Gastric motility in patients with presinusoidal portal hypertension

Malnutrition in Patients with Liver Cirrhosis

Liver cirrhosis is an increasing public health threat worldwide. Malnutrition is a serious complication of cirrhosis and is associated with worse outcomes. With this review, we aim to describe the prevalence of malnutrition, pathophysiological mechanisms, diagnostic tools and therapeutic targets to treat malnutrition. Malnutrition is frequently underdiagnosed and occurs-depending on the screening methods used and patient populations studied-in 5-92% of patients. Decreased energy and protein intake, inflammation, malabsorption, altered nutrient metabolism, hypermetabolism, hormonal disturbances and gut microbiome dysbiosis can contribute to malnutrition. The stepwise diagnostic approach includes a rapid prescreen, the use of a specific screening tool, such as the Royal Free Hospital Nutritional Prioritizing Tool and a nutritional assessment by dieticians. General dietary measures-especially the timing of meals-oral nutritional supplements, micronutrient supplementation and the role of amino acids are discussed. In summary malnutrition in cirrhosis is common and needs more attention by health care professionals involved in the care of patients with cirrhosis. Screening and assessment for malnutrition should be carried out regularly in cirrhotic patients, ideally by a multidisciplinary team. Further research is needed to better clarify pathogenic mechanisms such as the role of the gut-liver-axis and to develop targeted therapeutic strategies.

Clinical features and severity of gastric emptying delay in Brazilian patients with gastroparesis

CONTEXT

Gastroparesis is defined by delayed gastric emptying without mechanical obstruction of the gastroduodenal junction, which has been increasingly investigated. Nevertheless, knowledge on the relationships between etiology, symptoms and degree of delayed gastric emptying is limited.

OBJECTIVES

The demographic, clinical and etiological features of Brazilian patients with gastroparesis were studied and the relationships between these findings and the severity of gastric emptying were determined.

METHOD

This is a retrospective study of medical records of 41 patients with symptoms suggestive of gastroparesis admitted between 1998 and 2011, who had evidence of abnormally delayed gastric emptying on abdominal scintigraphy. Cases with idiopathic gastroparesis were compared with those of patients with neurologic disorders or diabetes mellitus, in whom autonomic neuropathy is likely to occur.

RESULTS

The majority of the patients were women (75.6%) with a median age of 41 years and a long-term condition (median: 15 years). Twelve patients (29.3%) had a body mass index of less than 20 kg/m2. The most common presenting symptoms were dyspepsia (53.6%), nausea and vomiting (46.3%), weight loss (41.4%) and abdominal pain (24.3%). Regarding etiology, 16 patients had digestive disorders including idiopathic gastroparesis (n = 12), 12 had postoperative conditions, 11 had diseases of the nervous system, five had diabetes mellitus and in three cases gastroparesis was associated to a variety of conditions. In the majority of patients (65.8%) gastric emptying was severely delayed. There was no association between etiology of gastroparesis, type of presenting symptoms and the degree of delay in gastric emptying. Gastroparesis patients with proven (neurological conditions) or presumed (diabetes) nervous system involvements were significantly younger (P = 0.001), had more recent symptom onset (P = 0:03) and a trend towards more severe gastric empty (P = 0:06). There were no significant differences between this subgroup of patients and that comprising cases of idiopathic gastroparesis regarding any of the variables studied.

CONCLUSIONS

The demographic, clinical and etiological characteristics of Brazilian patients with gastroparesis are quite varied, but there is a predominance of women with long-standing symptoms and marked delay in gastric emptying. The type of presenting symptoms and the degree of delay in gastric emptying do not predict the etiology of gastroparesis. However, severely delayed gastric emptying in younger patients with recent symptom onset should raise the suspicion of impaired neural control of gastro-duodenal motility.

