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Abdul-Razakq H, Emmanuel A, Brugaletta C, Sweis R, Perring S. An investigation into the effect of nasogastric intubation on markers of autonomic nervous function. Neurogastroenterol Motil 2022; 34:e14214. [PMID: 34337828 DOI: 10.1111/nmo.14214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/23/2021] [Accepted: 06/07/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Nasogastric (NG) intubation for esophageal manometry can be traumatic and may be associated with a temporary reduction/absence in esophageal peristalsis. This study explored the prevalence and effect on esophageal motor function. We also hypothesized that baseline anxiety as well as markers of autonomic nerve function were correlated to attenuated esophageal peristalsis. METHODS Twenty-seven patients with esophageal symptoms referred for esophageal manometry investigation (mean age 56.8 ± 16.7 years, range 23-85 years) reported baseline anxiety score (Likert scale) preintubation. Patients had continuous heart rate and blood pressure measured prior to intubation and until 10 min after catheter withdrawal. Quality of motility was assessed for each 5 ml water swallow using standard Chicago Classification metrics. KEY RESULTS Nasogastric-intubation elicited a significant increase in heart rate (p < 0.001), systolic (p < 0.001) and diastolic (p < 0.001) blood pressure, which was in part anticipatory. The median time taken for patients' first hypotensive peristalsis (Distal Contractile Integral; DCI ≥100 mmHg s cm) was 130 s (Interquartile range; 47-242 s) and for their first normal peristalsis (DCI ≥450 mm Hg s cm) was 150 s (IQR 61-320 s), with improvement and consistent stabilization in DCI there onward. This corresponded closely to the time for initial recovery of heart rate and systolic and diastolic blood pressure postintubation. CONCLUSIONS AND INFERENCES Nasogastric intubation resulted in heightened sympathetic responses and/or dampened parasympathetic responses, and an associated temporary reduction or absence in esophageal peristalsis.
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Affiliation(s)
- Humayra Abdul-Razakq
- GI Physiology Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Anton Emmanuel
- GI Physiology Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Concetta Brugaletta
- GI Physiology Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London Hospitals NHS Foundation Trust, London, UK
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Ribolsi M, Frazzoni M, De Bortoli N, Tolone S, Arsiè E, Mariani L, De Carlo G, Maniero D, Penagini R, Cicala M, Savarino E. Reflux characteristics triggering post-reflux swallow-induced peristaltic wave (PSPW) in patients with GERD symptoms. Neurogastroenterol Motil 2022; 34:e14183. [PMID: 34051123 PMCID: PMC9285402 DOI: 10.1111/nmo.14183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Esophageal chemical clearance has been evaluated with the post-reflux swallow-induced peristaltic wave (PSPW) index. The factors triggering PSPW in Gastro-esophageal reflux disease (GERD) have not yet been investigated. This multicenter study was aimed at evaluating the characteristics of reflux episodes associated with PSPW occurrence in patients with typical GERD symptoms. METHODS Impedance-pH tracings from patients with typical reflux symptoms were analyzed. Sixteen healthy subjects were included for comparison. Multivariate analysis was performed to determine predictors of PSPW events. KEY RESULTS Impedance-pH tracings from 60 patients and 16 healthy subjects were evaluated. A total of 3454 refluxes were recorded. In patients, comparing reflux episodes followed with those not followed by a PSPW, significantly higher proportions of acid (79% vs. 74%, p: 0.02), mixed (47% vs. 32%, p: 0.0001) and proximal refluxes (34% vs. 20%, p: 0.0001) were observed. A multivariate analysis, acid (OR: 1.3, 95% CI: 1.05-1.6), mixed (OR: 2, 95% CI: 1.6-2.3), and proximal (OR: 2.1, 95% CI: 1.7-2.5) refluxes were independently associated with PSPWs. Reflux episodes followed by a PSPW were characterized by a significantly higher bolus clearing time [(mean ± SD) 41 s ± 6 s vs. 30 s ± 5 s, p < 0.05] whereas nadir pH value of reflux events preceding PSPWs was tangentially but not significantly lower [(mean ± SD) 2.61 ± 1.22 vs. 2.74 ± 1.26, p: 0.057]. CONCLUSIONS AND INFERENCES Acid, mixed and proximal refluxes, and their duration are key factors in eliciting PSPWs. PSPW represents a response to reflux directly related to the potential harmfulness of reflux contents.
