Non-invasive assessment of gastrointestinal motility disorders in diabetic patients with and without cardiovascular signs of autonomic neuropathy

Prevalence and Risk Factors of Constipation Symptoms among Patients Undergoing Colonoscopy: A Single-Center Cross-Sectional Study

INTRODUCTION

Constipation is one of the most common gastrointestinal symptoms. It may compromise quality of life and social functioning and result in increased healthcare use and costs. We aimed to evaluate the prevalence and risk factors of constipation symptoms, as well as those of refractory constipation symptoms among patients who underwent colonoscopy.

METHODS

Over 4.5 years, patients who underwent colonoscopy and completed questionnaires were analyzed. Patients' symptoms were evaluated using the Gastrointestinal Symptoms Rating Scale.

RESULTS

Among 8,621 eligible patients, the prevalence of constipation symptoms was 33.3%. Multivariate analysis revealed female sex (odds ratio [OR] 1.7, p < 0.001), older age (OR 1.3, p < 0.001), cerebral stroke with paralysis (OR 1.7, p = 0.009), chronic renal failure (OR 2.6, p < 0.001), ischemic heart disease (OR 1.3, p = 0.008), diabetes (OR 1.4, p < 0.001), chronic obstructive pulmonary disease (OR 1.5, p = 0.002), benzodiazepine use (OR 1.7, p < 0.001), antiparkinsonian medications use (OR 1.9, p = 0.030), and opioid use (OR 2.1, p = 0.002) as independent risk factors for constipation symptoms. The number of patients taking any medication for constipation was 1,134 (13.2%); however, refractory symptoms of constipation were still present in 61.4% of these patients. Diabetes (OR 1.5, p = 0.028) and irritable bowel syndrome (OR 3.1, p < 0.001) were identified as predictors for refractory constipation symptoms.

CONCLUSIONS

Constipation occurred in one-third of patients, and more than half of patients still exhibited refractory symptoms of constipation despite taking laxatives. Multiple medications and concurrent diseases seem to be associated with constipation symptoms.

Effects of meditation on physiological and metabolic parameters in patients with type 2 diabetes mellitus "MindDM": study protocol for a randomized controlled trial

BACKGROUND

Sri Lanka is faced with the challenge of managing a large population with diabetes mellitus by 2030. Psychological stress plays a major role in disease outcome by exerting physiological, psychological and social effects on individuals with chronic disorders. Meditation-based interventions have positive effects on the management of stress and diabetes, which are mediated via modulation of neuro-humoral mechanisms and autonomic functions, among others. Mechanisms of bio-physiological effects of meditation are considered to be through reduction of stress hormones, improvement of insulin resistance and improvement of autonomic dysfunction.

METHODS

This study will be conducted as an open-label, randomized controlled clinical trial in the Faculty of Medicine, University of Colombo. The aim is to investigate the effects of meditation on glycaemic control and possible mechanisms of how meditation affects glycaemic control in patients with type 2 diabetes. The study was approved by the Ethics Review Committee of the Faculty of Medicine, University of Colombo (ERC/2019/094). Patients who are attending the professorial unit medical clinic with type 2 diabetes (172 in total) will be recruited based on inclusion-exclusion criteria. Patients who have never meditated or rarely meditated (less than once every three months) will be randomized using block randomization to meditation and waitlisted arms (1:1 allocation ratio). The meditation arm will undergo a mindfulness meditation program (selected after studying several meditation methods) conducted by a qualified instructor weekly for a period of 12 weeks in addition to usual care, while the waitlisted arm will only receive usual care. Daily meditation practices will be recorded in a diary. The primary outcome measure is HbA1c. Secondary outcome measures are fasting blood sugar, fructosamine, insulin resistance (calculated using fasting serum insulin), 24-h urinary cortisol, body mass index, cardiac autonomic reflex testing (Ewing's battery of tests) and orocecal transit time using hydrogen breath analysis. All these will be done prior to commencement of the intervention and after 3 months in both arms. Data will be analysed using SPSS V-23.

DISCUSSION

This study aims to identify the effect of mindfulness meditation on glycaemic control and the possible mechanisms (neuro humoral and autonomic functions) by which beneficial effects are mediated.

TRIAL REGISTRATION

Registered under Sri Lanka Clinical Trial Registry: SLCTR/2021/015 The Universal Trial Number (UTN) U1111-1266-8640.

The Prevalence of Enteropathy Symptoms from the Lower Gastrointestinal Tract and the Evaluation of Anorectal Function in Diabetes Mellitus Patients

Complications affecting the gastrointestinal tract often occur in the course of diabetes mellitus (DM). The aim of this study was to evaluate enteropathy symptoms and anorectal function using high-resolution anorectal manometry (HRAM). Fifty DM patients and 20 non-DM controls were enrolled into the study. Clinical data and laboratory tests were collected, physical examination and HRAM were performed. Symptoms in the lower gastrointestinal tract were reported by 72% of patients. DM patients with a long disease duration reported anal region discomfort (p = 0.028) and a sensation of incomplete evacuation (p = 0.036) more often than patients with shorter diabetes duration. Overall, DM patients had a lower maximal squeeze pressure (MSP) (p = 0.001) and a higher mean threshold of minimal rectal sensation (p < 0.01) than control subjects. They presented with enhanced features of dyssynergic defection than the control group. MSP and maximal resting pressure (MRP) were significantly lower in the group of long-term diabetes (p = 0.024; p = 0.026 respectively) than in patients with a short-term diabetes. The same observation was noted for patients with enteropathy symptoms that control for MSP (p < 0.01; p < 0.01; p = 0.03) and MRP (p < 0.001; p = 0.0036; p = 0.0046), respectively, for incontinence, constipation, and diarrhea. Symptoms in the lower gastrointestinal tract are often reported by DM patients. All DM patients have impaired function of the external anal sphincter and present enhanced features of dyssynergic defecation and also impaired visceral sensation. Patients with long-standing DM and patients with enteropathy symptoms have severely impaired function of both anal sphincters.

High-resolution colonic manometry and its clinical application in patients with colonic dysmotility: A review

The detailed process and mechanism of colonic motility are still unclear, and colonic motility disorders are associated with numerous clinical diseases. Colonic manometry is considered to the most direct means of evaluating colonic peristalsis. Colonic manometry has been studied for more than 30 years; however, the long duration of the examination, high risk of catheterization, huge amount of real-time data, strict catheter sterilization, and high cost of disposable equipment restrict its wide application in clinical practice. Recently, high-resolution colonic manometry (HRCM) has rapidly developed into a major technique for obtaining more effective information involved in the physiology and/or pathophysiology of colonic contractile activity in colonic dysmotility patients. This review focuses on colonic motility, manometry, operation, and motor patterns, and the clinical application of HRCM. Furthermore, the limitations, future directions, and potential usefulness of HRCM in the evaluation of clinical treatment effects are also discussed.