Prediction of octreotide efficacy by electrogastrography in the treatment of patients with esophageal variceal hemorrhage

Our aim is to investigate the significance of electrogastrography in the treatment of esophageal variceal hemorrhage with octreotide. Electrogastrography was performed in patients with esophageal variceal hemorrhage before and during the treatment consisting of various doses of octreotide (25 ug h(-1) group and 50 ug h(-1) group). The dominant power of electrogastrography and its relationship with the hemostatic efficacy of octreotide treatment were evaluated. Dominant power of electrogastrography decreased significantly during treatment with octreotide (P < 0.05). The reduction in the amplitude of dominant power in the 50 ug h(-1) group was significantly larger than in the 25 ug h(-1) group (P < 0.05), and it was correlated with hemostatic efficacy of octreotide treatment. We conclude that octreotide treatment in patients with esophageal variceal hemorrhage can result in a significant decrease of dominant power, which correlates with the hemostatic efficacy of octreotide, so the change of dominant power could be used as a predictor of evaluating the treatment efficacy of octreotide in esophageal variceal hemorrhage patients.

Increased intestinal permeability in malnourished patients with liver cirrhosis

BACKGROUND/OBJECTIVE

Malnutrition is a prominent feature in liver cirrhosis, with deleterious impact on clinical outcome. The objective of this study is to investigate whether malnutrition is associated with increased gastrointestinal permeability in liver cirrhosis reflected by altered urinary excretion of non-metabolizable sugar probes.

SUBJECTS/METHODS

Patients with advanced liver cirrhosis (Child Pugh Score B or C) were recruited. Nutritional status was determined according to the Subjective Global Assessment. Intestinal permeability was assessed by measuring the urinary excretion of orally administered, non-metabolized sugar probe molecules. The lactulose/mannitol ratio served as marker for intestinal permeability and reflects non-carrier-mediated transcellular and paracellular transport of the small intestine during the first 5 h. Sucrose recovery in urine within the first 5 h reflects gastroduodenal permeability; sucralose recovery in urine 5-26 h after consumption reflects colonic permeability.

RESULTS

Sixty-four patients (56.7±10.8 years; 33% female) were included in the study. Twenty-one patients were considered well nourished according to the Subjective Global Assessment, 23 moderately nourished and 20 patients severely malnourished; 74% had alcoholic liver disease and 67% had cirrhosis stage Child C. Gastroduodenal and colonic permeability was significantly increased in patients with liver cirrhosis compared with 63 healthy controls (0.23±0.22 and 1.37±1.42% vs 0.14±0.10 and 0.41±0.72% in controls), but not different between well and malnourished subjects. Small intestinal permeability (lactulose/mannitol ratio) was increased in all patients (0.069±0.055%) and further increased in malnourished patients (0.048±0.031% vs 0.084±0.061%, P=0.004) due to decreased mannitol recovery only.

CONCLUSIONS

Gastric, small intestinal and even colonic permeability was altogether increased in liver cirrhosis, and malnutrition was associated with further increased small intestinal permeability indicative of villous atrophy.

Gastrointestinal tract in liver disease: which organ is sick?

PURPOSE OF REVIEW

This article gives an overview of the several morphological and functional alterations in the gastrointestinal tract that occur in liver disease and their systemic impact.

RECENT FINDINGS

Recent endoscopic studies have revealed similar mucosal alterations in the upper gastrointestinal as well as the colon that include inflammatory-like changes and vascular lesions. Gut-barrier integrity is consequently impaired. There is an evidence that bacterial translocation with subsequent endotoxaemia provokes an inflammatory response that might trigger the cachexia syndrome in liver disease. Novel therapeutic approaches that address gut-barrier function such as supplementation with insulin-like growth factor or synbiotics have shown promising results.

SUMMARY

There are various alterations of the gastrointestinal tract in liver disease and portal hypertension, which might be less clinically overt than the cardinal potentially life-threatening features, ascites and oesophageal varices. However, these alterations, for example gut-barrier dysfunction and alterations of gut flora (microbiota) have immense impact on the portal enteropathy, as they both contribute to the systemic inflammation in liver cirrhosis, which is considered a risk factor for infections as well as the development of cachexia.

