Rectal sensitivity in diabetes patients with symptoms of gastroparesis

A Comprehensive Review of the Effects of Diabetes Mellitus on the Gastrointestinal System

Diabetes mellitus (DM) is a worldwide epidemic, making it a major non-communicable disease of public health concern. DM is a chronic disease affecting various organs of the body, leading to increased morbidity and frequently causing patients to seek medical care. Patients with DM often suffer from gastrointestinal disturbances, indicating the involvement of the gastrointestinal system (GIS). Common effects on the gastrointestinal tract (GIT) include esophageal dysmotility, gastroesophageal reflux disease (GERD), non-alcoholic fatty liver disease (NAFLD), glycogenic hepatopathy, gastroparesis, and enteropathy. Despite the high rates of GIT complications associated with diabetes, they are often under-recognized by physicians, leading to suboptimal treatment and a poor quality of life for patients. This article reviews the GIT manifestations of DM from the esophagus to the anal canal, including their pathophysiology and current management strategies.

Chronic constipation and its associated factors in patients with type-2 diabetes: A multicenter cross-sectional study

INTRODUCTION

Diabetes is one of the global public health concern and constipation is frequently seen among gastrointestinal symptoms in diabetes. Despite the fact that constipation is common, doctors and/or patients disregard it. This study aimed to determine the prevalence and contributing factors of constipation in patients with diabetes.

METHODS

Multi-center cross-sectional study was carried out and the data was analyzed using STATA 14. Binary and multilevel logistic regressions were also carried out to identify associated to factors. Factors having a p-value of less than 0.05 were deemed statistically significant in the final model.

RESULTS

206 diabetics participated in the survey. The mean age of the participants was 52.7 years (SD ± 11.9). The prevalence of constipation was 16% (95% CI: 10.97-21.07). Age (AOR = 13.56; 95% CI: 1.71, 107.21), females (AOR = 4.58; 95% CI: 1.76, 11.87), the duration of the diabetes (AOR = 3.16; 95% CI: 1.21, 8.24), and psychological distress (AOR = 12.49, 95% CI: 1.53, 101.8) were significant factors.

CONCLUSION

The magnitude of constipation was considerable, and it was linked to psychological distress, longer-lasting diabetes, being a woman, and ageing. Patients with type-2 diabetes need to receive careful treatment in order to reduce the severity of the condition and its additional complications.

The PanGut-study: Evoked potentials following rectal balloon distention, a way of evaluating diabetic autonomic neuropathy in the gut?

AIM

There is a lack of methods for investigating the autonomic nerves of the gastrointestinal tract. Our aim was to explore a novel test measuring visceral sensory evoked potentials (EPs) in response to rapid balloon distention in the rectum and compare it to established tests for diabetic neuropathy.

METHOD

Participants with longstanding type 2 diabetes, newly onset, untreated diabetes <1 year, and matched controls, were included. Tests included cardiovascular reflex tests, orthostatic blood pressure, electrical skin conductance assessment, sural nerve testing and monofilament test. The rectal balloon distention pressure at earliest sensation and threshold of unpleasantness were identified and used to elicit mechanical EPs.

RESULTS

The pressure at earliest sensation was higher in people with diabetes, 0.038 (0.012) bar vs. controls 0.030 (0.009) bar, p = 0.002, and in people with signs of peripheral neuropathy, 0.045 (0.014) bar, p < 0.01. Clinical correlations between EP amplitude and latency, and other tests were found.

CONCLUSIONS

Rectal hyposensitivity was associated with both longstanding and early diabetes, indicating enteric sensory dysfunction already in early stages of diabetes. Correlation analyses may indicate that central afferent processing is affected in parallel with peripheral neuronal function.

GI factors, potential to predict prostate motion during radiotherapy; a scoping review

Purpose

A scoping literature review was conducted to identify gastrointestinal (GI) factors most likely to influence prostate motion during radiotherapy. We proffer that patient specific measurement of these GI factors could predict motion uncertainty during radiotherapy, facilitating personalised care by optimising treatment technique e.g., daily adaption or via bespoke patient pre-habilitation and preparation.

Methods

The scoping review was undertaken as per JBI guidelines. Searches were conducted across four databases: Ovid Medline®, EMBASE, CINAHL and EBSCO discovery. Articles written in English from 2010-present were included. Those pertaining to paediatrics, biological women exclusively, infectious and post-treatment GI morbidity and diet were excluded.Common GI factors impacting men were identified and related symptoms, incidence and measurement tools examined. Prevalence among persons with prostate cancer was explored and suitable assessment tools discussed.