Use of high-resolution colonic manometry to establish etiology and direct treatment in patients with constipation: Case series with correlation to histology

BACKGROUND AND AIM

Different clinical treatments are available to treat patients with constipation. We aimed to study the etiology and direct treatment in a case series of patients with constipation by the use of high-resolution colonic manometry (HRCM).

METHODS

High-resolution colonic manometry was used to record the colorectal peristaltic contractions of the entire colon in patients. Based on the results of HRCM, 151 patients with constipation were classified into groups and received different clinical treatment such as a total or subtotal colectomy, local excision, or conservative treatment. Paraffin-embedded samples obtained after resection were studied using hematoxylin and eosin, as well as immunohistochemical staining.

RESULTS

All patients underwent HRCM over 24 h. Based on the amplitude, intensity, and trends in peristaltic contractions recorded by HRCM, we observed 117 patients with slow-transit constipation and 34 with functional outlet obstruction constipation. After an overall evaluation of the results of HRCM and anorectal function, 26, 23, 27, and 75 patients were treated with total colectomy, subtotal colectomy, local excision, and conservative treatment, respectively. Furthermore, histological examination of surgical samples showed vacuolar degeneration of nerve plexuses as well as of the muscularis propria, which also showed fibrosis in its outer layers in patients with constipation.

CONCLUSION

Different types of constipation showed different colonic motility patterns and morphological changes in the colonic wall. HRCM plays an important role in the diagnosis and classification of patients with constipation. Furthermore, HRCM can accurately identify the diseased colonic segments and help to choose the appropriate treatment.

Eggs: good or bad?

Eggs have one of the lowest energy to nutrient density ratios of any food, and contain a quality of protein that is superior to beef steak and similar to dairy. From a nutritional perspective, this must qualify eggs as 'good'. The greater burden of proof has been to establish that eggs are not 'bad', by increasing awareness of the difference between dietary and blood cholesterol, and accumulating sufficient evidence to exonerate eggs from their associations with CVD and diabetes. After 60 years of research, a general consensus has now been reached that dietary cholesterol, chiefly from eggs, exerts a relatively small effect on serum LDL-cholesterol and CVD risk, in comparison with other diet and lifestyle factors. While dietary guidelines have been revised worldwide to reflect this view, associations between egg intake and the incidence of diabetes, and increased CVD risk in diabetes, prevail. These associations may be explained, in part, by residual confounding produced by other dietary components. The strength of evidence that links egg intake to increased CVD risk in diabetes is also complicated by variation in the response of serum LDL-cholesterol to eggs and dietary cholesterol in types 1 and 2 diabetes. On balance, the answer to the question as to whether eggs are 'bad', is probably 'no', but we do need to gain a better understanding of the effects of dietary cholesterol and its association with CVD risk in diabetes.

Blunting of Colon Contractions in Diabetics with Gastroparesis Quantified by Wireless Motility Capsule Methods

Generalized gut transit abnormalities are observed in some diabetics with gastroparesis. Relations of gastric emptying abnormalities to colon contractile dysfunction are poorly characterized. We measured colon transit and contractility using wireless motility capsules (WMC) in 41 healthy subjects, 12 diabetics with gastroparesis (defined by gastric retention >5 hours), and 8 diabetics with normal gastric emptying (≤5 hours). Overall numbers of colon contractions >25 mmHg were calculated in all subjects and were correlated with gastric emptying times for diabetics with gastroparesis. Colon transit periods were divided into quartiles by time and contraction numbers were calculated for each quartile to estimate regional colon contractility. Colon transit in diabetics with gastroparesis was prolonged vs. healthy subjects (P<0.0001). Overall numbers of colon contractions in gastroparetics were lower than controls (P = 0.02). Diabetics with normal emptying showed transit and contraction numbers similar to controls. Gastric emptying inversely correlated with overall contraction numbers in gastroparetics (r = -0.49). Numbers of contractions increased from the 1^st to 4^th colon transit quartile in controls and diabetics with normal emptying (P≤0.04), but not gastroparetics. Numbers of contractions in the 3^rd and 4^th quartiles were reduced in gastroparetics vs. healthy controls (P≤0.05) and in the 4^th quartile vs. diabetics with normal emptying (P = 0.02). Numbers of contractions were greatest in the final 15 minutes of transit, but were reduced in gastroparetics vs. healthy controls and diabetics with normal emptying (P≤0.005). On multivariate analyses, differences in numbers of contractions were not explained by demographic or clinical variables. In conclusion, diabetics with gastroparesis exhibit delayed colon transit associated with reductions in contractions that are prominently blunted in latter transit phases and which correlate with delayed gastric emptying, while diabetics with normal emptying show no significant colonic impairments. These findings emphasize diabetic gastroparesis may be part of a generalized dysmotility syndrome.

Interleukin-6 (IL-6) mediated the increased contraction of distal colon in streptozotocin-induced diabetes in rats via IL-6 receptor pathway

Colonic dysmotility occurs in diabetes and blood plasma interleukin (IL)-6 levels are significantly elevated in type 1 diabetes mellitus. The aim of this study was to investigate whether IL-6 and the IL-6 receptor pathway mediates colonic dysfunction in type 1 diabetes mellitus. Male SD rats were treated with a single intraperitoneally injected dose of streptozotocin (STZ), and those displaying sustained high blood glucose were selected as diabetes mellitus models. Longitudinal muscle strips of colon were prepared to monitor colonic contraction in vitro. Contractile responses of strips of colon were recorded following treatment with IL-6 in control animals, and following anti IL-6 antibody treatment in STZ-induced diabetes in rats. Concentration of IL-6 in plasma and colon were determined by ELISA. Expressions of IL-6 α-receptor and IL-6 β-receptor in colon tissues were determined by immunohistochemistry or Western blot analysis. The non-diabetes rats treated with IL-6 and the untreated diabetes rats showed increased contraction of distal colon, whereas the diabetes rats treated with anti-IL-6 antibody showed decreased contraction of distal colon compared with the untreated diabetes rats. The IL-6 levels of plasma but not colon increased in diabetes rats. The expression of IL-6 α-receptor increased in diabetes rats. These results indicate that diabetes rats show an increase in the contractions of distal colon partly via the IL-6-IL-6 receptor pathway.