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Affiliation(s)
- Mentore Ribolsi
- Department of Digestive DiseasesCampus Bio Medico University of RomeRomaItaly
| | - Marzio Frazzoni
- Digestive Pathophysiology UnitBaggiovara HospitalModenaItaly
| | - Nicola De Bortoli
- Department of Translational Research and New Technology in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Salvatore Tolone
- General and Bariatric Surgery UnitDepartment of Surgery2nd University of NaplesNapoliItaly
| | - Elena Arsiè
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Fondazione IRCCS Ospedale Maggiore PoliclinicoMilanItaly
| | - Lucia Mariani
- Department of Translational Research and New Technology in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Giovanni De Carlo
- Department of Digestive DiseasesCampus Bio Medico University of RomeRomaItaly
| | - Daria Maniero
- Gastroenterology UnitDepartment of Surgery, Oncology and GastroenterologyUniversity of PaduaPadovaItaly
| | - Roberto Penagini
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Fondazione IRCCS Ospedale Maggiore PoliclinicoMilanItaly
| | - Michele Cicala
- Department of Digestive DiseasesCampus Bio Medico University of RomeRomaItaly
| | - Edoardo Savarino
- Gastroenterology UnitDepartment of Surgery, Oncology and GastroenterologyUniversity of PaduaPadovaItaly
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3
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Maeda-Iino A, Fukushima M, Sakoguchi Y, Omure H, Oishi A, Oga Y, Furukawa-Sainoki M, Kanmura S, Ido A, Miyawaki S. Effects of intra-oesophageal acid infusion and a stress task on masseter muscle activity and autonomic nervous activity in wakefulness. J Oral Rehabil 2020; 47:567-576. [PMID: 32064657 DOI: 10.1111/joor.12947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 01/27/2020] [Accepted: 02/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease may be an important risk factor for awake bruxism. Additionally, it has been known that a psychological stress task affects masseter muscle activity, and autonomic nervous system (ANS) activity modulation induces masseter muscle activity. OBJECTIVES This study aimed to investigate whether task-induced stress and experimental oesophageal acid infusion increase masseter muscle activity and alter ANS activity, compared to rest task and oesophageal saline infusion, respectively. METHODS Polygraphic monitoring, consisting of electromyography of the masseter muscle and electrocardiography, was performed in 12 healthy adult men during 30-min interventions with intra-oesophageal saline or acid infusion, while reading a book quietly, as rest, and while performing calculation, as a stress task. RESULTS At rest, masseter muscle activity and parasympathetic nervous system (PNS) activity during acid infusion were significantly higher (P = .019) and lower (P = .021) than during saline infusion, respectively. During saline infusion, both masseter muscle activity and sympathetic nervous system (SNS) activity or PNS activity while performing the calculation task were higher (P = .022 and .012, respectively) or lower (P = .007) than those during the reading task, respectively. In two-way repeated-measures ANOVA, intra-oesophageal infusion (saline or acid) significantly affected masseter muscle activity (P = .008) and PNS activity (P = .021). However, performing tasks (reading or calculation) significantly affected only PNS activity (P = .028). CONCLUSION Intra-oesophageal acid infusion significantly increased masseter muscle activity and decreased PNS activity. In contrast, stress task not only significantly decreased PNS activity, but only modestly increased masseter muscle activity and SNS activity.
