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Camilleri M, Yang DY. Algorithms or biomarkers in patients with lower DGBI? Neurogastroenterol Motil 2024:e14856. [PMID: 38934414 DOI: 10.1111/nmo.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/16/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Several organizations have proposed guidelines or clinical decision tools for the management of patients with disorders of gut-brain interactions (DGBI) affecting the lower digestive tract including irritable bowel syndrome and chronic idiopathic constipation. Such algorithms are based on sequential therapeutic trials and modifying the treatment strategy based on efficacy and adverse events. PURPOSE The aims of this review are to evaluate the evidence for efficacy of second- and third-line pharmacotherapies and to assess the evidence for the alternative option to manage subgroups of patients with symptoms suggestive of lower DGBI based on diagnostic tests or documented dysfunctions. The preeminent tests to identify such subgroups that present with symptoms that overlap with lower DGBI are detailed: digital rectal examination as well as anorectal manometry and balloon expulsion for evacuation disorders, detailed measurements of colonic transit, and diagnosis of bile acid diarrhea or carbohydrate malabsorption based on biochemical measurements. The review also addresses the cost implications of screening to exclude alternative diagnoses and the costs of therapy associated with the therapeutic options following an algorithmic approach to treatment from the perspective of society, insurer, or patient. Finally, the costs of the diagnostic tests to identify actionable biomarkers and the evidence of efficacy of individualized therapy based on formal diagnosis or documentation of abnormal functions are detailed in the review.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, Minnesota, USA
| | - David Yi Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, Minnesota, USA
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2
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Vakili O, Adibi Sedeh P, Pourfarzam M. Metabolic biomarkers in irritable bowel syndrome diagnosis. Clin Chim Acta 2024; 560:119753. [PMID: 38821336 DOI: 10.1016/j.cca.2024.119753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024]
Abstract
Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI) disorder characterized by altered bowel habits and abdominal discomfort during defecation. It significantly impacts life quality and work productivity for those affected. Global data suggests a slightly higher prevalence in females than in males. Today, unambiguous diagnosis of IBS remains challenging due to the absence of a specific biochemical, histopathological, or radiological test. Current diagnosis relies heavily on thorough symptom evaluation. Efforts by the Rome committees have established standardized diagnostic criteria (Rome I-IV), improving consistency and clinical applicability. Recent studies in this framework, seem to have successfully employed metabolomics techniques to identify distinct metabolite profiles in breath and stool samples of IBS patients, differentiating them from healthy controls and those with other functional GI disorders, such as inflammatory bowel disease (IBD). Building on this success, researchers are investigating the presence of similar metabolites in easily accessible biofluids such as urine, potentially offering a less invasive diagnostic approach. Accordingly, this review focuses on key metabolites specifically detected in IBS patients' biological specimens, with a focus on urinary metabolites, using various methods, particularly mass spectrometry (MS)-based techniques, including gas chromatography-MS (GC-MS), liquid chromatography-tandem MS (LC-MS/MS), and capillary electrophoresis-MS (CE-MS) metabolomics assays. These findings may make provision for a new set of non-invasive biomarkers for IBS diagnosis and management.
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Affiliation(s)
- Omid Vakili
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Peyman Adibi Sedeh
- Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Morteza Pourfarzam
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
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3
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Camilleri M, Jencks K. Pharmacogenetics in IBS: update and impact of GWAS studies in drug targets and metabolism. Expert Opin Drug Metab Toxicol 2024; 20:319-332. [PMID: 38785066 PMCID: PMC11139426 DOI: 10.1080/17425255.2024.2349716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/26/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Medications are frequently prescribed for patients with irritable bowel syndrome (IBS) or disorders of gut brain interaction. The level of drug metabolism and modifications in drug targets determine medication efficacy to modify motor or sensory function as well as patient response outcomes. AREAS COVERED The literature search included PubMed searches with the terms: pharmacokinetics, pharmacogenomics, epigenetics, clinical trials, irritable bowel syndrome, disorders of gut brain interaction, and genome-wide association studies. The main topics covered in relation to irritable bowel syndrome were precision medicine, pharmacogenomics related to drug metabolism, pharmacogenomics related to mechanistic targets, and epigenetics. EXPERT OPINION Pharmacogenomics impacting drug metabolism [CYP 2D6 (cytochrome P450 2D6) or 2C19 (cytochrome P450 2C19)] is the most practical approach to precision medicine in the treatment of IBS. Although there are proof of concept studies that have documented the importance of genetic modification of transmitters or receptors in altering responses to medications in IBS, these principles have rarely been applied in patient response outcomes. Genome-wide association (GWAS) studies have now documented the association of symptoms with genetic variation but not the evaluation of treatment responses. Considerably more research, particularly focused on patient response outcomes and epigenetics, is essential to impact this field in clinical medicine.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kara Jencks
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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4
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Dowrick JM, Jungbauer Nikolas L, Offutt SJ, Tremain P, Erickson JC, Angeli-Gordon TR. Translation of an existing implantable cardiac monitoring device for measurement of gastric electrical slow-wave activity. Neurogastroenterol Motil 2024; 36:e14723. [PMID: 38062544 DOI: 10.1111/nmo.14723] [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: 08/03/2023] [Accepted: 11/10/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Despite evidence that slow-wave dysrhythmia in the stomach is associated with clinical conditions such as gastroparesis and functional dyspepsia, there is still no widely available device for long-term monitoring of gastric electrical signals. Actionable biomarkers of gastrointestinal health are critically needed, and an implantable slow-wave monitoring device could aid in the establishment of causal relationships between symptoms and gastric electrophysiology. Recent developments in the area of wireless implantable gastric monitors demonstrate potential, but additional work and validation are required before this potential can be realized. METHODS We hypothesized that translating an existing implantable cardiac monitoring device, the Reveal LINQ™ (Medtronic), would present a more immediate solution. Following ethical approval and laparotomy in anesthetized pigs (n = 7), a Reveal LINQ was placed on the serosal surface of the stomach, immediately adjacent to a validated flexible-printed-circuit (FPC) electrical mapping array. Data were recorded for periods of 7.5 min, and the resultant signal characteristics from the FPC array and Reveal LINQ were compared. KEY RESULTS The Reveal LINQ device recorded slow waves in 6/7 subjects with a comparable period (p = 0.69), signal-to-noise ratio (p = 0.58), and downstroke width (p = 0.98) to the FPC, but with reduced amplitude (p = 0.024). Qualitatively, the Reveal LINQ slow-wave signal lacked the prolonged repolarization phase present in the FPC signals. CONCLUSIONS & INFERENCES These findings suggest that existing cardiac monitors may offer an efficient solution for the long-term monitoring of slow waves. Translation toward implantation now awaits.