Beta-arrestin2 is involved in the increase of distal colonic contraction in diabetic rats

Colonic dysmotility occurs in diabetes and the patients exhibit diarrhea or constipation. The pathogenetic mechanisms underlying colonic dysmotility in diabetic patients remain poorly understood. The effects of β-arrestin2 on colonic contraction in diabetic rats were investigated for the first time. Male SD rats were treated with a single intraperitoneally injected dose of streptozotocin, and those displaying sustained high blood glucose were selected as diabetes mellitus models. Longitudinal muscle strips of the distal colon were prepared to monitor contraction of the colon in vitro. Expression of β-arrestin2 was investigated by Western blot analysis. Anti-β-arrestin2 antibody had no direct effect on the contraction of distal colonic strips in both normal and diabetic rats. Carbachol-induced contractions of distal colonic strips were higher in diabetic rats than in normal rats. Anti-β-arrestin2 antibody partly blocked carbachol-induced increases of distal colonic strips in diabetic rats. The expression level of β-arrestin2 protein in the colon was higher in diabetic rats than in normal rats. These results suggest that β-arrestin2 is involved in the increase of distal colonic contraction in diabetic rats.

Delayed small intestinal transit in patients with long-standing type 1 diabetes mellitus: investigation of the relationships with clinical features, gastric emptying, psychological distress, and nutritional parameters

BACKGROUND

Studies on small intestinal transit in type 1 diabetes mellitus have reported contradictory results. This study assessed the orocecal transit time (OCTT) in a group of patients with type 1 diabetes mellitus and its relationships with gastrointestinal symptoms, glycemic control, chronic complications of diabetes, anthropometric indices, gastric emptying, small intestinal bacterial overgrowth (SIBO), and psychological distress.

SUBJECTS AND METHODS

Twenty-eight patients with long-standing (>10 years) type 1 diabetes mellitus (22 women, six men; mean age, 39 ± 9 years) participated in the study. The lactulose hydrogen breath test was used to determine OCTT and the occurrence of SIBO. The presence of anxiety and depression was assessed by the Hospital Anxiety and Depression scale. Gastric emptying was measured by scintigraphy. Anthropometric indices included body mass index, percentage body fat, midarm circumference, and arm muscle area.

RESULTS

There was a statistically significant increase in OCTT values in diabetes patients (79 ± 41 min) in comparison with controls (54 ± 17 min) (P=0.01). Individual analysis showed that OCTT was above the upper limit (mean+2 SD) in 30.8% of patients. All anthropometric parameters were significantly decreased (P<0.05) in patients with prolonged OCTT in comparison with those with normal OCTT. In contrast, there was no statistically significant association between prolonged OCTT and gastrointestinal symptoms, peripheral neuropathy, diabetic retinopathy, glycated hemoglobin, delayed gastric emptying, SIBO, anxiety, or depression.

CONCLUSIONS

Small bowel transit may be delayed in about one-third of patients with long-standing type 1 diabetes mellitus. This abnormality seems to have a negative effect on nutritional status in these patients.

Effect of diabetes mellitus on pharmacokinetic and pharmacodynamic properties of drugs

The effects of diabetes mellitus on the pharmacokinetics and pharmacodynamics of drugs have been well described in experimental animal models; however, only minimal data exist for humans and the current knowledge regarding the effects of diabetes on these properties remains unclear. Nevertheless, it has been observed that the pharmacokinetics and pharmacodynamics of drugs are changed in subjects with diabetes. It has been reported that diabetes may affect the pharmacokinetics of various drugs by affecting (i) absorption, due to changes in subcutaneous adipose blood flow, muscle blood flow and gastric emptying; (ii) distribution, due to non-enzymatic glycation of albumin; (iii) biotransformation, due to regulation of enzymes/transporters involved in drug biotransformation; and (iv) excretion, due to nephropathy. Previously published data also suggest that diabetes-mediated changes in the pharmacokinetics of a particular drug cannot be translated to others. Although clinical studies exploring the effect of diabetes on pharmacodynamics are still very limited, there is evidence that disease-mediated effects are not limited only to pharmacokinetics but also alter pharmacodynamics. However, for many drugs it remains unclear whether these influences reflect diabetes-mediated changes in pharmacokinetics rather than pharmacodynamics. In addition, even though diabetes-mediated pharmacokinetics and pharmacodynamics might be anticipated, it is important to study the effect on each drug and not generalize from observed data. The available data indicate that there is a significant variability in drug response in diabetic subjects. The discrepancies between individual clinical studies as well as between ex vivo and clinical studies are probably due to (i) the restricted and focused population of subjects in clinical studies; (ii) failure to consider type, severity and duration of the disease; (iii) histopathological characteristics generally being missing; and (iv) other factors such as varying medication use, dietary protein intake, age, sex and obesity. The obesity epidemic in the developed world has also inadvertently influenced the directions of pharmacological research. This review attempts to map new information gained since Gwilt published his paper in Clinical Pharmacokinetics in 1991. Although a large body of research has been conducted and significant progress has been made, we still have to conclude that the available information regarding the effect of diabetes on pharmacokinetics and pharmacodynamics remains unclear and further clinical studies are required before we can understand the clinical significance of the effect. An understanding of diabetes-mediated changes as well as of the source of the variability should lead to the improvement of the medical management and clinical outcomes in patients with this widespread disease.

Enhanced nerve-stimulated muscarinic and neurokinin contractions of ileum from streptozotocin guinea-pigs

Diabetes mellitus can lead to neuropathy of enteric neurons, resulting in abnormal gut motility. These studies investigated voltage-dependent contributions of muscarinic M₃ receptor activation by acetylcholine and neurokinin NK₁ receptor activation by neurokinins to nerve-stimulated contractions of longitudinal ileal strips from STZ guinea-pigs, a type 1 diabetic model with insulin deficiency, but mild hyperglycaemia. Contractions to bethanechol, substance P methyl ester, and nerve stimulation were greater in diabetic as compared to control ileum. The muscarinic M₃ receptor antagonist 4-DAMP at lower voltages and the neurokinin NK₁ receptor antagonist SR140333 at higher voltages, but not the neurokinin NK₁ receptor antagonist CP-96,345, were more effective at inhibiting nerve-stimulated immediate peak contractions and total areas of contraction of ileum from diabetic as compared to control animals. For diabetic ileum, voltage-dependent increases in the areas of nerve-stimulated contraction were observed in the presence of 4-DAMP and CP-96,345 but not SR140333. At low voltages only, nerve-stimulated release of acetylcholine was greater from diabetic as compared to control ileum. Fluorescence intensity of tachykinin-like immunoreactivity was increased in ileal myenteric ganglia from diabetic as compared to control animals. In diabetic guinea-pigs, stronger ileal nerve-stimulated contractions reflected increased release of acetylcholine at lower voltages and tachykinins at higher voltages, as well as increased sensitivity of smooth muscle M₃ and NK₁ receptors to acetylcholine and tachykinins. Hypoinsulinaemia may be a primary contributor to intestinal motility dysfunction in type 1 diabetes mellitus.

