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Varma R, Chakraborty SC, Ramu SK, Burton DD, Deb B, Ryks MD, Feuerhak KJ, Bailey KR, Bharucha AE. Effects of ondansetron on symptoms during a gastric emptying study and enteral lipid challenge and on daily symptoms in diabetic gastroenteropathy. Neurogastroenterol Motil 2024; 36:e14857. [PMID: 38946172 PMCID: PMC11321918 DOI: 10.1111/nmo.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/24/2024] [Accepted: 06/17/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND This study compared the effects of ondansetron and placebo in patients with diabetes mellitus and symptoms of dyspepsia (diabetic gastroenteropathy [DGE]). METHODS We performed a randomized, double-blinded, placebo-controlled study of ondansetron tablets (8 mg) three times daily for 4 weeks in DGE patients. Symptoms were assessed with the Gastroparesis Cardinal Symptom Index daily diaries. Gastric emptying (GE) of solids (scintigraphy) and duodenal lipid infusions (300 kcal over 2 h) were each assessed twice, with placebo and ondansetron. Drug effects on GE, symptoms during the GE study and during lipid infusion, and daily symptoms were analyzed. KEY RESULTS Of 41 patients, 37 completed both GE studies and one completed 1; 31 completed both lipid infusions and four only placebo; and all 35 randomized patients completed 4 weeks of treatment. Compared to placebo, ondansetron reduced the severity of fullness (p = 0.02) and belching (p = 0.049) during lipid infusion but did not affect GE T1/2. Both ondansetron and placebo improved daily symptoms versus the baseline period (p < 0.05), but the differences were not significant. In the analysis of covariance of daily symptoms during the treatment period, the interaction term between treatment and the acute effect of ondansetron on symptoms during lipid challenge was significant (p = .024). CONCLUSIONS & INFERENCES Ondansetron significantly reduced fullness during enteral lipid infusion in patients with DGE. Overall, ondansetron did not improve daily symptoms versus placebo. But patients in whom ondansetron improved symptoms during enteral lipid challenge were perhaps more likely to experience symptom relief during daily treatment.
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Affiliation(s)
- Revati Varma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Duane D. Burton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael D. Ryks
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kelly J. Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kent R. Bailey
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Wang XJ, O’Connor M, Peck T, Johnston G, Prichard DO. Extensive scintigraphic gastric motor function testing with concurrent symptom recording predicts prospectively measured daily dyspeptic symptoms. Neurogastroenterol Motil 2024; 36:e14819. [PMID: 38816956 PMCID: PMC11344222 DOI: 10.1111/nmo.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 03/14/2024] [Accepted: 05/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Absent "organic" disease, dyspeptic symptoms may arise from abnormal gastric sensation, accommodation, motility or emptying (GE). Extensive gastric sensorimotor evaluation is rarely undertaken because testing is prolonged, invasive, poorly tolerated or unavailable. AIMS To investigate whether gastric antral motor function, evaluated with scintigraphy, predicts GE. To explore whether motor testing with symptom recording predicts day-to-day symptoms in patients with dyspepsia. METHODS GE was determined using a scintigraphic solid-meal protocol (296 kcal, 35% fat). Antral motility was estimated from 10 min of scintigraphic time-activity curves acquired 40 min after meal consumption. An antral motility index (MI) was derived from contraction amplitude and frequency. Intra-gastric distribution of the meal on scintograms at 1 h (IGD1) was determined. Meal-induced symptoms were evaluated by questionnaire. Patients completed the Gastroparesis Cardinal Symptom Index Daily Diary (GCSI-DD) for 14 days. RESULTS Twelve healthy participants and 23 prospectively recruited patients completed the study. Nine patients had delayed, and 2 had rapid, GE. In univariate analysis MI explained 42% of GE half-time. In multivariate analysis MI and GE half-time explained 25% of the variance in meal-induced symptoms. While scintigraphic evaluation of gastric motor function with symptom recording explained 80% of the variance in the GCSI-DD, meal-induced symptoms were the only significant predictor. However, among patients with delayed GE, MI, GE half-time, IGD1, and meal-induced symptoms all significantly predicted GCSI-DD. CONCLUSIONS Antral motility predicts GE. In exploratory analyses, only meal-induced symptoms predicted daily symptoms among patients with dyspepsia. However, motor function also predicted symptoms in patients with delayed GE.