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Affiliation(s)
- Aya Maeda-Iino
- Field of Developmental Medicine, Health Research Course, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Mika Fukushima
- Field of Developmental Medicine, Health Research Course, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yoko Sakoguchi
- Field of Developmental Medicine, Health Research Course, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.,Sakoguchi Dental Clinic, Kagoshima, Japan
| | - Haruhito Omure
- Field of Developmental Medicine, Health Research Course, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.,Omure Orthodontic Clinic, Matsuyama, Japan
| | - Akihito Oishi
- Field of Developmental Medicine, Health Research Course, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yasuhiko Oga
- Field of Developmental Medicine, Health Research Course, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Minami Furukawa-Sainoki
- Field of Developmental Medicine, Health Research Course, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Shuji Kanmura
- Department of Endoscopy, Kagoshima University Hospital, Kagoshima, Japan
| | - Akio Ido
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Shouichi Miyawaki
- Field of Developmental Medicine, Health Research Course, Department of Orthodontics and Dentofacial Orthopedics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.,Faculty of Dental Medicine, Airlangga University, Surabaya, Indonesia
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4
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Gregersen H, Lo KM. What Is the Future of Impedance Planimetry in Gastroenterology? J Neurogastroenterol Motil 2018; 24:166-181. [PMID: 29605974 PMCID: PMC5885717 DOI: 10.5056/jnm18013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/09/2018] [Indexed: 12/13/2022] Open
Abstract
The gastrointestinal (GI) tract is efficient in transporting ingested material to the site of delivery in healthy subjects. A fine balance exists between peristaltic forces, the mixing and delivery of the contents, and sensory signaling. This fine balance is easily disturbed by diseases. It is mandatory to understand the pathophysiology to enhance our understanding of GI disorders. The inaccessibility and complex nervous innervation, geometry and mechanical function of the GI tract make mechanosensory evaluation difficult. Impedance planimetry is a distension technology that assesses luminal geometry, mechanical properties including muscle dynamics, and processing of nociceptive signals from the GI tract. Since standardized models do not exist for GI muscle function in vivo, models, concepts, and terminology must be borrowed from other medical fields such as cardiac mechanophysiology. The review highlights the impedance planimetric technology, muscle dynamics assessment, and 3 applied technologies of impedance planimetry. These technologies are the multimodal probes that assesses sensory function, the functional luminal imaging probe that dynamically measures the geometry of the lumen it distends, and Fecobionics that is a simulated feces providing high-resolution measurements during defecation. The advanced muscle analysis and 3 applied technologies can enhance the quality of future interdisciplinary research for gaining more knowledge about mechanical function, sensory-motor disorders, and symptoms. This is a step in the direction of individualized treatment for GI disorders based on diagnostic subtyping. There seems to be no better alternatives to impedance planimetry, but only the functional luminal imaging probe is currently commercially available. Wider use depends on commercialization of the multimodal probe and Fecobionics.
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Affiliation(s)
- Hans Gregersen
- GIOME, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong.,California Medical Innovations Institute, San Diego, California, USA
| | - Kar Man Lo
- GIOME Doublecove, Wu Kai Sha, New Territories, Hong Kong
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5
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Nowak JK, Łaźniak A, Lisowska A, Kycler Z, Bobkowski W, Walkowiak J. Gastroesophageal reflux is not associated with short-term variability of parasympathetic activity in children. Adv Med Sci 2017; 62:103-109. [PMID: 28235713 DOI: 10.1016/j.advms.2016.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 10/04/2016] [Accepted: 11/29/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE A lower parasympathetic activity was described in patients with the gastroesophageal reflux disease. We aimed to determine whether gastroesophageal reflux (GER) episodes are associated with a short-term parasympathetic tone variability in children. METHODS In order to address this question we performed simultaneous 24-h esophageal multichannel intraluminal impedance-pH and electrocardiographic monitoring in 16 children (age range 6-18 years), including 8 with asthma and 2 with gastroesophageal reflux disease. After describing duration, height, and acidity of 483 GER episodes we also measured parasympathetic-related heart rate variability parameters in 4 time periods: preceding, containing, following GER, and in-between GERs (control). High frequency (HF) power and root-mean square differences of successive R-R intervals (r-MSSD) were assessed in 2.5-min and 1-min periods, respectively. RESULTS We did not identify the searched short-term parasympathetic tone changes. CONCLUSIONS In conclusion, GER episodes and their characteristics were not associated with short-term variability of parasympathetic activity in children.