The effect of mosapride citrate on constipation in patients with diabetes

OBJECTIVE

Constipation is one of the most common gastrointestinal complications suspected to degrade the quality of life in diabetic patients. Mosapride citrate is a novel selective 5-HT4 receptor agonist, which enhances gastric emptying and motility in the upper gastrointestinal tract facilitating acetylcholine release from the enteric cholinergic neurons. Since the receptors of 5-HT4 have been recently found in the lower intestine including the rectum in humans, we tested if mosapride improves constipation in diabetic patients.

PATIENTS AND METHODS

Diabetic patients with constipation were treated with mosapride citrate (15 mg/day, n=20) or domperidone (30 mg/day, n=12) as controls for 8 weeks. Bowel frequency was monitored and gastrointestinal symptoms were evaluated by Gastrointestinal Symptoms Rating Scale (GSRS).

RESULTS

Administration of mosapride resulted in increased bowel frequency after 4 and 8 weeks of administration, while no change was seen in the control group. Mosapride increased bowel frequency in even patients with diabetic polyneuropathy. Mosapride improved reflux and constipation evaluated by GSRS. As previously reported, glycemic control also improved by mosapride in these patients.

CONCLUSIONS

Administration of mosapride increased bowel frequency and ameliorated symptoms of reflux and constipation possibly stimulating the lower intestine. Given that mosapride has those beneficial aspects, it may be a useful prokinetic agent in treating diabetic patients with constipation.

The role of humoral autoimmunity in gastrointestinal neuromuscular diseases

Dysfunction of the gastrointestinal neuromuscular apparatus (including interstitial cells of Cajal) is presumed to underlie a heterogeneous group of disorders collectively termed gastrointestinal neuromuscular diseases (GINMDs). There is increasing experimental and clinical evidence that some GINMDs are immune-mediated, with cell-mediated dysfunction relatively well studied. Humoral (antibody)-mediated autoimmunity is associated with several well-established acquired neuromuscular diseases and is now implicated in an increasing number of less well-characterised disorders, particularly of the central nervous system. The role of autoimmunity in GINMDs has been less studied. Whilst most work has focused on the presence of antibodies directed to nuclear antigens, particularly in the context of secondary disorders such as paraneoplastic intestinal pseudo-obstruction, the possibility that 'functional' anti-neuronal antibodies directed to membrane-bound ion channels may cause disease (channelopathy) is now also being realised. The evidence for humoral autoimmunity as an etiologic factor in primary (idiopathic) and secondary GINMDs is systematically presented using the original paradigms previously applied to established autoimmune neuromuscular disorders. The presence of anti-enteric neuronal antibodies, although repeatedly demonstrated, still requires the identification of specific neuronal autoantigens and validated evidence of pathogenicity.

Oesophageal motility disorders in type 1 diabetes mellitus and their relation to cardiovascular autonomic neuropathy

The relationship between cardiovascular autonomic neuropathy (CVAN) and oesophageal dysfunction in diabetes mellitus has not been well established because reports are contradictory. The aim of this study was to assess oesophageal function and its correlation with CVAN in type 1 diabetic patients without oesophageal symptoms. Forty-six type 1 diabetic patients without oesophageal symptoms (DG) and 34 healthy volunteers (CG) were studied. Both groups underwent CVAN tests and oesophageal manometry and pH-metry. Differences between groups regarding results of cardiovascular autonomic tests and oesophageal studies were statistically analysed. Compared with the CG, the DG group showed insufficient lower oesophageal sphincter (LOS) relaxation and a higher percentage of simultaneous waves (P < 0.01). Patients with CVAN (n = 22) showed a higher prevalence of pathological simultaneous contractions (>10%), and the prevalence of simultaneous waves related to the degree of autonomic neuropathy was: 9% of patients without CVAN, 7% of those suspected to have it and 50% of patients with CVAN (P < 0.001). Factors associated with the presence of pathological simultaneous waves (>10%) were the presence of CVAN and duration of diabetes (P < 0.05, logistic regression analysis). Increase in simultaneous waves and impaired relaxation of LOS are more frequent in diabetic patients with CVAN.

Comparison between coefficient of R-R interval variation and gastric emptying in type 2 diabetes mellitus patients

BACKGROUND

Autonomic neuropathy is a common complication of diabetes mellitus (DM).

METHOD

To clarify the relationship between cardiovascular autonomic function and gastric emptying rate, we investigated the gastric emptying and coefficient of R-R interval variation (CV(RR)) of 84 type 2 diabetic patients: 28 cases without peripheral neuropathy and 56 cases with peripheral neuropathy. All patients were subjected to a gastric emptying test according to the marker method (administration of a capsule containing 20 pieces of radiopaque marker during breakfast, followed by abdominal X-ray imaging 3 and 5 h later). Patients had their CV(RR) assessed at rest and during deep breathing.

RESULTS

Gastric emptying scores were significantly correlated with CV(RR) during deep breathing and with the duration of DM, but neither age nor CV(RR) at rest in all patients. Gastric emptying scores and CV(RR) at rest and during deep breathing in patients with peripheral neuropathy were significantly deteriorated than those in patients without peripheral neuropathy. A significant correlation between gastric emptying and CV(RR) during deep breathing could be observed in the patients with peripheral neuropathy, but not in those without it.

CONCLUSIONS

These findings showed that CV(RR) during deep breathing might be a good indicator of diabetic gastropathy and that peripheral neuropathy was closely related with cardiac and gastric autonomic neuropathy in the type 2 diabetic patients.

Choline acetyltransferase and inducible nitric oxide synthase are increased in myenteric plexus of diabetic guinea pig

Alterations in enzymes in myenteric neurons from ileum were investigated in guinea pigs treated with either the pancreatic beta cell toxin streptozotocin or vehicle. After 5-6 weeks, expressions of choline acetyltransferase, neuronal nitric oxide synthase and inducible nitric oxide synthase were determined in longitudinal and myenteric plexus preparations using indirect immunohistochemistry. In ileum from streptozotocin-treated animals, the density of choline acetyltransferase-immunoreactive nerve fibers within the tertiary plexus and the percent total myenteric neurons expressing inducible nitric oxide synthase were increased, but the percent total myenteric neurons expressing neuronal nitric oxide synthase was not changed. Diabetes resulted in selective alterations in myenteric neurons including an increased density of cholinergic tertiary fibers and percentage of neurons expressing the inducible isoform of nitric oxide synthase. These adaptive changes by myenteric neurons to diabetes may contribute to gastrointestinal dysfunctions associated with diabetes.

Autonomic neuropathy and gastrointestinal motility disorders in children and adolescents with type 1 diabetes mellitus

INTRODUCTION

There is little information on the gastrointestinal motility abnormalities and autonomic neuropathy of children with gastrointestinal symptoms and type 1 diabetes mellitus (T1DM).