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Affiliation(s)
- Jarrah M Dowrick
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | | | - Sarah J Offutt
- Pelvic Health, Medtronic PLC, Minneapolis, Minnesota, USA
| | - Peter Tremain
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Jonathan C Erickson
- Department of Physics and Engineering, Washington and Lee University, Lexington, Virginia, USA
| | - Timothy R Angeli-Gordon
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
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5
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Varghese C, Dachs N, Schamberg G, McCool K, Law M, Xu W, Calder S, Foong D, Ho V, Daker C, Andrews CN, Gharibans AA, O'Grady G. Longitudinal outcome monitoring in patients with chronic gastroduodenal symptoms investigated using the Gastric Alimetry system: study protocol. BMJ Open 2023; 13:e074462. [PMID: 38011983 PMCID: PMC10685974 DOI: 10.1136/bmjopen-2023-074462] [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: 04/10/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION The Gastric Alimetry platform offers a multimodal assessment of gastric function through body surface gastric mapping (BSGM) and concurrent symptom-tracking via a validated App. We aim to perform a longitudinal cohort study to examine the impact of Gastric Alimetry, and changes in clinical management on patient symptoms, quality of life and psychological health. METHODS AND ANALYSIS This is a prospective multicentre longitudinal observational cohort study of participants with chronic gastroduodenal symptoms. Consecutive participants undergoing Gastric Alimetry will be invited to participate. Quality of life will be assessed via EuroQol-5D and the Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life score. Gastrointestinal symptoms will be assessed via the Patient Assessment of Upper Gastrointestinal Symptom Severity index, and the Gastroparesis Cardinal Symptom Index. Psychometrics will be assessed, including anxiety via the General Anxiety Disorder-7, perceived stress using the Perceived Stress Scale 4, and depression via the Patient Health Questionnaire 9. Clinical parameters including diagnoses, investigations and treatments (medication and procedures) will also be captured. Assessments will be made the week after the BSGM test, at 30 days, 90 days, 180 days and 360 days thereafter. The primary outcome is feasibility of longitudinal follow-up of a cohort that have undergone Gastric Alimetry testing; from which patients' continuum of care can be characterised. Secondary outcomes include changes in patient-reported symptoms, quality of life and psychometrics (anxiety, stress and depression). Inferential causal analyses will be performed at the within patient level to explore causal associations between treatment changes and clinical outcomes. The impact of Gastric Alimetry on clinical management will also be captured. ETHICS AND DISSEMINATION The protocol has been approved in Aotearoa New Zealand by the Auckland Health Research Ethics Committee. Results will be submitted for conference presentation and peer-reviewed publication.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Gabriel Schamberg
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Alimetry Ltd, Auckland, New Zealand
| | | | - Mikaela Law
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Alimetry Ltd, Auckland, New Zealand
| | - William Xu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Daphne Foong
- Western Sydney University, Penrith South, New South Wales, Australia
| | - Vincent Ho
- Western Sydney University, Penrith South, New South Wales, Australia
| | - Charlotte Daker
- Department of Gastroenterology, North Shore Hospital, Auckland, New Zealand
| | | | - Armen A Gharibans
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Alimetry Ltd, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Alimetry Ltd, Auckland, New Zealand
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6
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Varghese C, Daker C, Lim A, Sebaratnam G, Xu W, Kean B, Cederwall C. Gastric Alimetry in the Management of Chronic Gastroduodenal Disorders: Impact to Diagnosis and Health Care Utilization. Clin Transl Gastroenterol 2023; 14:e00626. [PMID: 37589479 PMCID: PMC10684143 DOI: 10.14309/ctg.0000000000000626] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/02/2023] [Indexed: 08/18/2023] Open
Abstract
INTRODUCTION Chronic gastroduodenal symptoms are frequently overlapping within existing diagnostic paradigms, and current diagnostic tests are insensitive to underlying pathophysiologies. Gastric Alimetry has emerged as a new diagnostic test of gastric neuromuscular function with time-of-test symptom profiling. This study aimed to assess the impact to diagnosis and health care utilization after the introduction of Gastric Alimetry into clinical care. METHODS Consecutive data of patients from 2 tertiary centers with chronic gastroduodenal symptoms (Rome-IV defined or motility disorder) having integrated care and Gastric Alimetry testing were evaluated. Changes in diagnoses, interventions, and management were quantified. Pretest and posttest health care utilization was reported. A preliminary management framework was established through experiential learning. RESULTS Fifty participants (45 women; median age 30 years; 18 with gastroparesis, 24 with chronic nausea and vomiting syndrome, and 6 with functional dyspepsia) underwent Gastric Alimetry testing. One-third of patients had a spectral abnormality (18% dysrhythmic/low amplitude). Of the remaining patients, 9 had symptoms correlating to gastric amplitude, while 19 had symptoms unrelated to gastric activity. Gastric Alimetry aided management decisions in 84%, including changes in invasive nutritional support in 9/50 cases (18%; predominantly de-escalation). Health care utilization was significantly lower post-Gastric Alimetry testing when compared with the average utilization cost in the year before Gastric Alimetry testing (mean ± SD $39,724 ± 63,566 vs $19,937 ± 35,895, P = 0.037). DISCUSSION Gastric Alimetry aided diagnosis and management of patients with chronic gastroduodenal symptoms by enabling phenotype-informed care. The high majority of results aided management decisions, which was associated with reduced health care utilization.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Charlotte Daker
- Department of Gastroenterology, North Shore Hospital, Auckland, New Zealand
| | - Alexandria Lim
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - William Xu
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Bernard Kean
- Wellington Regional Hospital, Wellington, New Zealand
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Camilleri M, BouSaba J. Potential Value of Biomarker-Based Approaches for Evaluation and Management of Costly Functional Gastrointestinal Diseases. Clin Gastroenterol Hepatol 2023; 21:2462-2472. [PMID: 37164114 PMCID: PMC10524924 DOI: 10.1016/j.cgh.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota.