Results

A preliminary search identified four prominent GI-factors: mental health, co-morbidity and medication, physical activity, and pelvic floor disorder. The scoping search found 3644 articles; 1646 were removed as duplicates. A further 1249 were excluded after title and abstract screening, 162 remained subsequent to full text review: 42 mental health, 53 co-morbidity and medication, 39 physical activity and 28 pelvic floor disorder.Six GI factors prevalent in the prostate cancer population and estimated most likely to influence prostate motion were identified: depression, anxiety, diabetes, obesity, low physical activity, and pelvic floor disorder. Reliable, quick, and easy to use tools are available to quantify these factors.

Conclusion

A comprehensive GI factor assessment package suitable to implement into the radiotherapy clinic has been created. Unveiling these GI factors upfront will guide improved personalisation of radiotherapy.

Diabetic diarrhoea: A study on gastrointestinal motility, pH levels and autonomic function

BACKGROUND

Chronic diarrhoea is a common, but poorly investigated diabetes complication. Autonomic neuropathy is a leading pathophysiological theory founded on old, small studies. Studies of gastrointestinal motility and pH levels are lacking.

OBJECTIVES

Using new diagnostic methods, we aimed to find out if diabetic diarrhoea was associated with alterations in gastrointestinal motility, pH levels and autonomic function.

METHODS

Fifty-seven patients (42 women, 46 with type 1 diabetes) were prospectively included. Symptoms were evaluated with the gastrointestinal symptom rating scale, defining ≥4 points as cases with diarrhoea. Patients scoring <4 were used as controls. We used the wireless motility capsule to measure gastrointestinal transit times, pH levels and contractility parameters. Autonomic function was assessed by measuring heart rate variability, baroreflex sensitivity and orthostatic hypotension.

RESULTS

Seventeen patients (30%) had diarrhoea. Compared with controls, cases had slower gastric emptying (21:46 vs. 4:14, h:min, p = 0.03) and faster colonic transit (18:37 vs. 54:25, p < 0.001). Cases had increased intraluminal pH in the antrum (2.4 vs. 1.2, p = 0.009), caecum (7.3 vs. 6.4, p = 0.008) and entire colon (7.1 vs. 6.7, p = 0.05). They also had a decreased pH difference across the pylorus (3.3 vs. 4.9, p = 0.004) and ileocaecal junction (0.6 vs 1.0, p = 0.009). The groups did not differ in autonomic function, but diastolic blood pressure drop correlated r_s = -0.34 (p = 0.04) with colonic transit time.

CONCLUSIONS

Patients with diabetic diarrhoea had altered gastrointestinal transit and intraluminal pH levels, but minimal changes in autonomic function. Our results suggest that tests of gastrointestinal function are clinically useful in diabetic diarrhoea.

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.

Gastrointestinal symptoms and cardiac vagal tone in type 1 diabetes correlates with gut transit times and motility index

BACKGROUND

Although gastrointestinal (GI) symptoms are common in diabetes, they frequently do not correlate with measurable sensorimotor abnormalities. The wireless motility capsule (WMC) measures pressure, temperature, and pH as it traverses the GI tract wherefrom transit times and motility indices are derived. The aim was to investigate whether GI symptoms correlate with changes in (a) segmental transit times, (b) segmental motility index, (c) cardiac vagal tone, or (d) presence/absence of peripheral neuropathy in type 1 diabetes.

METHODS

Gastrointestinal symptoms in 104 participants with type 1 diabetes were measured using Gastroparesis Cardinal Symptoms Index and Gastrointestinal Symptom Rating Scale. All underwent standardized WMC investigation measuring segmental transit time and motility. Cardiac vagal tone and presence of peripheral neuropathy were measured using electrocardiographic and nerve conduction velocity testing.

KEY RESULTS

Colonic transit time was correlated with postprandial fullness (P = .01) and constipation (P = .03), while decreased colonic motility index was correlated with diarrhea (P = .01) and decreased bloating (P < .05). Symptoms were not correlated with gastric or small bowel transit time or motility index. In participants with low cardiac vagal tone, gastric motility index (P < .01) and colonic transit time (P < .05) were increased, but not in those with peripheral neuropathy. Abdominal pain was decreased with both peripheral neuropathy (P = .04) and decreased cardiac vagal tone (P = .02).

CONCLUSIONS AND INFERENCES

This study supports the rationale for whole gut investigation, using not only transit times but incorporating contractility indices as well. Furthermore, a decreased parasympathetic modulation and an increased hyposensate state appear to be present in type 1 diabetes.