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Hoff DAL, Brock C, Farmer AD, Dickman R, Ruffle JK, Shaker A, Drewes AM. Pharmacological and other treatment modalities for esophageal pain. Ann N Y Acad Sci 2016; 1380:58-66. [PMID: 27442914 DOI: 10.1111/nyas.13151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/23/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
Treatment of esophageal pain remains a major challenge for the clinician. Although many patients have heartburn and may respond to proton pump inhibitors, there in an unmet need for other treatment modalities in patients where there are no obvious pathological findings. Although analgesics are the mainstay in esophageal pain treatment, many patients are nonresponders to these drugs. The current concise review focuses on other systems affecting pain processing, where better understanding may serve as a framework for therapy. These are the parasympathetic nervous system, exercise, and personality profiles. Finally, treatment with analgesics for functional chest pain remains a challenge, and an overview of treatment with antidepressive drugs is provided.
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Affiliation(s)
- Dag Arne Lihaug Hoff
- Clinic of Medicine HMR Hospital Trust, Department of Medicine, Division of Gastroenterology & Hepatology, Aalesund Hospital, Aalesund, Norway.
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Adam D Farmer
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark.,Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, United Kingdom
| | - Ram Dickman
- Division of Gastroenterology, Rabin Medical Center, Beilinson Campus, Petach Tikva & Sackler School of Medicine, University of Tel Aviv, Israel
| | - James K Ruffle
- Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
| | - Anisa Shaker
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark
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7
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Farmer AD, Brock C, Frøkjaer JB, Gregersen H, Khan S, Lelic D, Lottrup C, Drewes AM. Understanding the sensory irregularities of esophageal disease. Expert Rev Gastroenterol Hepatol 2016; 10:907-14. [PMID: 26890720 DOI: 10.1586/17474124.2016.1155984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Symptoms relating to esophageal sensory abnormalities can be encountered in the clinical environment. Such sensory abnormalities may be present in demonstrable disease, such as erosive esophagitis, and in the ostensibly normal esophagus, such as non-erosive reflux disease or functional chest pain. In this review, the authors discuss esophageal sensation and the esophageal pain system. In addition, the authors provide a primer concerning the techniques that are available for investigating the autonomic nervous system, neuroimaging and neurophysiology of esophageal sensory function. Such technological advances, whilst not readily available in the clinic may facilitate the stratification and individualization of therapy in disorders of esophageal sensation in the future.
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Affiliation(s)
- Adam D Farmer
- a Mech-Sense , University Hospital Aalborg , Aalborg , Denmark.,b Centre for Digestive Diseases, Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London , London , UK.,c Department of Gastroenterology , University Hospitals of North Midlands , Stoke on Trent , UK
| | - Christina Brock
- a Mech-Sense , University Hospital Aalborg , Aalborg , Denmark
| | - Jens Brøndum Frøkjaer
- a Mech-Sense , University Hospital Aalborg , Aalborg , Denmark.,d Department of Radiology , Aalborg University Hospital , Aalborg , Denmark
| | - Hans Gregersen
- e GIOME, Key Laboratory for Biorheological Science and Technology , College of Bioengineering, Chongqing University , Chongqing , China
| | - Sheeba Khan
- c Department of Gastroenterology , University Hospitals of North Midlands , Stoke on Trent , UK
| | - Dina Lelic
- a Mech-Sense , University Hospital Aalborg , Aalborg , Denmark
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8
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Farmer AD, Franchina M, Gregersen H, Penagini R, Shaker A, Soffer E. Provocative testing of the esophagus and its future. Ann N Y Acad Sci 2016; 1380:33-47. [DOI: 10.1111/nyas.13109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/21/2016] [Accepted: 04/25/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Adam D. Farmer
- Centre for Digestive Diseases, Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine & Dentistry; Queen Mary University of London; London United Kingdom
- Department of Gastroenterology; University Hospitals of North Midlands; Stoke on Trent Staffordshire United Kingdom
| | - Marianna Franchina
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi of Milan and Gastroenterology and Endoscopy Unit; Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico; Milan Italy
| | - Hans Gregersen
- GIOME, College of Bioengineering; Chongqing University; Chongqing China
- Department of Surgery; Prince of Wales Hospital; Shatin Hong Kong SAR