| | - Joelle BouSaba
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
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Aghababaie Z, Wang THH, Nisbet LA, Matthee A, Dowrick J, Sands GB, Paskaranandavadivel N, Cheng LK, O'Grady G, Angeli-Gordon TR. Anaesthesia by intravenous propofol reduces the incidence of intra-operative gastric electrical slow-wave dysrhythmias compared to isoflurane. Sci Rep 2023; 13:11824. [PMID: 37479717 PMCID: PMC10362009 DOI: 10.1038/s41598-023-38612-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023] Open
Abstract
Gastric motility is coordinated by bioelectrical slow-wave activity, and abnormal electrical dysrhythmias have been associated with nausea and vomiting. Studies have often been conducted under general anaesthesia, while the impact of general anaesthesia on slow-wave activity has not been studied. Clinical studies have shown that propofol anaesthesia reduces postoperative nausea and vomiting (PONV) compared with isoflurane, while the underlying mechanisms remain unclear. In this study, we investigated the effects of two anaesthetic drugs, intravenous (IV) propofol and volatile isoflurane, on slow-wave activity. In vivo experiments were performed in female weaner pigs (n = 24). Zolazepam and tiletamine were used to induce general anaesthesia, which was maintained using either IV propofol (n = 12) or isoflurane (n = 12). High-resolution electrical mapping of slow-wave activity was performed. Slow-wave dysrhythmias occurred less often in the propofol group, both in the duration of the recorded period that was dysrhythmic (propofol 14 ± 26%, isoflurane 43 ± 39%, P = 0.043 (Mann-Whitney U test)), and in a case-by-case basis (propofol 3/12, isoflurane 8/12, P = 0.015 (Chi-squared test)). Slow-wave amplitude was similar, while velocity and frequency were higher in the propofol group than the isoflurane group (P < 0.001 (Student's t-test)). This study presents a potential physiological biomarker linked to recent observations of reduced PONV with IV propofol. The results suggest that propofol is a more suitable anaesthetic for studying slow-wave patterns in vivo.
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Affiliation(s)
- Zahra Aghababaie
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Tim Hsu-Han Wang
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Linley A Nisbet
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Ashton Matthee
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Jarrah Dowrick
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Gregory B Sands
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | | | - Leo K Cheng
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Gregory O'Grady
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Timothy R Angeli-Gordon
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand.
- Department of Surgery, University of Auckland, Auckland, New Zealand.
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Varghese C, Schamberg G, Calder S, Waite S, Carson D, Foong D, Wang WJ, Ho V, Woodhead J, Daker C, Xu W, Du P, Abell TL, Parkman HP, Tack J, Andrews CN, O'Grady G, Gharibans AA. Normative Values for Body Surface Gastric Mapping Evaluations of Gastric Motility Using Gastric Alimetry: Spectral Analysis. Am J Gastroenterol 2023; 118:1047-1057. [PMID: 36534985 DOI: 10.14309/ajg.0000000000002077] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/06/2022] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Body surface gastric mapping (BSGM) is a new noninvasive test of gastric function. BSGM offers several novel and improved biomarkers of gastric function capable of differentiating patients with overlapping symptom profiles. The aim of this study was to define normative reference intervals for BSGM spectral metrics in a population of healthy controls. METHODS BSGM was performed in healthy controls using Gastric Alimetry (Alimetry, New Zealand) comprising a stretchable high-resolution array (8 × 8 electrodes; 196 cm 2 ), wearable Reader, and validated symptom-logging App. The evaluation encompassed a fasting baseline (30 minutes), 482 kCal meal, and 4-hour postprandial recording. Normative reference intervals were calculated for BSGM metrics including the Principal Gastric Frequency, Gastric Alimetry Rhythm Index (a measure of the concentration of power in the gastric frequency band over time), body mass index (BMI)-adjusted amplitude (μV), and fed:fasted amplitude ratio. Data were reported as median and reference interval (5th and/or 95th percentiles). RESULTS A total of 110 subjects (55% female, median age 32 years [interquartile range 24-50], median BMI 23.8 kg/m 2 [interquartile range 21.4-26.9]) were included. The median Principal Gastric Frequency was 3.04 cycles per minute; reference interval: 2.65-3.35 cycles per minute. The median Gastric Alimetry Rhythm Index was 0.50; reference interval: ≥0.25. The median BMI-adjusted amplitude was 37.6 μV; reference interval: 20-70 μV. The median fed:fasted amplitude ratio was 1.85; reference interval ≥1.08. A higher BMI was associated with a shorter meal-response duration ( P = 0.014). DISCUSSION This study provides normative reference intervals for BSGM spectral data to inform diagnostic interpretations of abnormal gastric function.