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Affiliation(s)
- Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael O’Connor
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Taylor Peck
- Division of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Geoffrey Johnston
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - David O. Prichard
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Gastroenterology and Hepatology, St James’ Hospital, Dublin, Ireland
- University of Dublin, Trinity College, Dublin, Ireland
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O'Grady G, Varghese C, Schamberg G, Calder S, Du P, Xu W, Tack J, Daker C, Mousa H, Abell TL, Parkman HP, Ho V, Bradshaw LA, Hobson A, Andrews CN, Gharibans AA. Principles and clinical methods of body surface gastric mapping: Technical review. Neurogastroenterol Motil 2023; 35:e14556. [PMID: 36989183 PMCID: PMC10524901 DOI: 10.1111/nmo.14556] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/29/2023] [Accepted: 02/12/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND AND PURPOSE Chronic gastric symptoms are common, however differentiating specific contributing mechanisms in individual patients remains challenging. Abnormal gastric motility is present in a significant subgroup, but reliable methods for assessing gastric motor function in clinical practice are lacking. Body surface gastric mapping (BSGM) is a new diagnostic aid, employs multi-electrode arrays to measure and map gastric myoelectrical activity non-invasively in high resolution. Clinical adoption of BSGM is currently expanding following studies demonstrating the ability to achieve specific patient subgrouping, and subsequent regulatory clearances. An international working group was formed in order to standardize clinical BSGM methods, encompassing a technical group developing BSGM methods and a clinical advisory group. The working group performed a technical literature review and synthesis focusing on the rationale, principles, methods, and clinical applications of BSGM, with secondary review by the clinical group. The principles and validation of BSGM were evaluated, including key advances achieved over legacy electrogastrography (EGG). Methods for BSGM were reviewed, including device design considerations, patient preparation, test conduct, and data processing steps. Recent advances in BSGM test metrics and reference intervals are discussed, including four novel metrics, being the 'principal gastric frequency', BMI-adjusted amplitude, Gastric Alimetry Rhythm Index™, and fed: fasted amplitude ratio. An additional essential element of BSGM has been the introduction of validated digital tools for standardized symptom profiling, performed simultaneously during testing. Specific phenotypes identifiable by BSGM and the associated symptom profiles were codified with reference to pathophysiology. Finally, knowledge gaps and priority areas for future BSGM research were also identified by the working group.
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Affiliation(s)
- Gregory O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Alimetry Ltd, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Gabriel Schamberg
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Alimetry Ltd, Auckland, New Zealand
| | | | - Peng Du
- Alimetry Ltd, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - William Xu
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Jan Tack
- Department of Gastroenterology, University Hospitals, Leuven, Belgium
| | | | - Hayat Mousa
- Division of Gastroenterology, Lustgarten Motility Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Thomas L Abell
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Henry P Parkman
- Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Vincent Ho
- Western Sydney University, Sydney, New South Wales, Australia
| | | | | | - Christopher N Andrews
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Armen A Gharibans
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Alimetry Ltd, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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Xiao AH, Kathavarayan Ramu S, Gautam M, Bharucha AE. Defecatory disorders in patients with type 1 diabetes and chronic constipation. Neurogastroenterol Motil 2023:e14599. [PMID: 37052404 DOI: 10.1111/nmo.14599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/07/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Chronic constipation (CC) may be caused by defecatory disorders (DDs) and associated with reduced rectal sensation. Among patients with type 1 diabetes (T1D) and CC (T1DCC patients), the prevalence of DDs and reduced rectal sensation is unknown. We sought to compare complications of T1D, anorectal dysfunction, and CC symptoms, among T1DCC patients with versus without a DD. METHODS Anorectal pressures at rest and during squeeze and evacuation, as well as rectal sensation and rectal balloon expulsion time (BET) were measured with high-resolution anorectal manometry in 114 consecutive T1DCC patients. RESULTS Thirty-seven patients (32%) had prolonged BET, suggestive of a DD. Complications of T1D included peripheral neuropathy (n = 67, 59%), retinopathy (n = 42, 37%), and nephropathy (n = 26, 23%). Among these complications, only retinopathy was associated with, that is, more prevalent in patients with normal (45%) than prolonged BET (19%). Compared with patients with normal BET, patients with prolonged BET had a lower rectal pressure (mean [SD], 32 [23] mm Hg vs. 23 [19] mm Hg, p = 0.03), greater anal pressure (91 [23] mm Hg vs. 68 [36] mm Hg, p < 0.001), and lower rectoanal gradient (-67 [30] mm Hg vs. -36 [32] mm Hg, p < 0.0001) during evacuation. Anal resting pressure and anal squeeze increment were below normal in 14 (13%) and 32 (29%) of patients and one or more rectal sensory thresholds were above normal in 34 (30%) patients; these abnormalities affected similar proportions in the normal and prolonged BET cohorts. CONCLUSIONS Among T1DCC patients, 37 (32%) had prolonged BET, which was associated with anorectal pressures indicative of a DD but was not associated with reduced rectal sensation, suggesting that DDs are more likely explained by abdomino-anal dyscoordination than visceral disturbance.