| | - Roberto Penagini
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi of Milan and Gastroenterology and Endoscopy Unit; Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico; Milan Italy
| | - Anisa Shaker
- Department of Medicine; University of Southern California; Los Angeles California
| | - Edy Soffer
- Department of Medicine; University of Southern California; Los Angeles California
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Bulmer DC, Botha CA, Wheeldon A, Grey K, Mein CA, Lee K, Knowles CH, Winchester WJ, Aziz Q. Evidence of a role for GTP cyclohydrolase-1 in visceral pain. Neurogastroenterol Motil 2015; 27:656-62. [PMID: 25783971 DOI: 10.1111/nmo.12538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 02/09/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The enzyme guanosine triphosphate-cyclohydrolase-1 (GCH-1) is a rate limiting step in the de novo synthesis of tetrahydrobiopterin (BH4) a co-factor in monoamine synthesis and nitric oxide production. GCH-1 is strongly implicated in chronic pain based on data generated using the selective GCH-1 inhibitor 2,4-diamino-6-hydroxypyrimidine (DAHP), and studies which have identified a pain protective GCH-1 haplotype associated with lower BH4 production and reduced pain. METHODS To investigate the role for GCH-1 in visceral pain we examined the effects of DAHP on pain behaviors elicited by colorectal injection of mustard oil in rats, and the pain protective GCH-1 haplotype in healthy volunteers characterized by esophageal pain sensitivity before and after acid injury, and assessed using depression and anxiety questionnaires. KEY RESULTS In rodents pretreatment with DAHP produced a substantial dose related inhibition of pain behaviors from 10 to 180 mg/kg i.p. (p < 0.01 to 0.001). In healthy volunteers, no association was seen between the pain protective GCH-1 haplotype and the development of hypersensitivity following injury. However, a substantial increase in baseline pain thresholds was seen between first and second visits (26.6 ± 6.2 mA) in subjects who sensitized to esophageal injury and possessed the pain protective GCH-1 haplotype compared with all other groups (p < 0.05). Furthermore the same subjects who sensitized to acid and possessed the haplotype, also had significantly lower depression scores (p < 0.05). CONCLUSIONS & INFERENCES The data generated indicate that GCH-1 plays a role in visceral pain processing that requires more detailed investigation.
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Affiliation(s)
- D C Bulmer
- Wingate Institute of Neurogastroenterology, Blizard Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; GlaxoSmithKline Research & Development, Medicines Research Centre, Hertfordshire, UK
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10
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Botha C, Farmer AD, Nilsson M, Brock C, Gavrila AD, Drewes AM, Knowles CH, Aziz Q. Preliminary report: modulation of parasympathetic nervous system tone influences oesophageal pain hypersensitivity. Gut 2015; 64:611-7. [PMID: 24870622 DOI: 10.1136/gutjnl-2013-306698] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Autonomic nervous system dysfunction has been implicated in visceral hypersensitivity. However, the specific contribution of the parasympathetic nervous system (PNS) is unclear. We aimed to determine whether physiological and pharmacological manipulation of parasympathetic tone influences the development of hypersensitivity in a validated model of acid-induced oesophageal pain. DESIGN Prior to, and following, a 30-min distal oesophageal infusion of 0.15 M hydrochloric acid, pain thresholds to electrical stimulation were determined in the proximal non-acid exposed oesophagus in healthy subjects. Validated sympathetic (skin conductance response) and parasympathetic (cardiac vagal tone) parameters were measured at baseline and continuously thereafter. In study 1, 55 subjects were randomised in a pragmatic blinded crossover design to receive deep breathing or un-paced breathing during acid infusion. In study 2, 32 subjects were randomised in a blinded, crossover design to receive intravenous atropine or placebo (saline) with deep breathing during acid infusion. RESULTS Study 1: Deep breathing increased cardiac vagal tone (2.1±2.3 vs -0.3±2.3, p=0.0006) with concomitant withdrawal of skin conductance response (-0.6±4.9 vs 3±4.8, p=0.03) in comparison with un-paced breathing. Deep breathing prevented the development of acid-induced oesophageal hypersensitivity in comparison with sham breathing (p=0.0001). Study 2: Atropine, in comparison with placebo, blocked the attenuating effect of deep breathing on the development of acid-induced oesophageal hypersensitivity (p=0.046). CONCLUSIONS The development of oesophageal hyperalgesia is prevented by physiologically increasing parasympathetic tone. This effect is pharmacologically blocked with atropine, providing evidence that the PNS influences the development of oesophageal pain hypersensitivity.