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Affiliation(s)
- 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, Auckland, New Zealand
| | - Stefan Calder
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Alimetry, Auckland, New Zealand
| | | | - Daniel Carson
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | | | - Vincent Ho
- Western Sydney University, Sydney, Australia
| | | | | | - William Xu
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Peng Du
- Alimetry, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Thomas L Abell
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Kentucky, USA
| | - Henry P Parkman
- Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Jan Tack
- Department of Gastroenterology, University Hospitals, Leuven, Belgium
| | | | - Gregory O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Alimetry, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Armen A Gharibans
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Alimetry, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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10
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Camilleri M, Boeckxstaens G. Irritable bowel syndrome: treatment based on pathophysiology and biomarkers. Gut 2023; 72:590-599. [PMID: 36307180 PMCID: PMC9990119 DOI: 10.1136/gutjnl-2022-328515] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To appraise the evidence that pathophysiological mechanisms and individualised treatment directed at those mechanisms provide an alternative approach to the treatment of patients with irritable bowel syndrome (IBS). DESIGN A PubMED-based literature review of mechanisms and treatment of IBS was conducted independently by the two authors, and any differences of perspective or interpretation of the literature were resolved following discussion. RESULTS The availability of several noninvasive clinical tests can appraise the mechanisms responsible for symptom generation in IBS, including rectal evacuation disorders, abnormal transit, visceral hypersensitivity or hypervigilance, bile acid diarrhoea, sugar intolerances, barrier dysfunction, the microbiome, immune activation and chemicals released by the latter mechanism. The basic molecular mechanisms contributing to these pathophysiologies are increasingly recognised, offering opportunities to intervene with medications directed specifically to food components, receptors and potentially the microbiome. Although the evidence supporting interventions for each mechanism is not at the same level of proof, the current state-of-the-art provides the opportunity to advance the practice from treatment based on symptoms to individualisation of treatment guided by pathophysiology and clinically identified biomarkers. CONCLUSION These advances augur well for the implementation of evidence-based individualised treatment for patients with IBS based on actionable biomarkers or psychological disturbances.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Guy Boeckxstaens
- Center of Intestinal Neuroimmune Interaction, Division of Gastroenterology, Translational Research Center for GI Disorders (TARGID), Leuven University, Leuven, Belgium
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11
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Gharibans AA, Hayes TCL, Carson DA, Calder S, Varghese C, Du P, Yarmut Y, Waite S, Keane C, Woodhead JST, Andrews CN, O'Grady G. A novel scalable electrode array and system for non-invasively assessing gastric function using flexible electronics. Neurogastroenterol Motil 2023; 35:e14418. [PMID: 35699340 PMCID: PMC10078595 DOI: 10.1111/nmo.14418] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/29/2022] [Accepted: 05/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Disorders of gastric function are highly prevalent, but diagnosis often remains symptom-based and inconclusive. Body surface gastric mapping is an emerging diagnostic solution, but current approaches lack scalability and are cumbersome and clinically impractical. We present a novel scalable system for non-invasively mapping gastric electrophysiology in high-resolution (HR) at the body surface. METHODS The system comprises a custom-designed stretchable high-resolution "peel-and-stick" sensor array (8 × 8 pre-gelled Ag/AgCl electrodes at 2 cm spacing; area 225 cm2 ), wearable data logger with custom electronics incorporating bioamplifier chips, accelerometer and Bluetooth synchronized in real-time to an App with cloud connectivity. Automated algorithms filter and extract HR biomarkers including propagation (phase) mapping. The system was tested in a cohort of 24 healthy subjects to define reliability and characterize features of normal gastric activity (30 m fasting, standardized meal, and 4 h postprandial). KEY RESULTS Gastric mapping was successfully achieved non-invasively in all cases (16 male; 8 female; aged 20-73 years; BMI 24.2 ± 3.5). In all subjects, gastric electrophysiology and meal responses were successfully captured and quantified non-invasively (mean frequency 2.9 ± 0.3 cycles per minute; peak amplitude at mean 60 m postprandially with return to baseline in <4 h). Spatiotemporal mapping showed regular and consistent wave activity of mean direction 182.7° ± 73 (74.7% antegrade, 7.8% retrograde, 17.5% indeterminate). CONCLUSIONS AND INFERENCES BSGM is a new diagnostic tool for assessing gastric function that is scalable and ready for clinical applications, offering several biomarkers that are improved or new to gastroenterology practice.
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Affiliation(s)
- Armen A Gharibans
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Alimetry Ltd, Auckland, New Zealand.,Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Tommy C L Hayes
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Daniel A Carson
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Chris Varghese
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Peng Du
- Alimetry Ltd, Auckland, New Zealand.,Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | | | | | - Celia Keane
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Alimetry Ltd, Auckland, New Zealand
| | - Jonathan S T Woodhead
- Alimetry Ltd, Auckland, New Zealand.,Maurice Wilkins Centre for Molecular Biodiscovery, The University of Auckland, Auckland, New Zealand
| | - Christopher N Andrews
- Alimetry Ltd, Auckland, New Zealand.,Department of Medicine, University of Calgary, NB Calgary, Alberta, Canada
| | - Greg O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Alimetry Ltd, Auckland, New Zealand
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12
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Current and Future Therapeutic Options for Irritable Bowel Syndrome with Diarrhea and Functional Diarrhea. Dig Dis Sci 2022; 68:1677-1690. [PMID: 36376576 DOI: 10.1007/s10620-022-07700-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/12/2022] [Indexed: 11/15/2022]
Abstract
Irritable bowel syndrome with diarrhea and functional diarrhea are disorders of gut-brain interaction presenting with chronic diarrhea; they have significant impact on quality of life. The two conditions may exist as a continuum and their treatment may overlap. Response to first-line therapy with antispasmodics and anti-diarrheal agents is variable, leaving several patients with suboptimal symptom control and need for alternative therapeutic options. Our aim was to discuss current pharmacologic options and explore alternative therapeutic approaches and future perspectives for symptom management in irritable bowel syndrome with diarrhea and functional diarrhea. We conducted a search of PubMed, Cochrane, clinicaltrial.gov, major meeting abstracts for publications on current, alternative, and emerging drugs for irritable bowel syndrome with diarrhea and functional diarrhea. Currently approved therapeutic options for patients with first-line refractory irritable bowel syndrome with diarrhea and functional diarrhea include serotonin-3 receptor antagonists, eluxadoline and rifaximin. Despite their proven efficacy, cost and availability worldwide impact their utilization. One-third of patients with disorders of gut-brain interaction with diarrhea have bile acid diarrhea and may benefit from drugs targeting bile acid synthesis and excretion. Further understanding of underlying pathophysiology of irritable bowel syndrome with diarrhea and functional diarrhea related to bile acid metabolism, gastrointestinal transit, and microbiome has led to evaluation of novel therapeutic approaches, including fecal microbiota transplantation and enterobacterial "crapsules". These opportunities to treat disorders of gut-brain interaction with diarrhea should be followed with formal studies utilizing large samples of well-characterized patients at baseline and validated response outcomes as endpoints for regulatory approval.
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Camilleri M, Zhernakova A, Bozzarelli I, D'Amato M. Genetics of irritable bowel syndrome: shifting gear via biobank-scale studies. Nat Rev Gastroenterol Hepatol 2022; 19:689-702. [PMID: 35948782 DOI: 10.1038/s41575-022-00662-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 12/19/2022]
Abstract
The pathophysiology of irritable bowel syndrome (IBS) is multifactorial and probably involves genetic predisposition and the effect of environmental factors. Unlike other gastrointestinal diseases with a heritable component, genetic research in IBS has been scarce and mostly characterized by small underpowered studies, leading to inconclusive results. The availability of genomic and health-related data from large international cohorts and population-based biobanks offers unprecedented opportunities for long-awaited, well-powered genetic studies in IBS. This Review focuses on the latest advances that provide compelling evidence for the importance of genes involved in the digestion of carbohydrates, ion channel function, neurotransmitters and their receptors, neuronal pathways and the control of gut motility. These discoveries have generated novel information that might be further refined for the identification of predisposed individuals and selection of management strategies for patients. This Review presents a conceptual framework, the advantages and potential limitations of modern genetic research in IBS, and a summary of available evidence.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) and Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alexandra Zhernakova
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | | | - Mauro D'Amato
- Gastrointestinal Genetics Lab, CIC bioGUNE - BRTA, Derio, Spain. .,Ikerbasque, Basque Foundation for Science, Bilbao, Spain. .,Department of Medicine and Surgery, LUM University, Casamassima, Italy.