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Affiliation(s)
- Alexander H Xiao
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States
| | | | - Misha Gautam
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Sebaratnam G, Karulkar N, Calder S, Woodhead JS, Keane C, Carson DA, Varghese C, Du P, Waite SJ, Tack J, Andrews CN, Broadbent E, Gharibans AA, O’Grady G. Standardized system and App for continuous patient symptom logging in gastroduodenal disorders: Design, implementation, and validation. Neurogastroenterol Motil 2022; 34:e14331. [PMID: 35156270 PMCID: PMC9541247 DOI: 10.1111/nmo.14331] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/09/2022] [Accepted: 01/22/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Functional gastroduodenal disorders include functional dyspepsia, chronic nausea and vomiting syndromes, and gastroparesis. These disorders are common, but their overlapping symptomatology poses challenges to diagnosis, research, and therapy. This study aimed to introduce and validate a standardized patient symptom-logging system and App to aid in the accurate reporting of gastroduodenal symptoms for clinical and research applications. METHODS The system was implemented in an iOS App including pictographic symptom illustrations, and two validation studies were conducted. To assess convergent and concurrent validity, a diverse cohort with chronic gastroduodenal symptoms undertook App-based symptom logging for 4 h after a test meal. Individual and total post-prandial symptom scores were averaged and correlated against two previously validated instruments: PAGI-SYM (for convergent validity) and PAGI-QOL (for concurrent validity). To assess face and content validity, semi-structured qualitative interviews were conducted with patients. KEY RESULTS App-based symptom reporting demonstrated robust convergent validity with PAGI-SYM measures of nausea (rS =0.68), early satiation (rS =0.55), bloating (rS =0.48), heartburn (rS =0.47), upper gut pain (rS =0.40), and excessive fullness (rS =0.40); all p < 0.001 (n = 79). The total App-reported Gastric Symptom Burden Score correlated positively with PAGI-SYM (rS =0.56; convergent validity; p < 0.001), and negatively with PAGI-QOL (rS = -0.34; concurrent validity; p = 0.002). Interviews demonstrated that the pictograms had adequate face and content validity. CONCLUSIONS AND INFERENCES The continuous patient symptom-logging App demonstrated robust convergent, concurrent, face, and content validity when used within a 4-h post-prandial test protocol. The App will enable standardized symptom reporting and is anticipated to provide utility in both research and clinical practice.
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Affiliation(s)
| | | | - Stefan Calder
- The University of AucklandAucklandNew Zealand,Alimetry LtdAucklandNew Zealand
| | - Jonathan S.T. Woodhead
- Alimetry LtdAucklandNew Zealand,Maurice Wilkins Centre for Molecular BiodiscoveryAucklandNew Zealand
| | - Celia Keane
- The University of AucklandAucklandNew Zealand,Alimetry LtdAucklandNew Zealand
| | | | | | - Peng Du
- The University of AucklandAucklandNew Zealand,Alimetry LtdAucklandNew Zealand
| | | | - Jan Tack
- Department of GastroenterologyUniversity HospitalsLeuvenBelgium
| | - Christopher N. Andrews
- Alimetry LtdAucklandNew Zealand,Division of GastroenterologyCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | | | - Armen A. Gharibans
- The University of AucklandAucklandNew Zealand,Alimetry LtdAucklandNew Zealand
| | - Greg O’Grady
- The University of AucklandAucklandNew Zealand,Alimetry LtdAucklandNew Zealand
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Parkman HP, Van Natta ML, Maurer AH, Koch KL, Grover M, Malik Z, Sarosiek I, Abell TL, Bulat R, Kuo B, Shulman RJ, Farrugia G, Miriel L, Tonascia J, Hamilton F, Pasricha PJ, McCallum RW. Postprandial symptoms in patients with symptoms of gastroparesis: roles of gastric emptying and accommodation. Am J Physiol Gastrointest Liver Physiol 2022; 323:G44-G59. [PMID: 35502871 PMCID: PMC9236865 DOI: 10.1152/ajpgi.00278.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Patients often are evaluated for gastroparesis because of symptoms occurring with meals. Gastric emptying scintigraphy (GES) is used for gastroparesis diagnosis, although results are not well correlated with gastroparesis symptoms. The aim of this study is to assess relationships between gastroparesis symptoms, gastric emptying (GE), and gastric accommodation (GA). Patients with symptoms of gastroparesis completed the Patient Assessment of Upper GI Symptoms (PAGI-SYM) and recorded symptoms during GES and water load satiety test (WLST), an indirect assessment for GA. A total of 109 patients with gastroparesis symptoms were assessed. Symptom severity increased after GES meal for stomach fullness, belching, nausea, abdominal burning, and abdominal pain. There was no difference in symptoms after meal between patients with delayed (n = 66) and normal (n = 42) GE. Diabetic patients (n = 26) had greater gastric retention than idiopathic patients (n = 78), but idiopathic patients had greater postprandial nausea, stomach fullness, and abdominal pain. Water consumed during WLST averaged 421 ± 245 mL. Idiopathic