METHODS

The authors studied 33 consecutive patients (mean age, 15.3 years; 13 males) with T1DM (median duration, 7.7 years) attending the outpatient clinic because of chronic dyspepsia (CD; n = 14), or chronic constipation (CC; n = 19), and 48 consecutive non-T1DM patients (mean age, 13.7 years; 18 males), who presented with similar symptoms (18 with CD; 30 with CC). Fasting serum motilin concentrations and cardiovascular autonomic function tests (CAFT) were assessed and compared with those of age- and gender-matched healthy control subjects. Gastric emptying half time (GE t1/2) of a solid meal and mouth-to-anus transit time (MATT) were measured in patients with CD and CC, respectively.

RESULTS

CAFT was comparable between patients with T1DM and healthy control subjects. GE t1/2 and MATT were not different between T1DM patients and non-T1DM patients with CD and CC, respectively. However, a marginally significant positive correlation was found in the patients with T1DM between GE t1/2 and blood glucose concentrations (R = 0.54; P = 0.08). In addition, serum motilin concentrations were significantly lower in patients with T1DM compared with healthy control subjects (P < 0.0005), and in patients with T1DM and higher serum glucose concentrations compared with those with lower serum glucose concentrations (P = 0.03).

CONCLUSION

Autonomic neuropathy is not an etiological factor of gastrointestinal symptoms in children and adolescents with diabetes. Mild or moderate hyperglycemia does not affect gastrointestinal motility.

Electrogastrography as a diagnostic tool for delayed gastric emptying in functional dyspepsia and irritable bowel syndrome

Several pathophysiological mechanisms have been proposed in functional gastrointestinal (GI) disorders, e.g. altered GI motility and sensitivity. The aim of this study was to investigate gastric electrical activity (GEA) in patients with functional dyspepsia (FD) or irritable bowel syndrome (IBS) compared with healthy controls (HC), and to assess if abdominal symptoms and delayed gastric emptying are associated with alterations in GEA, as determined by electrogastrography (EGG). Forty patients with FD, IBS or both were compared with 22 HC. EGG was performed before and after a standard meal. Frequencies and amplitudes pre- and post-prandially were analysed. Furthermore, gastric emptying and symptom scores were assessed. Eight of 40 patients (20%; three FD, three IBS, two FD and IBS) had delayed gastric emptying. Disturbed gastric emptying and lack of a postprandial increase in the EGG amplitude were significantly correlated (r = 0.8; P < 0.005). No differences between controls and patients were observed in the distribution of EGG frequencies. Treatment with the prokinetically active macrolide erythromycin improved gastric emptying, GEA and symptoms (n = 4). The data suggest that EGG could be useful as a diagnostic tool in patients with FD and IBS to identify a subgroup of patients with delayed gastric emptying.

Evaluation of gallbladder volume and motility in non-insulin-dependent diabetes mellitus patients using real-time ultrasonography

AIMS

The prevalence of cholelithiasis is 2 to 3 times higher in patients with diabetes mellitus than in the normal population, especially in a group of patients with non-insulin-dependent diabetes mellitus (NIDDM). We investigated the pathogenesis of this increased prevalence by ultrasonography with a brief comparison of demographic features.

MATERIALS AND METHODS

The study group was consisted of NIDDM patients (41 males and 47 females, mean age 53.5 +/- 11 years), and the control group included healthy volunteers (33 males and 34 females, mean age 50.3 +/- 18 years). All patients were investigated after 12 hours of fasting and 30 minutes after a standard test meal. Pre-meal and post-meal gallbladder volumes were used for calculation of the ejection fraction of the gallbladder and fasting gallbladder volume.

RESULTS

In the study group, there was no correlation between the fasting gallbladder volume and age, parity, and body mass index. However, fasting gallbladder volume and duration of diabetes mellitus showed significant correlation (r = 0.212, P < 0.05). The mean ejection fraction of gallbladders in the study group was 48.48%, whereas that of the control group was 56.32%. There was a significant reduction of ejection fraction in the study group (P = 0.003).

CONCLUSION

Our study indicated that there were an increased fasting gallbladder volume and impaired ejection fraction in NIDDM patients. This may be the initiator of bile stasis in the gallbladder and subsequent cholesterol crystal and stone formation.

Autonomic nervous system evaluation: diagnosis of rectal and lower gut dysfunction

The main symptoms of autonomic dysfunction of the lower gut are diarrhoea, constipation and faecal incontinence, but these symptoms are not specific. The main diagnostic procedures in the evaluation of the lower gut are transit studies with radiopaque markers, hydrogen breath tests, tests for the differentiation between osmotic and secretory diarrhoea (fasting test and/or stool analysis for electrolytes and osmolality), anorectal manometry and EMG of the anal sphincters.

Risk factors for chronic constipation based on a general practice sample

OBJECTIVES

Many factors have been associated with the occurrence of constipation, particularly poor diet and lack of exercise. However, the importance of medications and general medical illnesses in constipation remains more uncertain. We aimed to identify risk factors for constipation from among patient clinical, therapeutic, and demographic characteristics.

METHODS

The sample was composed of patients explicitly diagnosed with chronic constipation (n = 7251), those diagnosed with constipation of unspecified chronicity (n = 6441), and a sample of controls (n = 7103). All were drawn from a general practice research database representing more than 10 yr of data collection.

RESULTS

A large number of clinical and therapeutic factors were independently associated with chronic constipation over and above age and gender. Primary neurological diseases were strongly associated with constipation but accounted for few cases. Opioids (OR = 1.6, population attributable risk [PAR] = 2.6%), diuretics (OR = 1.7, PAR = 5.6%), antidepressants (OR = 1.9, PAR = 8.2%), antihistamines (OR = 1.8, PAR = 9.2%), antispasmodics (OR = 3.3, PAR = 11.6%), anticonvulsants (OR = 2.8, PAR = 2.5%) and aluminum antacids (OR = 1.7, PAR = 3.0%) were associated with the highest risk among medications.

CONCLUSIONS

Constipation is common in primary care, and multiple medications seem to be an important contributing factor. Concurrent diseases are also associated but at most are only contributing to a minority of cases.

Small intestinal glucose absorption and duodenal motility in type 1 diabetes mellitus

OBJECTIVE

Small intestinal glucose absorption is increased in animal models of diabetes mellitus, but little data are available in humans. Small intestinal motility is reported to be frequently abnormal in patients with diabetes and could potentially affect glucose absorption. Our aim was to evaluate small intestinal glucose absorption and duodenal motor responses to intraduodenal nutrients, in patients with type 1 diabetes and controls.