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14
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Camilleri M, Dilmaghani S. Treatment of Irritable Bowel Syndrome Using Fecal Microbiota Transplantation: A Step Forward? Gastroenterology 2022; 163:815-817. [PMID: 35809615 PMCID: PMC9885897 DOI: 10.1053/j.gastro.2022.06.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota.
| | - Saam Dilmaghani
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
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15
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Calder S, Cheng LK, Andrews CN, Paskaranandavadivel N, Waite S, Alighaleh S, Erickson JC, Gharibans A, O'Grady G, Du P. Validation of noninvasive body-surface gastric mapping for detecting gastric slow-wave spatiotemporal features by simultaneous serosal mapping in porcine. Am J Physiol Gastrointest Liver Physiol 2022; 323:G295-G305. [PMID: 35916432 DOI: 10.1152/ajpgi.00049.2022] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Gastric disorders are increasingly prevalent, but reliable noninvasive tools to objectively assess gastric function are lacking. Body-surface gastric mapping (BSGM) is a noninvasive method for the detection of gastric electrophysiological features, which are correlated with symptoms in patients with gastroparesis and functional dyspepsia. Previous studies have validated the relationship between serosal and cutaneous recordings from limited number of channels. This study aimed to comprehensively evaluate the basis of BSGM from 64 cutaneous channels and reliably identify spatial biomarkers associated with slow-wave dysrhythmias. High-resolution electrode arrays were placed to simultaneously capture slow waves from the gastric serosa (32 × 6 electrodes at 4 mm spacing) and epigastrium (8 × 8 electrodes at 20 mm spacing) in 14 porcine subjects. BSGM signals were processed based on a combination of wavelet and phase information analyses. A total of 1,185 individual cycles of slow waves were assessed, out of which 897 (76%) were classified as normal antegrade waves, occurring in 10 (71%) subjects studied. BSGM accurately detected the underlying slow wave in terms of frequency (r = 0.99, P = 0.43) as well as the direction of propagation (P = 0.41, F-measure: 0.92). In addition, the cycle-by-cycle match between BSGM and transitions of gastric slow wave dysrhythmias was demonstrated. These results validate BSGM as a suitable method for noninvasively and accurately detecting gastric slow-wave spatiotemporal profiles from the body surface.NEW & NOTEWORTHY Gastric dysfunctions are associated with abnormalities in the gastric bioelectrical slow waves. Noninvasive detection of gastric slow waves from the body surface can be achieved through multichannel, high-resolution, body-surface gastric mapping (BSGM). BSGM matched the spatiotemporal characteristics of gastric slow waves recorded directly and simultaneously from the serosal surface of the stomach. Abnormal gastric slow waves, such as retrograde propagation, ectopic pacemaker, and colliding wavefronts can be detected by changes in the phase of BSGM.
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Affiliation(s)
- Stefan Calder
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.,Alimetry Ltd., Auckland, New Zealand
| | - Leo K Cheng
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Christopher N Andrews
- Alimetry Ltd., Auckland, New Zealand.,Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Jonathan C Erickson
- Department of Physics-Engineering, Washington and Lee University, Lexington, Virginia
| | - Armen Gharibans
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.,Alimetry Ltd., Auckland, New Zealand
| | - Gregory O'Grady
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.,Alimetry Ltd., Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.,Alimetry Ltd., Auckland, New Zealand
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16
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Abnormal Perception of Urge to Defecate: An Important Pathophysiological Mechanism in Women With Chronic Constipation. Am J Gastroenterol 2022; 117:1125-1136. [PMID: 35435855 DOI: 10.14309/ajg.0000000000001794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/13/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Although the association of absent or attenuated "call to stool" with constipation is well-recognized, no studies have systematically evaluated the perception of urge to defecate in a well-defined cohort of patients with chronic constipation (CC). METHODS A prospective study of 43 healthy adult women and 140 consecutive adult women attending a tertiary center for investigation of CC. All participants completed a 5-day viscerosensory questionnaire, and all women with CC also underwent anorectal physiologic investigations. Normal urge perception and abnormal urge perception were defined using a Naive Bayes model trained in healthy women (95% having normal urge). RESULTS In total, 181 toilet visits in healthy women and 595 in women with CC were analyzed. Abnormal urge perception occurred in 70 (50.0%) women with CC. In this group, the urge to defecate was more often experienced as abdominal sensation (69.3% vs 41.4%; P < 0.0001), and the viscerosensory referral area was 81% larger (median pixels anterior: 1,849 vs 1,022; P < 0.0001) compared to women with CC and normal urge perception. Abnormal (vs normal) urge in women with CC was associated with more severe constipation (Cleveland Clinic constipation score: 19 vs 15 P < 0.0001), irritable bowel syndrome (45.7% vs 22.9% P < 0.0001), and a functional evacuation disorder on defecography (31.3% vs 14.3% P = 0.023). A distinct pattern of abnormal urge was found in women with CC and rectal hyposensitivity. DISCUSSION Abnormal urge perception was observed in 50% of women with CC and was frequently described as abdominal sensation, supporting the concept that sensory dysfunction makes an important contribution to the pathophysiology of constipation.