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Affiliation(s)
- Claude Botha
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Adam D Farmer
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Matias Nilsson
- Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Ana D Gavrila
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Charles H Knowles
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Qasim Aziz
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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11
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Farmer AD, Aziz Q. Mechanisms of visceral pain in health and functional gastrointestinal disorders. Scand J Pain 2014; 5:51-60. [PMID: 29913680 DOI: 10.1016/j.sjpain.2014.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 01/07/2014] [Indexed: 02/07/2023]
Abstract
Background and aims Chronic visceral pain is common both in patients with identifiable organic disease and also in those without any structural, biochemical or immunological abnormality such as in the functional gastrointestinal disorders (FGIDs). We aim to provide a contemporaneous summary of pathways involved in visceral nociception and how a variety of mechanisms may influence an individual's experience of visceral pain. Methods In this narrative review, we have brought together evidence through a detailed search of Medline in addition to using our experience and exposure to recent research developments from ourselves and other research groups. Results FGIDs are a heterogeneous group of disorders whose aetiology largely remains an enigma. The germane hypothesis for the genesis and maintenance of chronic visceral pain in FGIDs is the concept of visceral hypersensitivity. A number of peripheral and central mechanisms have been proposed to account for this epiphenomenon. In the periphery, inflammatory mediators activate and sensitize nociceptive afferent nerves by reducing their transduction thresholds and by inducing the expression and recruitment of hitherto silent nociceptors culminating in an increase in pain sensitivity at the site of injury known as primary hyperalgesia. Centrally, secondary hyperalgesia, defined as an increase in pain sensitivity in anatomically distinct sites, occurs at the level of the spinal dorsal horn. Moreover, the stress responsive physiological systems, genetic and psychological factors may modulate the experience of visceral pain. We also address some novel aetiological concepts in FGIDs, namely the gastrointestinal microbiota, connective tissue abnormalities and the gastrointestinal neuromuscular disorders. Firstly, the gastrointestinal microbiota is a diverse and dynamic ecosystem, that safeguards the host from external pathogens, aids in the metabolism of polysaccharides and lipids, modulates intestinal motility, in addition to modulating visceral perception. Secondly, connective tissue disorders, which traditionally have been considered to be confined largely to the musculoskeletal system, have an increasing evidence base demonstrating the presence of visceral manifestations. Since the sensorimotor apparatus of the GI tract is embedded within connective tissue it should not be surprising that such disorder may result in visceral pain and abnormal gut motility. Thirdly, gastrointestinal neuromuscular diseases refer to a heterogeneous group of disorders in which symptoms arise from impaired GI motor activity often manifesting as abnormal transit with or without radiological evidence of transient or persistent dilation of the viscera. Although a number of these are readily recognizable, such as achalasia or Hirschsprung's disease, the cause in a number of patients is not. An international working group has recently addressed this "gap", providing a comprehensive morphologically based diagnostic criteria. Conclusions/implications Although marked advances have been made in understanding the mechanisms that contribute to the development and maintenance of visceral pain, many interventions have failed to produce tangible improvement in patient outcomes. In the last part of this review we highlight an emerging approach that has allowed the definition and delineation of temporally stable visceral pain clusters, which may improve participant homogeneity in future studies, potentially facilitate stratification of treatment in FGID and lead to improvements in diagnostic criteria and outcomes.