METHODS

Eight type 1 patients (two with autonomic neuropathy) and nine controls were studied during euglycemia. A manometric catheter was positioned across the pylorus, and nutrient infused intraduodenally (90 kcal over 30 min), followed by a bolus of 3-O-methylglucose (3-OMG). Blood was sampled to measure glucose and 3-OMG concentrations.

RESULTS

During nutrient infusion, the number of duodenal waves did not differ between patients and controls. After the infusion, patients with diabetes had more propagated duodenal wave sequences (p < 0.05). The area under the plasma 3-OMG curve did not differ between the groups but correlated with both the blood glucose concentration at the time of 3-OMG administration (r = 0.64, p < 0.005) and the number of duodenal waves (r = 0.52, p < 0.05) and antegrade propagated duodenal sequences (r = 0.51, p < 0.05) preceding the 3-OMG bolus.

CONCLUSIONS

During euglycemia, duodenal motor responses to small intestinal nutrient are comparable in patients with relatively uncomplicated type 1 diabetes and healthy subjects, but duodenal motility after nutrient infusion is increased in patients. Small intestinal glucose absorption is similar in patients and controls, but may be dependent on the blood glucose concentration and duodenal motor activity.

Gastric emptying in diabetes: clinical significance and treatment

The outcome of recent studies has led to redefinition of concepts relating to the prevalence, pathogenesis and clinical significance of disordered gastric emptying in patients with diabetes mellitus. The use of scintigraphic techniques has established that gastric emptying is abnormally slow in approx. 30-50% of outpatients with long-standing Type 1 or Type 2 diabetes, although the magnitude of this delay is modest in many cases. Upper gastrointestinal symptoms occur frequently and affect quality of life adversely in patients with diabetes, although the relationship between symptoms and the rate of gastric emptying is weak. Acute changes in blood glucose concentration affect both gastric motor function and upper gastrointestinal symptoms. Gastric emptying is slower during hyperglycaemia when compared with euglycaemia and accelerated during hypoglycaemia. The blood glucose concentration may influence the response to prokinetic drugs. Conversely, the rate of gastric emptying is a major determinant of post-prandial glycaemic excursions in healthy subjects, as well as in Type 1 and Type 2 patients. A number of therapies currently in development are designed to improve post-prandial glycaemic control by modulating the rate of delivery of nutrients to the small intestine.

Colorectal symptoms in patients with neurological diseases

Several neurological diseases cause constipation or faecal incontinence restricting social activities and influencing quality of life. As several new treatment modalities have become available within the last few years, doctors treating patients with neurological diseases should be aware of the symptoms and have a basic knowledge of relevant treatment options. Constipation and faecal incontinence are common symptoms in patients with traumatic spinal cord injuries, spina bifida, multiple sclerosis, diabetic polyneuropathy, Parkinson's disease, stroke, and cerebral palsy. New treatment modalities are: prokinetic agents, enemas administered through the enema continence catheter or through an appendicostomy, and biofeed-back. Sacral nerve stimulation is still mostly at an experimental level and colostomy should be restricted to the few patients with most severe problems resistant to other therapy.

Delayed gastric emptying in human immunodeficiency virus infection: correlation with symptoms, autonomic function, and intestinal motility

Gastric emptying may be delayed in HIV infection. We aimed to characterize the pattern of gastric emptying in HIV seropositive subjects and correlate the findings with symptoms, as well as to identify possible etiological factors. Solid gastric emptying was measured using scintigraphy in 54 HIV seropositive subjects and 12 HIV seronegative controls. Gastrointestinal symptoms were evaluated using a standardized numerical score, and autonomic function was assessed using spectral analysis of heart rate variability. Fasting and postprandial duodenojejunal activity was recorded using strain gauge manometry catheters. Gastric emptying rate, but not lag phase, was significantly delayed in HIV-infected subjects, particularly those with enteric infections and more advanced disease. Delayed gastric emptying did not correlate with symptoms, autonomic dysfunction, or small intestinal motility. In conclusion, abnormalities found in autonomic function and gastric emptying in HIV infection are multifactorial in nature. The contribution of upper gastrointestinal motor dysfunction to gastric symptoms in such individuals is unclear.

Gastroesophageal reflux in diabetes mellitus

OBJECTIVE

Although abnormal gastroesophageal (GE) reflux is the most frequent alteration of the gastrointestinal tract, its prevalence in diabetes mellitus (DM) is not widely known. The objective of this study was to analyze both the presence of abnormal GE reflux in diabetic patients with no esophageal symptoms and the influence of cardiovascular autonomic neuropathy (CVAN) in the development of abnormal GE reflux.

METHODS

Fifty insulin-dependent diabetic patients, averaging 29.2 +/- 9.0 yr of age, who had had diabetes for > 5 yr and showed no symptoms or history of gastroesophageal disease, were compared with a control group composed of 36 healthy volunteers (18 men, 18 women) whose average age was 35.9 +/- 10.1 yr. The cardiovascular autonomic nervous system was examined in the diabetics and control subjects who complied with inclusion criteria. Long-term (24-h) ambulatory esophageal pH monitoring was performed, as well as a manometric study of the lower esophageal sphincter.

RESULTS

The parameters obtained from the monitoring showed significant differences (p < 0.01) between DM and control subjects. Abnormal GE reflux, defined as any percentage of time with esophageal pH < 4 exceeding 3.5% of total time (8.7 +/- 5.6%; range, 4.1-24.4%), was detected in 14 patients. Diabetic subjects were classified according to cardiovascular autonomic neuropathy tests (without CVAN [n = 19, 38%] and with abnormal CVAN tests [n = 31, 62%]). The pH monitoring parameters showed significant differences between these two groups (p < 0.05).

CONCLUSIONS

A higher prevalence (28%) of abnormal GE reflux appeared among asymptomatic diabetic patients than among the general population. The presence of abnormal GE reflux in diabetic patients was associated with the existence of cardiovascular autonomic neuropathy (abnormal GE reflux = 38.7% in diabetic patients with abnormal CVAN tests vs 10.5% in diabetic patients without CVAN).

Autonomic dysfunction and the gastrointestinal tract

Autonomic neuropathy of the gastrointestinal tract may represent a primary disorder, but much more often it is secondary due to systemic disorders like diabetes mellitus. This review gives an overview about the common clinical manifestations and the principles and limitations in diagnostic work-up of autonomic dysfunction of the gastrointestinal tract. Diagnostic evaluation usually includes a combination of screening tests for autonomic neuropathy and specialized diagnostic procedures for the detection of sequela of autonomic neuropathy in gastrointestinal motility.