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Simmonds S, Cheng LK, Ruha W, Taberner AJ, Du P, Angeli-Gordon TR. Anatomically-Specific, 3D-Printed Cradles Enable In Vivo Mapping of the Bioelectrical Activation across the Gastroduodenal Junction. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:377-380. [PMID: 36086449 DOI: 10.1109/embc48229.2022.9871769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Rhythmic bioelectrical 'slow waves' are a key regulatory mechanism underpinning digestion. The pyloric sphincter separates the independent slow wave and contractile behavior of the stomach and small intestine, while also regulating gastric emptying. In this study, we develop and validate anatomically-specific electrode cradles and analysis techniques in pigs, to map in vivo slow wave activation across this critical pylorus region for the first time. 3D printed electrode cradles were developed from reconstructions of magnetic resonance images, to accurately capture anatomical geometry. A low-pass Savitzky-Golay filter with an equivalent cut-off frequency of ~2 Hz was chosen as the optimal filter for analysis of both gastric and intestinal slow waves. Slow waves in the terminal antrum occurred with a frequency of (2.81±0.55) cycles per minute (cpm), velocity of (5.04 ± 0.29) mm s-1, and amplitude of (1.38±0.37) mV, before terminating at a zone of quiescence at the pylorus that was (41.22±7.4)nm wide. The proximal duodenal pacemaker initiated slow waves at a frequency of (18.1±0.80) cpm, velocity of (11.3±2.4) mm s-1, and amplitude of (0.376±0.027) mV. This work enables quantitative definitions of numerous physiological features of the in vivo pylorus region, including the electrically quiescent zone and duodenal pacemaker location. Clinical Relevance- This work establishes a novel method for in vivo measurement of bioelectrical slow wave activity of the pyloric region, which is a key target for physiological investigation and clinical intervention. In the future, the methods developed here may inform diagnosis and/or treatment of functional gastrointestinal disorders.
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18
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Gastric herpes simplex virus type 1 infection is associated with functional gastrointestinal disorders in the presence and absence of comorbid fibromyalgia: a pilot case-control study. Infection 2022; 50:1303-1311. [PMID: 35445970 PMCID: PMC9522778 DOI: 10.1007/s15010-022-01823-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/31/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Animal studies have linked gastric herpesvirus infections to symptoms associated with functional gastrointestinal disorders (FGIDs). Herpesviruses have also been hypothesized to contribute to fibromyalgia (FM), a chronic pain syndrome frequently comorbid with FGIDs. The purpose of this study was to compare the prevalence of gastric herpesvirus infection in patients with FGIDs, with and without comorbid FM, to that of controls. METHODS For this pilot case-control study, we enrolled 30 patients who met both the Rome IV diagnostic criteria for one or more FGIDs and the American College of Rheumatology 2010 criteria for FM, 15 patients with one or more FGIDs without comorbid FM, and 15 control patients. Following endoscopic examination, gastric biopsies were analyzed for herpesvirus DNA and protein, Helicobacter pylori infection, and histological evidence of gastritis. Importantly, the viral nonstructural protein ICP8 was used as a marker to differentiate cell-associated actively replicating virus from latent infection and/or free virus passing through the GI tract. RESULTS Gastric herpes simplex virus type 1 (HSV-1) infection, as indicated by ICP8 presence, was significantly associated with FGIDs in the presence (OR 70.00, 95% CI 7.42-660.50; P < .001) and absence (OR 38.50, 95% CI 3.75-395.40; P < .001) of comorbid FM. Neither histological gastritis nor H. pylori infection were found to be associated with FGIDs or FM. CONCLUSIONS HSV-1 infection was identified in gastric mucosal biopsies from patients with diverse FGIDs, with and without comorbid FM. Larger, multi-center studies investigating the prevalence of this association are warranted.
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19
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Abnormalities on Electrogastrography in Nausea and Vomiting Syndromes: A Systematic Review, Meta-Analysis, and Comparison to Other Gastric Disorders. Dig Dis Sci 2022; 67:773-785. [PMID: 33956280 DOI: 10.1007/s10620-021-07026-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Functional nausea and vomiting syndromes and gastroparesis, collectively grouped as nausea and vomiting syndromes (NVS), are overlapping conditions with incompletely understood pathophysiology. Gastric slow wave abnormalities are thought to contribute. AIMS This study aimed to systematically review and meta-analyze the prevalence of slow wave abnormalities measured by electrogastrography (EGG) in patients with NVS. METHODS MEDLINE, EMBASE, EMBASE classic, and CENTRAL databases were systematically searched for articles using EGG in adults (≥ 18 years) with NVS. EGG metrics of interest were percentage time in bradygastria, normogastria, and tachygastria as well as dominant frequency and dominant power. Outcomes were also compared with functional dyspepsia (FD), gastroesophageal reflux disease (GORD), and control cohorts. RESULTS Seven hundred and sixty NVS patients and 308 controls were included from 24 studies. Overall, 64% of patients had EGG abnormalities. Average percent time in normogastria was low during fasting (50%; 95% CI 40-63%) and fed (53%; 95% CI 41-68%) states in patients, with substantial periods in fasting bradygastria (34.1%; 95% CI 25-47%) and postprandial tachygastria (21%; 95% CI 17-26%). Across gastric disorders, pooling of 84 studies showed a comparably high prevalence of EGG abnormalities in NVS (24 studies; n = 760) and GORD (13 studies; n = 427), compared to FD (47 studies; n = 1751) and controls (45 studies; n = 1027). CONCLUSIONS Frequency-based gastric slow wave abnormalities are prominent in NVS. The strength and consistency of these associations across many studies suggests that gastric dysrhythmia may be an important factor in NVS, motivating the development of more reliable methods for their clinical assessment.