Implications of rectal preconditioning for interpretation of sensory-motor data

Testing of biomechanical properties of intestine requires the tissue to be preconditioned by applying cyclic loading to obtain repeatable mechanical data. However, little is known about the mechanosensory properties during intestinal preconditioning. We aimed to study the relationship between mechanical preconditioning of the human rectum and sensory response. Three fast rectal bag distensions to the pain threshold were done in seven healthy females. A visual analog scale (VAS) was used for sensory assessment. At each distension, we determined (1) time, bag cross-sectional area (CSA), radius (r), r/r₀, pressure and tension to reach VAS = 1, 3 and 5 (pain threshold); (2) the same parameters at induced contraction start; (3) CSA where the pressure started to increase (CSA_P>baseline) and (4) the number of contractions. The time, CSA, r/r₀ and tension to reach VAS = 1 and VAS = 3 increased from distension 1 to 3 (4.9 < F < 11.5, 0.05 > P > 0.007), primarily due to difference between the first and second distension. For VAS = 5, r/r₀ was smaller in distension 3 than distension 1 (P < 0.05), whereas time, CSA and tension did not differ between distensions (P > 0.5). Compared with distension 1, CSA, r/r₀ and tension at contraction start, and CSA_P>baseline were bigger in distensions 2 and 3 (5.5 < F < 10.9, 0.05 > P > 0.009). The pressure to reach the VAS levels, the contraction numbers and pressure at contraction start did not differ among distensions (P > 0.6). During mechanical preconditioning, CSA, tension and deformation increased at sub-pain levels, reflecting sensory adaptation. The data point to acute remodeling of a strain-dependent mechanism in the rectal wall.

A longitudinal study on patients with diabetes and symptoms of gastroparesis - associations with impaired quality of life and increased depressive and anxiety symptoms

AIMS

To examine patient reported outcomes (PRO) in patients previously assessed for diabetic gastroparesis, and to investigate how symptoms of gastroparesis evolve over time. In addition, to further evaluate outcomes in those with versus without diabetic gastroparesis at baseline.

METHODS

Thirty-four patients with diabetes and gastrointestinal (GI) symptoms, diagnosed with or without diabetic gastroparesis in 2011-2013, were included in this follow-up study. PRO were measured with the Patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM), 36-Item Short Form Survey (SF-36), Patient assessment of upper gastrointestinal disorders-quality of life (PAGI-QOL) and Hospital Anxiety and Depression Scale (HADS). Demographic factors and clinical variables were also recorded.

RESULTS

Participants diagnosed with gastroparesis had improved glycemic control (p=0.04) and less GI symptoms (p=0.001), after a follow-up time of 3.2years (mean). Both groups reported severely impaired quality of life (QoL). In total 47% reported symptoms of anxiety, 38% symptoms of depression (scores≥8). GI symptom severity or other PRO could not differentiate between the two groups.

CONCLUSIONS

Patients diagnosed with diabetic gastroparesis, as well as those with gastroparesis symptoms - but normal gastric emptying, suffer from severely impaired QoL and a high burden of anxiety and depressive symptoms.

Pathogenesis of diabetic gastrointestinal dysfunction

Diabetic gastrointestinal dysfunction is a common complication in patients with diabetes mellitus. Most of the symptoms are related to impaired gastrointestinal function. The pathogenesis and etiology of diabetic gastroenteropathy are complex, involving the parasympathetic and sympathetic nervous systems, enteric neurons, smooth muscle cells, the network of interstitial cells of Cajal, cholinergic receptors and neuronal nitric oxide synthase. This article reviews the pathogenesis of diabetic gastrointestinal dysfunction.

Rectal Mechano-sensory Function in Patients with Carcinoid Diarrhea

BACKGROUND/AIMS

In patients with neuroendocrine tumors, excessive production of serotonin and other amines may cause the carcinoid syndrome,which is mainly characterized by diarrhea and flushing. Little is known about the pathophysiology of carcinoid diarrhea. In severalother groups of patients, diarrhea may be associated with rectal hypersensitivity and increased rectal tone. Therefore, the aim of thepresent study was to compare rectal sensitivity and compliance in patients with carcinoid diarrhea and in healthy subjects.

METHODS

Twelve patients (6 males, aged 54-78 years, median 65 years), with carcinoid diarrhea and 19 healthy subjects (7 males, aged 50-78 years, median 61 years) were included. Rectal mechanical and heat stimulation was used for assessment of rectal mechano-sensory properties.

RESULTS

Overall, 5.3% higher temperatures were needed to elicit sensory responses in patients with carcinoid diarrhea than in healthy subjects (P = 0.015). Posthoc analyses revealed that the sensory threshold to heat was 48.1 ± 3.1°C in patients vs 44.7 ± 4.7°C in healthy subjects (P = 0.041). In contrast, patients and healthy subjects showed no overall differences in rectal sensory response to mechanical distension (P = 0.731) or rectal compliance (P = 0.990).

