Diabetes

Background/Aims

Delayed gastric emptying (GE) is associated with high morbidity and mortality in subjects with diabetes. The aim of this study is to investigate associations between GE time and the major cardiovascular events (coronary heart diseases and ischemic stroke) in diabetic subjects with upper gastrointestinal (UGI) symptoms.

Methods

Among 259 subjects with chronic UGI symptoms who underwent gastric emptying study (GES) over 13 years, 122 diabetic subjects without gastric surgery and/or rapid GE were enrolled in this study. We also gathered data about baseline demographics, clinical characteristics, estimated GE half-time (GE T_½) and incidence of cardiovascular events following GES.

Results

The mean age of subjects was 64.0 ± 17.4 years. There were 86 women and 104 subjects with type 2 diabetes. There were 52 (42.6%) subjects with normal GE, 50 (41.0.%) subjects with mild delayed GE, and 20 (16.4%) subjects with marked delayed GE. During follow-up (median, 207 weeks), cardiovascular events occurred in 7 (13.5%) subjects with normal GE, 4 (8.0%) subjects with mild delayed GE and 7 (35.0%) subjects with marked GE (P = 0.015). Univariate analysis showed that GE T_½ was significantly associated with incidence of cardiovascular events (crude OR, 1.74; 95% CI, 1.12–2.69; P = 0.014). In a multivariate model, association between GE T_½ and incidence of cardiovascular events remained statistically significant after adjustment for baseline characteristics and comorbidities (adjusted OR, 1.94; 95% CI, 1.21–3.12; P = 0.006).

Conclusion

A delay of GE was associated with an increased incidence of cardiovascular events in diabetic subjects with chronic UGI symptoms.

Clinical factors associated with the occurrence of nausea and vomiting in type 2 diabetes patients treated with glucagon-like peptide-1 receptor agonists

AIMS/INTRODUCTION

Research has proved a correlation between glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and gastrointestinal adverse events. Predominantly, nausea and vomiting are frequent gastrointestinal adverse events that lead to the discontinuation of GLP-1 RAs treatment. The present study aims to investigate clinical factors related to nausea and vomiting, considering diabetic complications and agents affecting the gastrointestinal tract, such as proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs), in patients with type 2 diabetes treated with GLP-1 RAs.

MATERIALS AND METHODS

This retrospective study included Japanese patients with type 2 diabetes who started receiving GLP-1 RAs therapy. We assessed nausea and vomiting up to 48 weeks after treatment with GLP-1 RAs and used Fine-Gray's proportional hazards model to investigate clinical factors related to nausea and vomiting.

RESULTS

A total of 130 patients were included in this study. Patients with PPIs or H2RAs showed a higher incidence of nausea and vomiting at 48 weeks than those without PPIs or H2RAs. The multivariate analysis revealed that female sex, retinopathy and treatment with PPIs or H2RAs were statistically significant risk factors for nausea and vomiting. Analysis of patients without PPIs or H2RAs showed that female sex and retinopathy were also statistically significant risk factors.

CONCLUSIONS

The present study showed a significant correlation of PPIs or H2RAs, female sex, and diabetic retinopathy with nausea and vomiting in patients with type 2 diabetes treated with GLP-1 RAs. Hence, the occurrence of nausea and vomiting in patients with these factors warrants attention.

Gastric Emptying Scintigraphy Before Gastric per Oral Endoscopic Myotomy: Imaging May Inform Treatment

Gastric emptying scintigraphy (GES) helps to diagnose gastroparesis and is typically only used for whole stomach retention patterns. However, it may provide significantly more information when looking specifically at proximal and distal retention patterns. This article reviews global GES changes following gastric per oral endoscopic myotomy; how global, proximal, and distal GES measurements correlate to gastroparesis symptoms; and how proximal and distal GES may serve as proxies for the various mechanisms involved in gastroparesis. The authors' data on how GES may be used to select which patients will have success from G-POEM is also reviewed.

Prevalence and predictors of delayed gastric emptying among Indian patients with long-standing type 2 diabetes mellitus

BACKGROUND AND AIMS

Upper gastrointestinal symptoms are more prevalent among type 2 diabetes mellitus (T2DM) patients. The prevalence of delayed gastric emptying (GE) and factors predictive of it have not been studied in Indian T2DM patients and the present study aimed to study the same.