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20
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Varghese C, Carson DA, Bhat S, Hayes TCL, Gharibans AA, Andrews CN, O'Grady G. Clinical associations of functional dyspepsia with gastric dysrhythmia on electrogastrography: A comprehensive systematic review and meta-analysis. Neurogastroenterol Motil 2021; 33:e14151. [PMID: 33830590 DOI: 10.1111/nmo.14151] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/30/2021] [Accepted: 03/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Functional dyspepsia (FD) is a common gastroduodenal disorder, yet its pathophysiology remains poorly understood. Bioelectrical gastric slow-wave abnormalities are thought to contribute to its multifactorial pathophysiology. Electrogastrography (EGG) has been used to record gastric electrical activity; however, the clinical associations require further evaluation. AIMS This study aimed to systematically assess the clinical associations of EGG in FD. METHODS MEDLINE, EMBASE, and CENTRAL databases were systematically searched for articles using EGG in adults with FD. Primary outcomes were percentage normal versus abnormal rhythm (bradygastria, normogastria, and tachygastria). Secondary outcomes were dominant power, dominant frequency, percentage coupling, and the meal responses. RESULTS 1751 FD patients and 555 controls from 47 studies were included. FD patients spent less time in normogastria while fasted (SMD -0.74; 95%CI -1.22 to -0.25) and postprandially (-0.86; 95%CI -1.35 to -0.37) compared with controls. FD patients also spent more fasted time in bradygastria (0.63; 95%CI 0.33-0.93) and tachygastria (0.45; 95%CI 0.12-0.78%). The power ratio (-0.17; 95%CI -0.83-0.48) and dominant frequency meal-response ratio (0.06; 95%CI -0.08-0.21) were not significantly different to controls. Correlations between EGG metrics and the presence and timing of FD symptoms were inconsistent. EGG methodologies were diverse and variably applied. CONCLUSION Abnormal gastric slow-wave rhythms are a consistent abnormality present in FD, as defined by EGG and, therefore, likely play a role in pathophysiology. The aberrant electrophysiology identified in FD warrants further investigation, including into underlying mechanisms, associated spatial patterns, and symptom correlations.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Daniel A Carson
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Tommy C L Hayes
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Armen A Gharibans
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | | | - Greg O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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21
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O'Grady G, Gharibans AA, Du P, Huizinga JD. The gastric conduction system in health and disease: a translational review. Am J Physiol Gastrointest Liver Physiol 2021; 321:G527-G542. [PMID: 34549598 DOI: 10.1152/ajpgi.00065.2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Gastric peristalsis is critically dependent on an underlying electrical conduction system. Recent years have witnessed substantial progress in clarifying the operations of this system, including its pacemaking units, its cellular architecture, and slow-wave propagation patterns. Advanced techniques have been developed for assessing its functions at high spatiotemporal resolutions. This review synthesizes and evaluates this progress, with a focus on human and translational physiology. A current conception of the initiation and conduction of slow-wave activity in the human stomach is provided first, followed by a detailed discussion of its organization at the cellular and tissue level. Particular emphasis is then given to how gastric electrical disorders may contribute to disease states. Gastric dysfunction continues to grow in their prevalence and impact, and while gastric dysrhythmia is established as a clear and pervasive feature in several major gastric disorders, its role in explaining pathophysiology and informing therapy is still emerging. New insights from high-resolution gastric mapping are evaluated, together with historical data from electrogastrography, and the physiological relevance of emerging biomarkers from body surface mapping such as retrograde propagating slow waves. Knowledge gaps requiring further physiological research are highlighted.
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Affiliation(s)
- Gregory O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Armen A Gharibans
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Jan D Huizinga
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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22
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Maselli DB, Camilleri M. Pharmacology, Clinical Effects, and Therapeutic Potential of Cannabinoids for Gastrointestinal and Liver Diseases. Clin Gastroenterol Hepatol 2021; 19:1748-1758.e2. [PMID: 32673642 PMCID: PMC7854774 DOI: 10.1016/j.cgh.2020.04.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/30/2020] [Accepted: 04/07/2020] [Indexed: 02/07/2023]
Abstract
Cannabis and cannabinoids (such as tetrahydrocannabinol and cannabidiol) are frequently used to relieve gastrointestinal symptoms. Cannabinoids have effects on the immune system and inflammatory responses, as well as neuromuscular and sensory functions of digestive organs, including pancreas and liver. Cannabinoids can cause hyperemesis and cyclic vomiting syndrome, but they might also be used to reduce gastrointestinal, pancreatic, or hepatic inflammation, as well as to treat motility, pain, and functional disorders. Cannabinoids activate cannabinoid receptors, which inhibit release of transmitters from presynaptic neurons and also inhibit diacylglycerol lipase alpha, to prevent synthesis of the endocannabinoid 2-arachidonoyl glycerol. However, randomized trials are needed to clarify their effects in patients; these compounds can have adverse effects on the central nervous system (such as somnolence and psychosis) or the developing fetus, when used for nausea and vomiting during pregnancy. Cannabinoid-based therapies can also hide symptoms and disease processes, such as in patients with inflammatory bowel diseases. It is important for gastroenterologists and hepatologists to understand cannabinoid mechanisms, effects, and risks.
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Affiliation(s)
- Daniel B Maselli
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Bhat S, Varghese C, Carson DA, Hayes TCL, Gharibans AA, Andrews CN, O'Grady G. Gastric dysrhythmia in gastroesophageal reflux disease: a systematic review and meta-analysis. Esophagus 2021; 18:425-435. [PMID: 33594598 DOI: 10.1007/s10388-021-00820-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a commonly diagnosed gastrointestinal disorder, with a substantial impact on the quality of life. The underlying pathophysiology of GERD is multifactorial and incompletely understood. Abnormal gastric electrical activity, measured using electrogastrography (EGG), may contribute. This study aimed to systematically review and meta-analyse the existing literature in which EGG was used in patients with GERD. METHODS Databases were systematically searched for studies using EGG in adults with GERD. The primary outcome was the percentage of recording time in the normogastric frequency range. Secondary outcomes were dominant frequency, dominant power, power ratio and prevalence of any EGG abnormality. RESULTS In total, 591 participants (427 patients with GERD; 164 healthy controls) from 13 studies were included. GERD patients spent 17.3% (SMD - 1.18, 95%CI: - 1.84, - 0.52) and 18.7% (SMD - 1.11, 95%CI: - 1.55, - 0.68) less of the preprandial and postprandial recording time in normogastric frequency ranges, respectively, compared to healthy controls. The dominant frequency, dominant power and power ratio were not significantly different to healthy controls in the preprandial and postprandial periods. The pooled prevalence of any EGG abnormality was significantly greater in patients with GERD than in healthy controls [46% (95%CI: 39-64%) vs. 10% (95%CI: 4-23%); p < 0.0001]. Correlations between GERD symptoms and EGG recordings were inconsistently studied. EGG techniques were heterogeneous. CONCLUSIONS Consistent abnormalities in gastric slow-wave activity, as measured by EGG, were identified in adults with GERD. Further investigation into these abnormalities using novel emerging electrophysiology techniques is desirable, to better define their contribution toward GERD pathophysiology.
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Affiliation(s)
- Sameer Bhat
- Department of Surgery, The University of Auckland, Private Bag, 92019, Auckland, New Zealand.