Gastrointestinal motor function in diabetes mellitus: Relationship to blood glucose concentrations

The application of novel investigative techniques has established that there is a high prevalence of disordered gastrointestinal motor function in patients with diabetes mellitus and has provided insights into its pathogenesis and clinical significance. Acute changes in the blood glucose concentration, even within the normal postprandial range, affect both gastrointestinal motor function and the perception of sensations arising from the gastrointestinal tract. Gastric emptying is slower during hyperglycaemia and accelerated during hypoglycaemia; the perception of gastric distension is greater during hyperglycaemia than euglycaemia. The pathways mediating the effects of the blood glucose concentration on gut motility and sensation are poorly defined. The rate of gastric emptying is an important determinant of postprandial blood glucose concentrations and there is increasing evidence that gastric emptying can be modulated therapeutically in order to optimize glycaemic control in patients with diabetes.

Abnormal intragastric distribution of a liquid nutrient meal in patients with diabetes mellitus

Disordered gastric motility and emptying are well known complications of diabetes mellitus (DM), but the pattern of intragastric distribution of food has not been extensively studied in diabetics. We examined the partition of a liquid nutrient meal between the proximal and distal stomach and the relationships between intragastric distribution of food and gastric emptying (GE) and the symptoms in DM patients with and without autonomic neuropathy (AN). Fourteen healthy volunteers and 20 DM patients (13 with AN; 9 with dyspepsia symptoms) ingested a liquid nutrient meal (250 ml; 437 kcal) labeled with [99mTc]phytate. Anterior and posterior serial images of the stomach were taken for 90 min with a gamma camera. Regions of interest for the proximal and the distal halves of the stomach and for the total gastric area were defined. Counts from each region along time allowed estimation of GE and the proportion of activity retained in the proximal stomach after meal ingestion (initial) and throughout GE (mean). GE half-times in controls (median; range: 66 min; 29-90 min) were not significantly different from diabetics (76 min; 5->150 min, P > 0.10), but abnormal GE was found in 11 DM patients (seven delayed and four rapid). In DM patients, initial retention in the proximal stomach (42%; 16-79%) was significantly lower (P < 0.02) than in controls (55%; 44-71%). Mean retention in the proximal stomach throughout emptying also was significantly lower (P < 0.05) in DM patients (43%; 18-58%) than in controls (51%; 32-69%). There were no differences between subgroups of patients with normal, delayed, or rapid gastric emptying regarding mean meal retention in the proximal stomach. Patients with evidence of AN or with dyspepsia symptoms had significantly decreased retention of food in the proximal stomach throughout gastric emptying. We concluded that patients with diabetes mellitus have abnormally decreased retention of gastric contents in the proximal stomach after a liquid meal, which seems to be related to the occurrence of autonomic neuropathy and dyspepsia symptoms, but not to disordered gastric emptying.

Effect of cisapride on gastric dysrhythmia and emptying of indigestible solids in type-II diabetic patients

BACKGROUND

Abnormal gastric slow-wave frequencies have been observed in diabetic gastroparesis. To evaluate the effect of cisapride on gastric dysrhythmia and emptying of indigestible solids, 20 type-II diabetic patients with symptoms suggestive of gastroparesis were enrolled in this study.

METHODS

Cutaneous electrogastrography, gastric emptying of radiopaque markers, and evaluation of upper gastrointestinal symptoms were performed before and after administration of an 8-week course of cisapride.

RESULTS

The fasting-state percentages of dominant frequency in normal and tachygastric ranges improved significantly after an 8-week course of cisapride treatment (P < 0.01 and P < 0.05, respectively). The post-meal percentages of dominant frequency in the tachygastric range also improved significantly after cisapride treatment (P < 0.05). The upper gastrointestinal symptoms score decreased significantly, and gastric emptying of radiopaque markers also increased significantly after 8 weeks of cisapride treatment (P < 0.01).

CONCLUSIONS

In conclusion, this study showed that cisapride can improve gastric dysrhythmia during both fasting and post-meal phases in patients with diabetic gastroparesis. In addition, upper GI symptoms and gastric emptying of indigestible solids may also show significant improvement after 8 weeks of cisapride treatment.

Pancreatic polypeptide secretion in diabetic patients with delayed gastric emptying and autonomic neuropathy

Measuring postprandial pancreatic polypeptide (PP) plasma concentration is a sensitive method for autonomic nervous system assessment. Delayed gastric emptying (DGE) often does not correlate clearly with cardiac autonomic neuropathy (CAN). This study was conducted to evaluate whether decreased PP secretion (PPS) accompanies DGE and CAN in diabetes. Fourteen long-standing diabetics with DGE assessed by scintigraphy (group A), 14 well-matched diabetics with normal gastric emptying (NGE) (group B), and 12 healthy controls (group C) were the study subjects. CAN and postprandial PPS at 0, 30, and 60 min after test meal ingestion were examined in all the subjects, and the area under curve of PP secretion was calculated. There was no correlation between DGE and CAN (eight diabetics with CAN in A and six in B). Basal PP values were almost the same in all the patients (mean 77.27 +/- 11.0 pg/mL). The area under curve of PP secretion values (PPAUC) after test meal ingestion were significantly higher in B (211.84 +/- 36.13 pg/mL/h; p < 0.0001) and C (233.68 +/- 23.43 pg/mL/h; p < 0.00001) than in A (147.59 +/- 31.77 pg/mL/h). Diabetics with CAN had lower PPS expressed as PPAUC than those without CAN, which was independent of gastric emptying rate (152.31 +/- 37.18 versus 207.12 +/- 39.21 pg/mL/h; p < 0.001). There were no significant differences between test meal-stimulated PPAUC in diabetics without CAN (207.12 +/- 39.21 pg/mL/h) and controls (233.68 +/- 23.43 pg/mL/h), and this was also independent of gastric emptying rate. In patients with both DGE and CAN, the PPS was completely blunt (PPAUC 124.04 +/- 5.71 versus 233.68 +/- 23.43 pg/mL/h in controls; p < 0.001). The PPS in diabetics with CAN and NGE was significantly lower than in controls (PPAUC 190.0 +/- 37.45 versus 233.68 +/- 23.43 pg/mL/h; p < 0.01). In conclusion, the PPS in diabetics with CAN was decreased significantly and independently of DGE. The PP secretion was very low in diabetics with both CAN and DGE.

Rapid distal small bowel transit associated with sympathetic denervation in type I diabetes mellitus

BACKGROUND

The pattern of progression of a meal from the stomach to the caecum in diabetes mellitus is controversial and the differential roles of transit through the jejunum and the ileum have not been investigated in diabetes.

AIMS

To determine gastric emptying and transit rates through proximal and distal regions of the small bowel in type I diabetic patients.

SUBJECTS

The study included six diabetic patients with evidence of autonomic neuropathy (DM-AN group), 11 diabetics without autonomic dysfunction (DM group), and 15 control volunteers.