METHODS

This hospital-based cross-sectional study involved adult (age between 18 and 65 years) outpatients with T2DM of ≥5-year duration. Measurements of GE of a labelled standardized solid rice idli meal by gastric emptying scintigraphy (GES), symptoms of delayed GE (by standardized questionnaire) and autonomic function by cardiovascular autonomic function tests (AFTs) were carried out. Thirty healthy subjects served as controls for GES and AFTs.

RESULTS

One hundred and forty T2DM patients (age range: 32-65 years) were studied. Delayed GE was documented in ≈29 % (40/140) and rapid GE in 2 % (3/140) of T2DM patients. Univariate analysis showed significant positive association between delayed GE and duration of DM, body mass index (BMI), HbA1c, retinopathy, peripheral neuropathy, autonomic dysfunction and coronary artery disease (p < 0.05 for all). However, there was no significant correlation of age, sex, symptoms suggestive of gastroparesis and nephropathy with delayed GE. Hypoglycemic episodes were significantly more frequent in those with delayed GE (p < 0.05). Multiple logistic regression analysis revealed only BMI and HbA1c to be significant independent predictors of delayed GE.

CONCLUSION

Presence and severity of symptoms of gastroparesis did not predict delayed GE. Delayed GE, irrespective of symptoms, was associated with microvascular and macrovascular diabetic complications and increased risk of hypoglycemic episodes. HbA_1c and BMI were independent predictors of delayed GE.

Evaluation of gastric emptying in diabetic gastropathy by an ultrasonic whole stomach cylinder method

In order to explore the accuracy of ultrasonic whole stomach cylinder measurement (UWSCM) in the evaluation of gastric emptying, we measured the gastric emptying times (ET) at 25% (T1), 50% (T2) and 75% (T3) of healthy subjects and patients with diabetic gastropathy by UWSCM and scintigraphy. The ET of patients were compared with their clinical symptom scores. We found that the ET measured by UWSCM showed no significant difference with scintigraphy (p > 0.05). The correlation between them was good, and the correlation coefficient of T3 reached 0.744 (p < 0.05). All emptying times in the diabetic patients were longer than those in the healthy subjects (p < 0.05). The T3 in the diabetic group measured by UWSCM had the best correlation with the symptom index (r = 0.469, p < 0.05). We conclude that ET measured by UWSCM is accurate and T3 combining the symptoms index provides an accurate clinical basis for gastropathy.

Microangiopathy is common in submucosal vessels of the colon in patients with diabetes mellitus

OBJECTIVES

The pathophysiology behind gastrointestinal dysmotility in diabetes mellitus is unknown. Both esophageal dysmotility and gastroparesis have been shown to be associated with retinopathy, suggesting that microangiopathy is important in the common etiology. The aim of the present study was to examine whether patients with diabetes exhibit microangiopathy in the colon, and if present, to correlate microangiopathy with the clinical picture.

METHODS

Consecutive patients subjected to colon surgery were identified in the southernmost districts of Skåne between January 2011 and May 2013. Medical records were scrutinized, and patients with a history of diabetes were noted. Gender, age, type of diabetes, treatment, complications, and other concomitant diseases were registered. Histopathologic re-evaluation of surgical biopsies with morphometric analyses of submucosal vessels in the colon was performed. Morphometric examination and clinical data were compared with non-diabetic patients.

RESULTS

Of 1135 identified patients during the time period studied, 95 patients with diabetes were recognized and included. Fifty-three non-diabetic, randomly chosen patients served as controls. The mean age was 71.8 ± 10.2 and 71.4 ± 9.5 years in diabetic and non-diabetic patients, respectively. Microangiopathy was found in 68.4% of diabetic patients and in 7.5% of non-diabetic patients (p < 0.001). The wall-to-lumen ratio was 0.31 (0.23-0.46) in patients with diabetes compared with 0.16 (0.12-0.21) in non-diabetic patients (p < 0.001). No clinical association with microangiopathy could be verified.

CONCLUSION

Microangiopathy in the colon is more common in diabetic than in non-diabetic patients. The clinical significance of microangopathy has yet to be clarified.