Hyperplastic Polyposis following Treatment of Gastric Vascular Ectasia: A Case Report and Review of Clinical Correlates

The etiology of gastric antral vascular ectasia (GAVE) and hyperplastic polyps (HP) is not fully understood, but there is no known overlap. We report a case of gastroduodenal HP arising in a patient treated for GAVE.

Dynamic antral scintigraphy following solid and liquid meals in healthy human subjects

AIMS

Dynamic antral scintigraphy (DAS), a non-invasive technique for the assessment of post-prandial gastric contractions, has been used to demonstrate abnormal contractility in several clinical conditions. The objective of the present study was to assess differences between solid and liquid meals regarding gastric contractions in healthy volunteers using DAS.

METHODS

Ten healthy male volunteers were studied after ingesting solid or liquid meals [approximately 1670 kJ (approximately 400 kcal)] labelled with 99mTc phytate and administered in a random order. Gastric images were acquired for 120 min for gastric emptying half-time (T1/2) measurement. Dynamic (1 frame x s(-1)) images of the gastric antrum were acquired at 30 min intervals for 4 min for the assessment of antral contractility.

RESULTS

Gastric emptying T1/2 values for solid and liquid meals were similar (58.1+/-19.06 min vs. 69.4+/-6.76 min; P=0.13). For the solid meal, average values for both frequency (3.08+/-0.15 cycles x min(-1) vs. 2.78+/-0.18 cycles x min(-1); P=0.003) and amplitude (33.94+/-5.2% variation vs. 24.09+/-7.37% variation; P=0.002) of antral contractions were significantly higher than those obtained with the liquid meal. For either of the test meals, none of the antral contractility variables correlated with gastric emptying T1/2.

CONCLUSIONS

Dynamic antral scintigraphy is capable of detecting differences between solid and liquid meals concerning post-prandial gastric antral contractions under physiological conditions. The frequency and amplitude of gastric antral contractions after a solid meal are greater than after an exclusively liquid meal of similar calorie content, in spite of lack of a difference regarding gastric emptying.

Role of gastric sensorimotor dysfunction in gastrointestinal symptoms and energy intake in liver cirrhosis

OBJECTIVE

Altered gastric sensorimotor function is related to the symptomatology in several gastrointestinal diseases. Gastrointestinal symptoms in patients with cirrhosis may result in low energy intake contributing to malnutrition and increased morbidity. The aim of this study was to investigate gastric accommodation to a meal and sensitivity to gastric distension with reference to energy intake, nutritional status and gastrointestinal symptoms in liver cirrhosis.

MATERIAL AND METHODS

Sixteen patients with cirrhosis and 15 healthy controls underwent a gastric barostat study to assess gastric accommodation to a meal and sensory thresholds for first perception and discomfort. The patients also underwent a slow caloric satiety drinking test. Food intake and nutritional status were also evaluated and gastrointestinal symptoms were assessed by means of a questionnaire.

RESULTS

Compared with controls, patients with cirrhosis had enhanced gastric accommodation (p<0.05) but lower daily energy intake (p<0.05). Patients with versus those without compromised nutritional status had enhanced gastric accommodation (p<0.05). Gastric accommodation was correlated to daily energy intake in controls (r=0.67, p<0.05) but not in cirrhotic patients (p>0.4). The end-point of the satiety test was inversely related to gastric volumes in cirrhotic patients. Mean post-meal balloon volumes were positively correlated to the Model for End Stage Liver Disease (MELD) score (r=0.53, p<0.05). Sensory thresholds did not differ between patients and controls but were related to gastrointestinal symptom severity and cirrhosis severity scores in the patients.