METHODS

Gastric emptying and small bowel transit of a liquid meal were evaluated scintigraphically in these subjects. Transit through regions of interest corresponding to the proximal and distal small intestine up to the caecum was determined and correlated with gastric emptying rates, cardiovascular measurements of autonomic function, and the occurrence of diarrhoea.

RESULTS

Gastric emptying and transit through the proximal small bowel were similar in the three groups. The meal arrived to the caecum significantly earlier in DM-AN patients (median; range: 55 min; 22-->180 min) than in the DM group (100 min; 44-->180 min, p < 0.05) or in controls (120 min; 80-->180 min, p < 0.02). Accumulation of chyme in the distal small bowel was decreased in DM-AN patients, who showed values for peak activity (30%; 10-55%) significantly lower than in the DM group (49%; 25-77%, p = 0.02) and controls (50%; 30-81%, p = 0.02). In DM patients (n = 17), the time of meal arrival to the caecum was significantly correlated with both orthostatic hypotension (coefficient of contingency, C = 0.53, p < 0.01) and diarrhoea (C = 0.47, p < 0.05), but not with gastric emptying rates.

CONCLUSIONS

Patients with type I diabetes mellitus and sympathetic denervation have abnormally rapid transit of a liquid meal through the distal small bowel, which may play a part in diarrhoea production.

[13C]octanoic acid breath test for non-invasive assessment of gastric emptying in diabetic patients: validation and relationship to gastric symptoms and cardiovascular autonomic function

Since there is a need for a widely applicable non-invasive test to assess gastric emptying in diabetic patients, we evaluated the sensitivity, specificity, and reproducibility of the [13C]octanoic acid breath test as compared with scintigraphy. Moreover, we examined the relationship between the breath test indices and gastric symptoms, cardiovascular autonomic function, and metabolic parameters. Forty healthy control subjects and 34 diabetic patients were studied. Three indices of gastric emptying, assessed by the breath test, were computed: half-emptying time (t1/2breath), gastric emptying coefficient (GEC), and lag phase. Furthermore, the half-emptying time, measured by scintigraphy (t1/2scint), was calculated and gastric symptoms and cardiovascular autonomic neuropathy (CAN) were scored. The coefficients of variation of day-to-day reproducibility in 10 healthy subjects were 29.6% for t1/2breath, 7.4% for GEC, and 46.5% for lag phase. An abnormal delay for t1/2scint (> 100 min) or t1/2breath (> 200 min) was noted in 12 patients. Based on the results for t1/2scint, the sensitivity of t1/2breath and GEC was 75% and the specificity was 86%. Both t1/2breath (rs = 0.523; p < 0.05) and GEC (r2 = -0.594; p < 0.05) were significantly associated with the gastric symptom score. A significant relationship to the CAN score was demonstrated for t1/2breath (rs = 0.448; p < 0.05), GEC (rs = -0.467; p < 0.05), and t1/2scint (rs = 0.602; p < 0.05). There were no significant associations of the breath test indices with the blood glucose levels during the test, HbA1c, age, and duration of diabetes. In patients with abnormal t1/2scint (n = 12) not only was t1/2breath significantly prolonged and GEC reduced, but also the scores of CAN and gastric symptoms were significantly increased as compared with those who had a normal t1/2scint (n = 22). We conclude that the [13C]octanoic acid breath test represents a suitable measure of delayed gastric emptying in diabetic patients which is associated with the severity of gastric symptoms and CAN but not affected by the blood glucose level.

Gastric clearance of radiopaque markers in non-ulcer dyspepsia patients

BACKGROUND

The use of radiopaque markers has been proposed as an easy, non-invasive method for measuring gastric emptying. In this study we intended to evaluate the effectiveness of this test in determining the gastric motor function in patients with non-ulcer dyspepsia.

METHODS

Simultaneous recording of scintigraphic solid gastric emptying and gastric clearance of radiopaque markers were conducted in 65 non-ulcer dyspepsia patients.

RESULTS

Forty-two patients (64.4%) showed abnormal gastric clearance of radiopaque markers, and 38 patients (58.5%) showed delayed solid gastric emptying. There was no correlation between delayed solid gastric emptying and abnormal gastric clearance of radiopaque markers (p > 0.05). Although the frequency of abnormal gastric clearance of radiopaque markers was higher than that of delayed solid gastric emptying (64.6% versus 58.5%), it was not statistically significant.

CONCLUSIONS

On the basis of the results of our study, gastric clearance of radiopaque markers may be used as an easy, non-invasive screening test for the purpose of detecting gastric motor dysfunction. However, this test is not superior to scintigraphic gastric emptying studies.

Prevalence, etiology, and prognostic significance of upper gastrointestinal hemorrhage in diabetic ketoacidosis

We reviewed the discharge records of all diabetic ketoacidosis hospitalizations over 30 months for the presence of clinically significant upper gastrointestinal hemorrhage. Of 284 hospitalizations in 193 patients, hemorrhage occurred in 26 hospitalizations (9%) in 25 patients (13%). None required invasive therapy to achieve hemostasis, and there were no bleeding recurrences and no deaths due to bleeding. Endoscopy in eight revealed esophagitis in all (five had erosions or ulcerations), one Mallory-Weiss tear, five with gastritis (mild in four), four with duodenitis (one erosive), one duodenal ulcer, and no gastric ulcers. Hemorrhage patients had a longer diabetes duration (14.85 vs 9.16 years, P < 0.02), and more nephropathy (40% vs 11%, P < 0.001), retinopathy (28% vs 12%, P < 0.03) and gastroparesis (36% vs 10%, P < 0.002) than those without hemorrhage. Ulcer medication (42% vs 23%, P < 0.03) or anticoagulant (12% vs 1%, P < 0.005) but not nonsteroidal antiinflammatory drug usage (12% vs 12%) was higher in the hemorrhage group. Admission glucose (P < 0.02), BUN (P < 0.04), and creatinine (P < 0.02) levels were higher in hemorrhage patients, but arterial pH, serum ketones, hemoglobin, platelet count, and coagulation values were not. Hemorrhage patients required more blood transfusions (27% vs 10%, P < 0.003) and intensive care unit admissions (69% vs 43%, P < 0.009). Total (15% vs 3%, P < 0.003) and intensive care unit mortality (22% vs 6%, P < 0.026) were higher in the hemorrhage group. We conclude that upper gastrointestinal hemorrhage complicates 9% of diabetic ketoacidosis hospitalizations. Blood transfusion may be required, but the bleeding is self-limited and not severe. The most common lesion is erosive esophagitis. Hemorrhage correlates with glucose level, admission to the intensive care unit, duration of diabetes, the presence of diabetic complications, and portends a high non-bleeding-related mortality.