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Private Bag, 92019, Auckland, New Zealand
| | - Daniel A Carson
- Department of Surgery, The University of Auckland, Private Bag, 92019, Auckland, New Zealand
| | - Tommy C L Hayes
- Department of Surgery, The University of Auckland, Private Bag, 92019, Auckland, New Zealand
| | - Armen A Gharibans
- Department of Surgery, The University of Auckland, Private Bag, 92019, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | | | - Gregory O'Grady
- Department of Surgery, The University of Auckland, Private Bag, 92019, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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24
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Camilleri M, Kuo B. Editorial: finding the ideal prokinetic for gastroparesis-we are not there yet. Authors' reply. Aliment Pharmacol Ther 2021; 54:212-213. [PMID: 34170533 DOI: 10.1111/apt.16475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Braden Kuo
- Harvard School of Medicine, Boston, MA, USA
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25
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Electrogastrography Abnormalities in Pediatric Gastroduodenal Disorders: A Systematic Review and Meta-analysis. J Pediatr Gastroenterol Nutr 2021; 73:9-16. [PMID: 33797449 DOI: 10.1097/mpg.0000000000003140] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Electrogastrography (EGG) is a non-invasive method of measuring gastric electrophysiology. Abnormal gastric electrophysiology is thought to contribute to disease pathophysiology in patients with gastroduodenal symptoms but this has not been comprehensively quantified in pediatric populations. This study aimed to quantify the abnormalities in gastric electrophysiology on EGG in neonatal and pediatric patients.Databases were systematically searched for articles utilizing EGG in neonatal and pediatric patients (≤18 years). Primary outcomes were prevalence of abnormality, percentage of time in normal rhythm, and power ratio. Secondary outcomes were correlations between patient symptoms and abnormal gastric electrophysiology on EGG.A total of 33 articles (1444 participants) were included. EGG methodologies were variable. Pooled prevalence of abnormalities on EGG ranged from 61% to 86% in patients with functional dyspepsia (FD), gastro-esophageal reflux disease (GERD), and type 1 diabetes mellitus (T1DM). FD patients averaged 20.8% (P = 0.011) less preprandial and 21.6% (P = 0.031) less postprandial time in normogastria compared with controls. Electrophysiological abnormalities were inconsistent in GERD. T1DM patients averaged 46.2% (P = 0.0003) less preprandial and similar (P = 0.32) postprandial time in normogastria compared with controls, and had a lower power ratio (SMD -2.20, 95% confidence interval [CI]: -4.25 to -0.15; P = 0.036). Symptom correlations with gastric electrophysiology were inconsistently reported.Abnormalities in gastric electrophysiology were identifiable across a range of pediatric patients with gastroduodenal symptoms on meta-analysis. However, techniques have been inconsistent, and standardized and more reliable EGG methods are desirable to further define these findings and their potential utility in clinical practice.
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O'Grady G, Gharibans A, Calder S, Andrews C. Retrograde slow-wave activation: a missing link in gastric dysfunction? Neurogastroenterol Motil 2021; 33:e14112. [PMID: 33644950 DOI: 10.1111/nmo.14112] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/09/2021] [Indexed: 12/28/2022]
Affiliation(s)
- Greg O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Armen Gharibans
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Stefan Calder
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Chris Andrews
- Department of Gastroenterology, University of Calgary, Calgary, Canada
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Abstract
IMPORTANCE The prevalence of irritable bowel syndrome (IBS) in the United States is between 7% and 16%, most common in women and young people, with annual direct costs estimated at more than $1 billion dollars in the United States. Traditionally, the diagnosis of IBS has been based on the positive identification of symptoms that correlate with several different syndromes associated with disorders such as IBS diarrhea, IBS constipation, functional diarrhea, functional constipation, chronic functional abdominal pain, or bloating. Several peripheral and central mechanisms initiate gastrointestinal motor and sensory dysfunctions leading to IBS symptoms. Those dysfunctions may require evaluation in patients whose symptoms do not respond to first-line treatments. OBSERVATIONS Validation studies of consensus symptom-based criteria have identified deficiencies that favor a simpler identification of the predominant symptoms of abdominal pain, bowel dysfunction, and bloating and exclusion of alarm symptoms such as unintentional weight loss, rectal bleeding, or recent change in bowel function. Symptom-based diagnosis of IBS is enhanced with additional history for symptoms of somatoform and psychological disorders and alarm symptoms, physical examination including digital rectal examination, and screening tests to exclude organic disease (by measuring hemoglobin and C-reactive protein concentrations). The initial treatment plan should include patient education, reassurance, and first-line treatments such as fiber and osmotic laxatives for constipation, opioids for diarrhea, antispasmodics for pain and for management of associated psychological disorders. For patients who do not respond to those IBS treatments, testing for specific functional disorders may be required in a minority of patients with IBS. These disorders include rectal evacuation disorder, abnormal colonic transit, and bile acid diarrhea. Their identification is followed by individualized treatment, such as pelvic floor retraining for rectal evacuation disorders, sequestrants for bile acid diarrhea, and secretory agents for constipation, although there is only limited evidence that this individualized management approach is effective. CONCLUSIONS AND RELEVANCE Advances in the identification of specific dysfunctions as causes of individual symptoms in the "IBS spectrum" leads to the potential to enhance the diagnosis and management of symptoms for the majority of patients for whom first-line therapies of IBS and management of comorbid psychological disorders are insufficient.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Camilleri M. Irritable Bowel Syndrome: Straightening the road from the Rome criteria. Neurogastroenterol Motil 2020; 32:e13957. [PMID: 32808411 PMCID: PMC7640950 DOI: 10.1111/nmo.13957] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/10/2020] [Accepted: 07/12/2020] [Indexed: 12/20/2022]
Abstract
A sequence of consensus-based Rome criteria for irritable bowel syndrome (IBS) has been published since 1989. The fundamental definition based on abdominal pain in association with bowel dysfunction has been consistent. However, two major changes occurred in the Rome II and IV criteria. The former change involved "splitting off" of symptoms that were not consistently associated with pain, such as functional, constipation, diarrhea, and bloating. In Rome IV, the main changes were the exclusion of discomfort (in contrast to pain) and the more stringent frequency criteria for the pain to be eligible for diagnosis of IBS (specifically, on average, at least 1 day per week in the last 3 months). Validation studies of the consensus, symptom-based criteria have identified multiple deficiencies that question the rationale for "splitting" the different syndromes, and favor a simpler identification of the classical symptoms of abdominal pain, bowel dysfunction, and bloating, and exclusion of alarm symptoms. Advances in the identification of actionable biomarkers related to the symptoms suggestive of functional gastrointestinal disorders have the potential to usher a change in practice from positive diagnosis of symptom complexes followed by empirical treatment to identification of the mechanisms causing the symptoms and targeted therapy.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
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