CONCLUSIONS

Gastric accommodation is increased in cirrhotic patients but there seems to be some disturbance in its relation to energy intake. The satiety drinking test is not a good surrogate marker of accommodation in cirrhotic patients. In cirrhosis the severity of gastrointestinal symptoms is related to gastric sensitivity.

Contribution of ascites to impaired gastric function and nutritional intake in patients with cirrhosis and ascites

BACKGROUND & AIMS

Protein calorie malnutrition and weight loss are common among patients with cirrhosis and ascites. The cause of these symptoms is unclear, with several putative mechanisms proposed. The primary aims of this study were to compare gastric volumes and accommodation between patients with cirrhosis complicated by ascites and healthy controls, and to evaluate the effect of large-volume paracentesis in the patient group.

METHODS

Patients with cirrhosis and ascites underwent assessment of gastric volumes as measured by single-photon emission computed tomography, gastric sensation assessed by a validated nutrient drink test, and a 3-day assessment of caloric intake before and after large-volume paracentesis. Age- and sex-adjusted linear regression models were used to compare gastric volumes and accommodation ratios between patients and healthy volunteers. Paired Wilcoxon rank-sum tests were used to compare gastric measures before and after paracentesis among the patient group.

RESULTS

Fifteen patients (median age, 54 y) were compared with 112 healthy (age- and sex-matched) controls. Median postprandial gastric volumes (627 mL patients vs 721 healthy controls) and gastric accommodation were reduced significantly in patients compared with healthy controls (P = .02 and .006, respectively). After paracentesis: (1) fasting gastric volumes were increased (median 312 mL post- vs 241 mL pre-, P = .04), (2) patients tolerated ingestion of larger maximum volumes (median 964 mL post- vs 738 mL pre-, P = .04), and (3) caloric intake was increased (median 34% kcal post- vs 3110 kcal pre-, P = .005).

CONCLUSIONS

Postprandial gastric volumes and accommodation ratios are reduced in patients with cirrhosis and ascites compared with healthy controls. In addition, large-volume paracentesis increases fasting gastric volumes, volumes ingested until maximal satiation, and caloric intake.

Gastroduodenal motility

PURPOSE OF REVIEW

The neuromuscular function of the stomach and duodenum provides the mechanical forces that drive digestion and are responsible for sensations of satiety and of dyspepsia. This article reviews (1) the neuroendocrine factors controlling upper gastrointestinal motility, (2) noninvasive techniques to evaluate gastroduodenal motility, and (3) the pathophysiology and treatment of gastroparesis.

RECENT FINDINGS

Nutrients in the duodenum inhibit gastric emptying via a feedback pathway that involves release of cholecystokinin and serotonin (5-HT) from neuroendocrine cells; both act peripherally, cholecystokinin via cholecystokinin A receptors and serotonin via 5-HT3 receptors. The dorsal vagal complex plays a central role in the gastric inhibition mediated by tumor necrosis factor-alpha. The construction of maps that define intestinal movements in time and space has now been extended to the stomach. MRI compares favorably with the barostat in assessing gastric volume accommodation to meals and drugs and has the advantage of being noninvasive and showing contractions. Gastroparesis is increasingly recognized as a complication of end-stage liver disease; ascites plays no role in this, but portal hypertension stiffens the gastric walls and creates hypoxic conditions that may interfere with the neuromuscular functions of the stomach. Promising for the treatment of gastroparesis are clonidine, sildenafil, and intrapyloric botulinum toxin. Electrical stimulation triggers a vagally mediated relaxation of the stomach.

SUMMARY

Drugs may be designed that specifically act on 5-HT3, cholecystokinin, or TNF-alpha receptors. Spatiotemporal maps should boost the diagnostic yield from dynamic imaging of motility using ultrasound, computed axial tomography scan, or MRI and the understanding of the mechanical forces driving digestion. Symptomatic benefit in gastroparesis may derive more from improved accommodation than gastric emptying.