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Affiliation(s)
- Adam D Farmer
- Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London E1 2AJ, UK
| | - Qasim Aziz
- Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London E1 2AJ, UK
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Farmer AD, Coen SJ, Kano M, Paine PA, Shwahdi M, Jafari J, Kishor J, Worthen SF, Rossiter HE, Kumari V, Williams SC, Brammer M, Giampietro VP, Droney J, Riley J, Furlong PL, Knowles CH, Lightman SL, Aziz Q. Psychophysiological responses to pain identify reproducible human clusters. Pain 2013; 154:2266-2276. [DOI: 10.1016/j.pain.2013.05.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 04/29/2013] [Accepted: 05/09/2013] [Indexed: 01/01/2023]
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Kuo P, Bravi I, Marreddy U, Aziz Q, Sifrim D. Postprandial cardiac vagal tone and transient lower esophageal sphincter relaxation (TLESR). Neurogastroenterol Motil 2013; 25:841-e639. [PMID: 23895280 DOI: 10.1111/nmo.12195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 06/27/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transient lower esophageal sphincter relaxation (TLESR) is a vagally mediated reflex that occurs most frequently after a meal. Cardiac vagal tone (CVT) decreases after a meal, and correlates with changes in gastric electrical activity. Furthermore, decreased CVT has been reported in patients with gastro-esophageal reflux disease. We therefore aimed to characterize the association between postprandial changes in CVT and the occurrence of TLESR and reflux. METHODS Ten healthy volunteers underwent simultaneous autonomic nervous system, gastric myoelectric activity, lower esophageal-sphincter pressure, and reflux monitoring for 30 min in the fasting state, followed by a standard meal, and a further 4 h postprandially. Results are in mean ± SEM. KEY RESULTS The number of TLESRs (P < 0.0001) and reflux episodes (P < 0.0001) increased after the meal, while CVT decreased (P < 0.01). Cardiac sensitivity to baroreceptor reflex (CSB) showed similar time course changes to CVT (P = 0.06). During the first postprandial hour there was a strong correlation between the number of TLESRs and reflux episodes with CVT (R(2) = 0.51 and R(2) = 0.50, respectively; P < 0.05). There was also an increase in the dominant power and power ratio on electrogastrography (P < 0.05) after the meal. CONCLUSIONS & INFERENCES In healthy volunteers, the increase in the number of TLESRs and reflux episodes after a meal occurred mostly at a time of reduced CVT. Further studies should explore whether modulation of CVT can modify frequency of TLESRs and also this relationship should be further explored in patients with reflux disease.
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Affiliation(s)
- P Kuo
- Centre for Digestive Diseases, Blizard Institute and Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Conditioned pain modulation in children and adolescents: effects of sex and age. THE JOURNAL OF PAIN 2013; 14:558-67. [PMID: 23541066 DOI: 10.1016/j.jpain.2013.01.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/10/2013] [Accepted: 01/11/2013] [Indexed: 11/21/2022]
Abstract
UNLABELLED Conditioned pain modulation (CPM) refers to the diminution of perceived pain intensity for a test stimulus following application of a conditioning stimulus to a remote area of the body, and is thought to reflect the descending inhibition of nociceptive signals. Studying CPM in children may inform interventions to enhance central pain inhibition within a developmental framework. We assessed CPM in 133 healthy children (mean age = 13 years; 52.6% girls) and tested the effects of sex and age. Participants were exposed to 4 trials of a pressure test stimulus before, during, and after the application of a cold water conditioning stimulus. CPM was documented by a reduction in pressure pain ratings during cold water administration. Older children (12-17 years) exhibited greater CPM than younger children (8-11 years). No sex differences in CPM were found. Lower heart rate variability at baseline and after pain induction was associated with less CPM, controlling for child age. The findings of greater CPM in the older age cohort suggest a developmental improvement in central pain inhibitory mechanisms. The results highlight the need to examine developmental and contributory factors in central pain inhibitory mechanisms in children to guide effective, age appropriate pain interventions. PERSPECTIVE In this healthy sample, younger children exhibited less CPM than did older adolescents, suggesting a developmental improvement in CPM. Cardiac vagal tone was associated with CPM across age. The current findings may inform the development of targeted, developmentally appropriate pain interventions for children.
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