CONCLUSIONS

Patients with carcinoid diarrhea have higher sensory thresholds to heat stimulation in comparison to healthy subjects, but normalrectal sensation to mechanical distension and normal compliance. Therefore, treatment of carcinoid diarrhea should aim at prolonging gastrointestinal transit and decreasing secretion, rather than modifying rectal mechano-sensory function.

Diabetic neuropathy in the gut: pathogenesis and diagnosis

The activity of the digestive tract is usually regulated to match its content: physiological stimuli in the gut induce modulatory reflexes that control digestive function so that digestion is normally not perceived. However, under certain circumstances, digestive stimuli may activate sensory afferents and give rise to conscious sensations. Both reflex and sensory signals are modulated by a balance of excitatory and inhibitory mechanisms. Patients with diabetes may develop a neuropathy affecting the control of gastric and/or intestinal motor function and the sensory innervation as well. During fasting the stomach is contracted and relaxes to accommodate a meal. After ingestion the stomach progressively recontracts and this contraction gently produces gastric emptying. Impairment of excitatory pathways affects the contraction of the stomach, which may result in delayed gastric emptying and vomiting of retained food. Conversely, alteration of the inhibitory neural pathways results in impaired relaxation of the stomach in response to a meal; in this case increased wall tension may produce early satiation, fullness and nausea. Diabetic neuropathy may distort the control of intestinal motility, which can lead to diverse symptoms such as diarrhoea, constipation, intestinal distension and abdominal pain. Neuropathy in diabetes may also affect the sensory nerves of the gut, and depending on which pathways are involved, perception may be increased or reduced. In summary, in patients with diabetic neuropathy, disorders of gut motor function are associated with sensory abnormalities, and the combination of impaired pathways determines the clinical consequences. This review summarises a presentation given at the 'Diagnosis and treatment of autonomic diabetic neuropathy in the gut' symposium at the 2015 annual meeting of the EASD. It is accompanied by another mini-review on a topic from this symposium (by Hans Törnblom, DOI: 10.1007/s00125-015-3829-9 ) and a commentary by the Session Chair, Péter Kempler (DOI: 10.1007/s00125-015-3826-y ).

Gastroparesis

PURPOSE OF REVIEW

This review summarizes recent progress in the epidemiology, pathophysiology, and treatment of gastroparesis.

RECENT FINDINGS

The relationship between delayed gastric emptying and symptom pattern in gastroparesis and, related to it, its separation from functional dyspepsia remains an area of controversy and uncertainty. Pathophysiological studies have focused on the role of pyloric resistance and duodenal motility in generation of symptoms. In diabetic patients, glycemic control did not determine short-term changes in gastric emptying rate in type 2 diabetes, but poor glycemic control was a major risk factor for long-term development of gastroparesis in type 1 diabetes. At the cellular level, diabetic gastroparesis is characterized by loss of interstitial cells of Cajal (ICCs), and this is inversely correlated to the number of CD206+ macrophages, which are thought to have a protective effect on ICCs. Treatment trials have focused on dietary factors and a nasal spray formulation of metoclopramide. A meta-analysis of prokinetic studies found no association between symptom improvement and enhancement of gastric emptying in gastroparesis. Two controlled studies showed no benefit of tricyclic antidepressants (nortriptyline, amitriptyline) in idiopathic gastroparesis and functional dyspepsia with delayed emptying.

SUMMARY

The relationship between delay in gastric emptying, symptom pattern, and response to prokinetic therapy in gastroparesis is poor. In diabetes, gastroparesis is characterized by loss of ICCs, and this is inversely correlated to the number of CD206+ macrophages. Dietary interventions may help to alleviate symptoms. Tricyclic antidepressants do not provide symptomatic benefit to patients with idiopathic gastroparesis.

Diabetes-related dysfunction of the small intestine and the colon: focus on motility

In contrast to gastric dysfunction, diabetes-related functional impairments of the small and large intestine have been studied less intensively. The gastrointestinal tract accomplishes several functions, such as mixing and propulsion of luminal content, absorption and secretion of ions, water, and nutrients, defense against pathogens, and elimination of waste products. Diverse functions of the gut are regulated by complex interactions among its functional elements, including gut microbiota. The network-forming tissues, the enteric nervous system) and the interstitial cells of Cajal, are definitely impaired in diabetic patients, and their loss of function is closely related to the symptoms in diabetes, but changes of other elements could also play a role in the development of diabetes mellitus-related motility disorders. The development of our understanding over the recent years of the diabetes-induced dysfunctions in the small and large intestine are reviewed in this article.