patients had greater nausea scores during WLST than diabetic patients. In comparison to those with normal water consumption (≥238 mL; n = 80), patients with impaired water ingestion (<238 mL; n = 26) had increased stomach fullness, early satiety, postprandial fullness, and loss of appetite on PAGI-SYM. Patients with delayed and normal GE had similar symptom profiles during GES and WLST. Idiopathic patients had less gastric retention but more symptoms after GES meal and after WLST compared with diabetic patients. Patients with impaired water consumption during WLST had increased symptoms by PAGI-SYM. These data suggest that impaired GA, rather than GE, may be important in explaining postprandial symptoms in patients with symptoms of gastroparesis.NEW & NOTEWORTHY Patients with delayed and normal gastric emptying (GE) had similar symptom profiles during gastric emptying scintigraphy (GES). Idiopathic patients with symptoms of gastroparesis had less gastric retention by GES; but more symptoms after GES meal and after water load satiety test (WLST) compared with diabetic patients. In patients with symptoms of gastroparesis, symptoms after WLST increased with decreasing water consumption. Early satiety and loss of appetite were associated with decreased water consumption during WLST. Thus, impaired accommodation and perhaps visceral hypersensitivity are important in explaining postprandial symptoms in gastroparesis.
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Affiliation(s)
- Henry P. Parkman
- 1Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Mark L. Van Natta
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Alan H. Maurer
- 1Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Kenneth L. Koch
- 3Department of Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Madhusudan Grover
- 4Department of Gastroenterology, School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Zubair Malik
- 1Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Irene Sarosiek
- 5Department of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Thomas L. Abell
- 6Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Robert Bulat
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Braden Kuo
- 7Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Robert J. Shulman
- 8Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Gianrico Farrugia
- 4Department of Gastroenterology, School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Laura Miriel
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James Tonascia
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Frank Hamilton
- 9Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Pankaj J. Pasricha
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard W. McCallum
- 5Department of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
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Deb B, O’Brien DR, Chunawala ZS, Bharucha AE. Duodenal Mucosal Expression of COVID-19-Related Genes in Health, Diabetic Gastroenteropathy, and Functional Dyspepsia. J Clin Endocrinol Metab 2022; 107:e2600-e2609. [PMID: 35090021 PMCID: PMC8807322 DOI: 10.1210/clinem/dgac038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT SARS-CoV-2 infects the gastrointestinal tract and may be associated with symptoms that resemble diabetic gastroparesis. Why patients with diabetes who contract COVID-19 are more likely to have severe disease is unknown. OBJECTIVE We aimed to compare the duodenal mucosal expression of SARS-CoV-2 and inflammation-related genes in diabetes gastroenteropathy (DGE), functional dyspepsia (FD), and healthy controls. METHODS Gastrointestinal transit, and duodenal mucosal mRNA expression of selected genes were compared in 21 controls, 39 DGE patients, and 37 FD patients from a tertiary referral center. Pathway analyses were performed. RESULTS Patients had normal, delayed (5 FD [13%] and 13 DGE patients [33%]; P = 0.03 vs controls), or rapid (5 FD [12%] and 5 DGE [12%]) gastric emptying (GE). Compared with control participants, 100 SARS-CoV-2-related genes were increased in DGE (FDR < 0.05) vs 13 genes in FD; 71 of these 100 genes were differentially expressed in DGE vs FD but only 3 between DGE patients with normal vs delayed GE. Upregulated genes in DGE include the SARS-CoV2 viral entry genes CTSL (|Fold change [FC]|=1.16; FDR < 0.05) and CTSB (|FC|=1.24; FDR < 0.05) and selected genes involved in viral replication (eg, EIF2 pathways) and inflammation (CCR2, CXCL2, and LCN2, but not other inflammation-related pathways eg, IL-2 and IL-6 signaling). CONCLUSION Several SARS-CoV-2-related genes were differentially expressed between DGE vs healthy controls and vs FD but not between DGE patients with normal vs delayed GE, suggesting that the differential expression is related to diabetes per se. The upregulation of CTSL and CTSB and replication genes may predispose to SARS-CoV2 infection of the gastrointestinal tract in diabetes.
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Affiliation(s)
- Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel R O’Brien
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Zainali S Chunawala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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